Barbell Medicine Podcast

Parts of the country now get a few weeks of wildfire smoke every year, and the obvious question is whether there is a point where the air is bad enough that the workout costs you more than it gives you. We went and looked. There is a real number, it comes from about 1.5 million people, and it is not the number that gets quoted. This is a free preview of Direct Line, our monthly ask-us-anything for Barbell Medicine Plus subscribers. Two of this month's twelve questions are here in full. First: training in wildfire smoke. What PM2.5 is, why the AQI on your phone and the number in the paper are not the same quantity, where the 90-minutes-at-100-micrograms figure comes from and why it is softer than it sounds, what happened when six cities modeled telling people to stay inside, and why your breathing rate during a set of squats matters more than you would think. Second: the effective reps model. A subscriber noticed that if a set only counts when you are within five reps of failure, the triceps in a heavy bench press should not count, and if you are going to count that as a fractional set for the triceps, then a warm-up set counts for the chest. Both cannot be true. We go through the meta-regression on proximity to failure, the 67-study analysis that tested whether an indirect set should count as one, as half, or as zero, and where we actually put our sets. Join Barbell Medicine Plus today: https://barbellmedicine.supercast.com/ Buy the book, Signal: https://www.barbellmedicine.com/shop/learning/signal/ New Barbell Medicine Hybrid 5K and 10K Run + Lift Programs Barbell Medicine coaching and templates: https://www.barbellmedicine.com Timestamps 1:47 The question: is there a point where the air is too bad to train? 2:37 What PM2.5 actually is 3:05 AQI vs micrograms, and why your phone disagrees with the paper 3:50 Where the "90 minutes" number comes from 4:54 Austin: what breathing this air does to your lungs 9:14 1.5 million adults: does dirty air cancel the benefit of exercise? 10:44 Six cities modeled staying indoors. Mortality did not improve. 11:22 Lifting vs cycling: breathing rate is the whole mechanism 12:33 Indoor air during a wildfire, and what filtration does not fix 13:24 Is wildfire smoke worse than city pollution? 14:38 What we would actually tell a patient 18:35 The question: hard sets, fractional sets, and the five-rep rule 19:18 Reps in reserve, hard sets, and fractional sets defined 20:19 The meta-regression: no threshold, just a line 21:13 Do indirect sets count as half a set? 23:08 Would you rather: every set at 5 RIR, or every set to failure? 25:22 Why you get worse at judging RIR the further you are from failure 28:42 The numbers we use: RPE 7 to 9 for hypertrophy, 4 to 6 for strength 29:20 Austin: individual variation dwarfs all of this 33:28 Why nobody can measure training load in the weight room Resources Tainio M, de Nazelle AJ, Götschi T, et al. Can air pollution negate the health benefits of cycling and walking? Prev Med. 2016;87:233-236. doi:10.1016/j.ypmed.2016.02.002. PMID 27156248 Ku PW, Steptoe A, Hamer M, et al. Does ambient PM2.5 reduce the protective association of leisure-time physical activity with mortality? A systematic review, meta-analysis, and individual-level pooled analysis of cohort studies involving 1.5 million adults. BMC Med. 2025;23(1):647. doi:10.1186/s12916-025-04496-y. PMID 41310726 Giallouros G, Kouis P, Papatheodorou SI, Woodcock J, Tainio M. The long-term impact of restricting cycling and walking during high air pollution days on all-cause mortality: health impact assessment study. Environ Int. 2020;140:105679. doi:10.1016/j.envint.2020.105679. PMID 32353667 Sun S, Cao W, Qiu H, et al. Benefits of physical activity not affected by air pollution: a prospective cohort study. Int J Epidemiol. 2020;49(1):142-152. doi:10.1093/ije/dyz184. PMID 31504557 Robles P, Araujo T, Brooks D, et al. Cardiorespiratory responses to short bouts of resistance training exercises in individuals with chronic obstructive pulmonary disease: a comparison of exercise intensities. J Cardiopulm Rehabil Prev. 2017;37(5):356-362. doi:10.1097/HCR.0000000000000282. PMID 28858033 Liang Y, Sengupta D, Campmier MJ, Lunderberg DM, Apte JS, Goldstein AH. Wildfire smoke impacts on indoor air quality assessed using crowdsourced data in California. Proc Natl Acad Sci U S A. 2021;118(36):e2106478118. doi:10.1073/pnas.2106478118. PMID 34465624 Aguilera R, Corringham T, Gershunov A, Benmarhnia T. Wildfire smoke impacts respiratory health more than fine particles from other sources: observational evidence from Southern California. Nat Commun. 2021;12(1):1493. doi:10.1038/s41467-021-21708-0. PMID 33674571 US Environmental Protection Agency. Air Quality Index (AQI) breakpoints. Air Quality System code tables. Accessed August 10, 2026. https://aqs.epa.gov/aqsweb/documents/codetables/aqi_breakpoints.html Robinson ZP, Pelland JC, Remmert JF, Refalo MC, Jukic I, Steele J, et al. Exploring the dose-response relationship between estimated resistance training proximity to failure, strength gain, and muscle hypertrophy: a series of meta-regressions. Sports Med. 2024;54(9):2209-2231. doi:10.1007/s40279-024-02069-2. PMID 38970765 Pelland JC, Remmert JF, Robinson ZP, Hinson SR, Zourdos MC. The resistance training dose response: meta-regressions exploring the effects of weekly volume and frequency on muscle hypertrophy and strength gains. Sports Med. 2026;56(2):481-505. doi:10.1007/s40279-025-02344-w Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Most lifters have been told they need to eat in a Calorie surplus to build muscle. That rule has always come with a list of exceptions: unless you're new, unless you're carrying extra body fat, unless you're coming back from time off. Dr. Eric Helms joins Dr. Jordan Feigenbaum to work out what the rule is actually tracking, starting from a question with a real number attached: what does a pound of muscle cost to build? And then, do you need to be in a surplus to build muscle? Timestamps: 0:00 The rule, and its exceptions 2:08 Where "you need a surplus" came from 7:12 Heuristics versus theories 11:40 Hypertrophy, maintenance, deficit and surplus defined 14:58 Body fat as a savings account 18:24 How fast anyone can actually build muscle 23:39 What sets the ceiling: stimulus, not genetics 26:37 Microgravity, astronauts, and a 20 kg barbell 31:49 What constrains growth if steroids don't break the ceiling 36:44 If training sets the ceiling, what does energy do 38:45 What 1 kg of muscle costs to build 44:05 Why 3,500 Calories doesn't tell you what to eat 44:55 REDs and the dual intervention model 47:51 The 2000s bulking studies 51:34 Garthe 2013: elite athletes and a 500 Calorie surplus 58:30 Protein: 1.6 versus 2.5 g/kg 1:03:31 What starvation research shows the body protects 1:10:29 Vargas-Molina: maintenance versus deficit 1:19:17 What to do if you're lean 1:39:34 What would prove this wrong 1:57:57 Three buckets Resources: Buy the book, Signal: https://www.barbellmedicine.com/shop/learning/signal/ New Barbell Medicine Hybrid 5K and 10K Run + Lift Programs Barbell Medicine coaching and templates: https://www.barbellmedicine.com Nikolaidis MG, Paschalis V, Margaritelis NV. The energetic cost of building human skeletal muscle. bioRxiv. Preprint posted online August 17, 2026. doi:10.64898/2026.08.17.745156 Rozenek R, Ward P, Long S, Garhammer J. Effects of high-calorie supplements on body composition and muscular strength following resistance training. J Sports Med Phys Fitness. 2002;42(3):340-347. Garthe I, Raastad T, Refsnes PE, Koivisto A, Sundgot-Borgen J. Effect of two different weight-loss rates on body composition and strength and power-related performance in elite athletes. Int J Sport Nutr Exerc Metab. 2011;21(2):97-104. Garthe I, Raastad T, Refsnes PE, Sundgot-Borgen J. Effect of nutritional intervention on body composition and performance in elite athletes. Eur J Sport Sci. 2013;13(3):295-303. doi:10.1080/17461391.2011.643923 Helms ER, Zinn C, Rowlands DS, Brown SR. A systematic review of dietary protein during caloric restriction in resistance trained lean athletes: a case for higher intakes. Int J Sport Nutr Exerc Metab. 2014;24(2):127-138. doi:10.1123/ijsnem.2013-0054 Slater GJ, Dieter BP, Marsh DJ, Helms ER, Shaw G, Iraki J. Is an energy surplus required to maximize skeletal muscle hypertrophy associated with resistance training. Front Nutr. 2019;6:131. doi:10.3389/fnut.2019.00131 Murphy C, Koehler K. Energy deficiency impairs resistance training gains in lean mass but not strength: a meta-analysis and meta-regression. Scand J Med Sci Sports. 2022;32(1):125-137. doi:10.1111/sms.14075 Helms ER, Spence A, Sousa C, et al. Effect of small and large energy surpluses on strength, muscle, and skinfold thickness in resistance-trained individuals: a parallel groups design. Sports Med Open. 2023;9(1):102. doi:10.1186/s40798-023-00651-y Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023;57(17):1073-1097. doi:10.1136/bjsports-2023-106994 Speakman JR, Hall KD. Models of body weight and fatness regulation. Philos Trans R Soc Lond B Biol Sci. 2023;378(1888):20220231. doi:10.1098/rstb.2022.0231 Vargas-Molina S, García-Palumbo A, García-Sillero M, et al. Comparison of two nutritional protocols in body re-composition of resistance-trained participants. Eur J Appl Physiol. 2026;126(7):4019-4030. doi:10.1007/s00421-026-06209-6 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Muscle is where most of the glucose goes, and muscle insulin resistance is the first thing that breaks on the road to type 2 diabetes. Both of those are true, and neither one means that building more muscle is the treatment for obesity. This episode works through what actually decides whether a tissue handles fuel well: not how much of it you have, but how fast it's moving fuel through. We go through the one-legged exercise studies, the 18,000-person analysis of what body composition actually predicts, the athlete's paradox, the energy cost of building a kilogram of muscle, the GLP-1 lean mass panic, and why sarcopenic obesity is named after the wrong organ. This is part two of a two-part series on storage capacity. Part one covered where body fat goes and what happens when the storage runs out. Timestamps 0:00 The one-leg study, and the muscle-centric claim 02:06 What obesity is, and the garage analogy 05:06 How glucose gets into a muscle cell 11:21 Insulin sensitivity improves without building muscle 17:11 The best case for muscle-centric medicine 21:13 What predicts falls and death: strength, not lean mass 25:18 Separating muscle size from muscle function 31:33 Liver fat: amount, type, and flux 37:54 Should you build muscle first? The arithmetic 42:37 Building muscle in a calorie deficit 50:29 GLP-1s, DXA, and the lean mass panic 58:23 Sarcopenic obesity, and why the name is wrong 01:04:37 Why size still tells you something 01:11:46 So what is obesity? Resources: Buy the book, Signal: https://www.barbellmedicine.com/shop/learning/signal/ New Barbell Medicine Hybrid 5K and 10K Run + Lift Programs Barbell Medicine coaching and templates: https://www.barbellmedicine.com 1. Richter EA, Mikines KJ, Galbo H, Kiens B. Effect of exercise on insulin action in human skeletal muscle. J Appl Physiol (1985). 1989;66(2):876-885. doi:10.1152/jappl.1989.66.2.876. PMID: 2496078. https://doi.org/10.1152/jappl.1989.66.2.876 2. Cawthon PM, Travison TG, Manini TM, et al. Establishing the link between lean mass and grip strength cut points with mobility disability and other health outcomes. J Gerontol A Biol Sci Med Sci. 2020;75(7):1317-1323. doi:10.1093/gerona/glz081. PMID: 30869772. https://doi.org/10.1093/gerona/glz081 3. Bhasin S, Travison TG, Manini TM, et al. Sarcopenia definition: the position statements of the Sarcopenia Definition and Outcomes Consortium. J Am Geriatr Soc. 2020;68(7):1410-1418. doi:10.1111/jgs.16372. PMID: 32150289. https://doi.org/10.1111/jgs.16372 4. Elgaddal N, Kramarow EA, Reuben C. Physical activity among adults aged 18 and over: United States, 2020. NCHS Data Brief No. 443. Hyattsville, MD: National Center for Health Statistics; 2022. PMID: 36043905. https://www.cdc.gov/nchs/products/databriefs/db443.htm 5. Whitfield GP, Carlson SA, Ussery EN, Fulton JE, Galuska DA, Petersen R. Trends in meeting physical activity guidelines among urban and rural dwelling adults, United States, 2008-2017. MMWR Morb Mortal Wkly Rep. 2019;68(23):513-518. doi:10.15585/mmwr.mm6823a1. PMID: 31194722. https://doi.org/10.15585/mmwr.mm6823a1 6. Wang T, Wang J, Hu X, Huang XJ, Chen GX. Current understanding of glucose transporter 4 expression and functional mechanisms. World J Biol Chem. 2020;11(3):76-98. doi:10.4331/wjbc.v11.i3.76. PMID: 33274014. https://doi.org/10.4331/wjbc.v11.i3.76 7. DeFronzo RA, Tripathy D. Skeletal muscle insulin resistance is the primary defect in type 2 diabetes. Diabetes Care. 2009;32(Suppl 2):S157-S163. doi:10.2337/dc09-S302. PMID: 19875544. https://doi.org/10.2337/dc09-S302 8. Richter EA, Hargreaves M. Exercise, GLUT4, and skeletal muscle glucose uptake. Physiol Rev. 2013;93(3):993-1017. doi:10.1152/physrev.00038.2012. PMID: 23899560. https://doi.org/10.1152/physrev.00038.2012 9. Petersen KF, Dufour S, Savage DB, et al. The role of skeletal muscle insulin resistance in the pathogenesis of the metabolic syndrome. Proc Natl Acad Sci U S A. 2007;104(31):12587-12594. doi:10.1073/pnas.0705408104. PMID: 17640906. https://doi.org/10.1073/pnas.0705408104 10. Rabøl R, Petersen KF, Dufour S, Flannery C, Shulman GI. Reversal of muscle insulin resistance with exercise reduces postprandial hepatic de novo lipogenesis in insulin resistant individuals. Proc Natl Acad Sci U S A. 2011;108(33):13705-13709. doi:10.1073/pnas.1110105108. PMID: 21808028. https://doi.org/10.1073/pnas.1110105108 11. Perseghin G, Price TB, Petersen KF, et al. Increased glucose transport-phosphorylation and muscle glycogen synthesis after exercise training in insulin-resistant subjects. N Engl J Med. 1996;335(18):1357-1362. doi:10.1056/NEJM199610313351804. PMID: 8857019. https://doi.org/10.1056/NEJM199610313351804 12. Mikines KJ, Sonne B, Farrell PA, Tronier B, Galbo H. Effect of physical exercise on sensitivity and responsiveness to insulin in humans. Am J Physiol. 1988;254(3 Pt 1):E248-E259. doi:10.1152/ajpendo.1988.254.3.E248. PMID: 3126668. https://doi.org/10.1152/ajpendo.1988.254.3.E248 13. Mikines KJ, Sonne B, Tronier B, Galbo H. Effects of acute exercise and detraining on insulin action in trained men. J Appl Physiol (1985). 1989;66(2):704-711. doi:10.1152/jappl.1989.66.2.704. PMID: 2496077. https://doi.org/10.1152/jappl.1989.66.2.704 14. Yu R, Duncombe SL, Nemoto Y, et al. Physical activity trajectories and mortality. Br J Sports Med. 2025;59(17):1228-1241. doi:10.1136/bjsports-2024-109122. PMID: 40639966. https://doi.org/10.1136/bjsports-2024-109122 15. Saint-Maurice PF, Coughlan D, Kelly SP, et al. Association of leisure-time physical activity across the adult life course with all-cause and cause-specific mortality. JAMA Netw Open. 2019;2(3):e190355. doi:10.1001/jamanetworkopen.2019.0355. PMID: 30848809. https://doi.org/10.1001/jamanetworkopen.2019.0355 16. Wang Y, Luo D, Liu J, Song Y, Jiang B, Jiang H. Low skeletal muscle mass index and all-cause mortality. PLoS One. 2023;18(6):e0286745. doi:10.1371/journal.pone.0286745. PMID: 37288745. https://doi.org/10.1371/journal.pone.0286745 17. Umpierre D, Ribeiro PAB, Kramer CK, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes. JAMA. 2011;305(17):1790-1799. doi:10.1001/jama.2011.576. PMID: 21540423. https://doi.org/10.1001/jama.2011.576 18. Goodpaster BH, Carlson CL, Visser M, et al. Attenuation of skeletal muscle and strength in the elderly: the Health ABC Study. J Appl Physiol (1985). 2001;90(6):2157-2165. doi:10.1152/jappl.2001.90.6.2157. PMID: 11356778. https://doi.org/10.1152/jappl.2001.90.6.2157 19. Paquin J, Lagacé JC, Brochu M, Dionne IJ. Exercising for insulin sensitivity, is there a mechanistic relationship with quantitative changes in skeletal muscle mass? Front Physiol. 2021;12:656909. doi:10.3389/fphys.2021.656909. PMID: 34054574. https://doi.org/10.3389/fphys.2021.656909 20. Eriksson J, Taimela S, Eriksson K, Parviainen S, Peltonen J, Kujala U. Resistance training in the treatment of non-insulin-dependent diabetes mellitus. Int J Sports Med. 1997;18(4):242-246. doi:10.1055/s-2007-972627. PMID: 9231838. https://doi.org/10.1055/s-2007-972627 21. Cuff DJ, Meneilly GS, Martin A, Ignaszewski A, Tildesley HD, Frohlich JJ. Effective exercise modality to reduce insulin resistance in women with type 2 diabetes. Diabetes Care. 2003;26(11):2977-2982. doi:10.2337/diacare.26.11.2977. PMID: 14578226. https://doi.org/10.2337/diacare.26.11.2977 22. Bucci M, Huovinen V, Guzzardi MA, et al. Resistance training improves skeletal muscle insulin sensitivity in elderly offspring of overweight and obese mothers. Diabetologia. 2016;59(1):77-86. doi:10.1007/s00125-015-3780-8. PMID: 26486356. https://doi.org/10.1007/s00125-015-3780-8 23. Mavros Y, Kay S, Anderberg KA, et al. Changes in insulin resistance and HbA1c are related to exercise-mediated changes in body composition in older adults with type 2 diabetes: interim outcomes from the GREAT2DO trial. Diabetes Care. 2013;36(8):2372-2379. doi:10.2337/dc12-2196. PMID: 23474589. https://doi.org/10.2337/dc12-2196 24. Janssen I, Heymsfield SB, Wang ZM, Ross R. Skeletal muscle mass and distribution in 468 men and women aged 18-88 yr. J Appl Physiol (1985). 2000;89(1):81-88. doi:10.1152/jappl.2000.89.1.81. PMID: 10904038. https://doi.org/10.1152/jappl.2000.89.1.81 25. Orwoll ES, Peters KE, Hellerstein M, Cummings SR, Evans WJ, Cawthon PM. The importance of muscle versus fat mass in sarcopenic obesity: a re-evaluation using D3-creatine muscle mass versus DXA lean mass measurements. J Gerontol A Biol Sci Med Sci. 2020;75(7):1362-1368. doi:10.1093/gerona/glaa064. PMID: 32232396. https://doi.org/10.1093/gerona/glaa064 26. Holten MK, Zacho M, Gaster M, Juel C, Wojtaszewski JFP, Dela F. Strength training increases insulin-mediated glucose uptake, GLUT4 content, and insulin signaling in skeletal muscle in patients with type 2 diabetes. Diabetes. 2004;53(2):294-305. doi:10.2337/diabetes.53.2.294. PMID: 14747278. https://doi.org/10.2337/diabetes.53.2.294 27. Manca A, Dragone D, Dvir Z, Deriu F. Cross-education of muscular strength following unilateral resistance training: a meta-analysis. Eur J Appl Physiol. 2017;117(11):2335-2354. doi:10.1007/s00421-017-3720-z. PMID: 28936703. https://doi.org/10.1007/s00421-017-3720-z 28. Bilet L, Phielix E, van de Weijer T, et al. One-leg inactivity induces a reduction in mitochondrial oxidative capacity, intramyocellular lipid accumulation and reduced insulin signalling upon lipid infusion. Diabetologia. 2020;63(6):1211-1222. doi:10.1007/s00125-020-05128-1. PMID: 32185462. https://doi.org/10.1007/s00125-020-05128-1 29. Lee J, Kim D, Kim C. Resistance training for glycemic control, muscular strength, and lean body mass in old type 2 diabetic patients: a meta-analysis. Diabetes Ther. 2017;8(3):459-473. doi:10.1007/s13300-017-0258-3. PMID: 28382531. https://doi.org/10.1007/s13300-017-0258-3 30. Goodpaster BH, He J, Watkins S, Kelley DE. Skeletal muscle lipid content and insulin resistance: evidence for a paradox in endurance-trained athletes. J Clin Endocrinol Metab. 2001;86(12):5755-5761. doi:10.1210/jcem.86.12.8075. PMID: 11739435. https://doi.org/10.1210/jcem.86.12.8075 31. Amati F, Dubé JJ, Alvarez-Carnero E, et al. Skeletal muscle triglycerides, diacylglycerols, and ceramides in insulin resistance: another paradox in endurance-trained athletes? Diabetes. 2011;60(10):2588-2597. doi:10.2337/db10-1221. PMID: 21873552. https://doi.org/10.2337/db10-1221 32. Bergman BC, Perreault L, Hunerdosse DM, Koehler MC, Samek AM, Eckel RH. Increased intramuscular lipid synthesis and low saturation relate to insulin sensitivity in endurance-trained athletes. J Appl Physiol (1985). 2010;108(5):1134-1141. doi:10.1152/japplphysiol.00684.2009. PMID: 20299618. https://doi.org/10.1152/japplphysiol.00684.2009 33. Dubé JJ, Amati F, Stefanovic-Racic M, Toledo FGS, Sauers SE, Goodpaster BH. Exercise-induced alterations in intramyocellular lipids and insulin resistance: the athlete's paradox revisited. Am J Physiol Endocrinol Metab. 2008;294(5):E882-E888. doi:10.1152/ajpendo.00769.2007. PMID: 18319352. https://doi.org/10.1152/ajpendo.00769.2007 34. Dubé JJ, Amati F, Toledo FGS, et al. Effects of weight loss and exercise on insulin resistance, and intramyocellular triacylglycerol, diacylglycerol and ceramide. Diabetologia. 2011;54(5):1147-1156. doi:10.1007/s00125-011-2065-0. PMID: 21327867. https://doi.org/10.1007/s00125-011-2065-0 35. Ter Horst KW, Vatner DF, Zhang D, et al. Hepatic insulin resistance is not pathway selective in humans with nonalcoholic fatty liver disease. Cell Rep. 2017;19(10):1997-2004. doi:10.1016/j.celrep.2017.05.035. PMID: 28591572. PMCID: PMC5469939. https://doi.org/10.1016/j.celrep.2017.05.035 36. Lyu K, Zhang Y, Zhang D, et al. A membrane-bound diacylglycerol species induces PKCepsilon-mediated hepatic insulin resistance. Cell Metab. 2020;32(4):654-664.e5. doi:10.1016/j.cmet.2020.08.001. PMID: 32882164. PMCID: PMC7544641. https://doi.org/10.1016/j.cmet.2020.08.001 37. Sargeant JA, Gray LJ, Bodicoat DH, et al. The effect of exercise training on intrahepatic triglyceride and hepatic insulin sensitivity: a systematic review and meta-analysis. Obes Rev. 2018;19(10):1446-1459. doi:10.1111/obr.12719. PMID: 30092609. https://doi.org/10.1111/obr.12719 38. Rinella ME, Lazarus JV, Ratziu V, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology. 2023;78(6):1966-1986. doi:10.1097/HEP.0000000000000520. PMID: 37363821. https://doi.org/10.1097/HEP.0000000000000520 39. Stine JG, DiJoseph K, Pattison Z, et al. Exercise training is associated with treatment response in liver fat content by magnetic resonance imaging independent of clinically significant body weight loss in patients with nonalcoholic fatty liver disease: a systematic review and meta-analysis. Am J Gastroenterol. 2023;118(7):1204-1213. doi:10.14309/ajg.0000000000002098. PMID: 36705333. https://doi.org/10.14309/ajg.0000000000002098 40. Mucinski JM, Salvador AF, Moore MP, et al. Histological improvements following energy restriction and exercise: the role of insulin resistance in resolution of MASH. J Hepatol. 2024;81(5):781-793. doi:10.1016/j.jhep.2024.06.017. PMID: 38914313. PMCID: PMC12007730. ClinicalTrials.gov NCT03151798. https://doi.org/10.1016/j.jhep.2024.06.017 41. Nikolaidis MG, Paschalis V, Margaritelis NV. The energetic cost of building human skeletal muscle. bioRxiv. Preprint posted August 20, 2026. doi:10.64898/2026.08.17.745156. Preprint, not peer reviewed. https://doi.org/10.64898/2026.08.17.745156 42. Helms ER, Spence AJ, Sousa C, et al. Effect of small and large energy surpluses on strength, muscle, and skinfold thickness in resistance-trained individuals: a parallel groups design. Sports Med Open. 2023;9(1):102. doi:10.1186/s40798-023-00651-y. PMID: 37914977. https://doi.org/10.1186/s40798-023-00651-y 43. Murphy C, Koehler K. Energy deficiency impairs resistance training gains in lean mass but not strength: a meta-analysis and meta-regression. Scand J Med Sci Sports. 2022;32(1):125-137. doi:10.1111/sms.14075. PMID: 34623696. https://doi.org/10.1111/sms.14075 44. Elia M, Stubbs RJ, Henry CJ. Differences in fat, carbohydrate, and protein metabolism between lean and obese subjects undergoing total starvation. Obes Res. 1999;7(6):597-604. doi:10.1002/j.1550-8528.1999.tb00720.x. PMID: 10574520. https://doi.org/10.1002/j.1550-8528.1999.tb00720.x 45. Colles SL, Dixon JB, Marks P, Strauss BJ, O'Brien PE. Preoperative weight loss with a very-low-energy diet: quantitation of changes in liver and abdominal fat by serial imaging. Am J Clin Nutr. 2006;84(2):304-311. doi:10.1093/ajcn/84.1.304. PMID: 16895876. https://doi.org/10.1093/ajcn/84.1.304 46. Vargas-Molina S, García-Palumbo A, García-Sillero M, et al. Effects of a moderate caloric deficit on body composition in resistance-trained individuals. Eur J Appl Physiol. 2026;126(7):4019-4030. doi:10.1007/s00421-026-06209-6. PMID: 41940947. https://doi.org/10.1007/s00421-026-06209-6 47. Longland TM, Oikawa SY, Mitchell CJ, Devries MC, Phillips SM. Higher compared with lower dietary protein during an energy deficit combined with intense exercise promotes greater lean mass gain and fat mass loss: a randomized trial. Am J Clin Nutr. 2016;103(3):738-746. doi:10.3945/ajcn.115.119339. PMID: 26817506. https://doi.org/10.3945/ajcn.115.119339 48. Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384(11):989-1002. doi:10.1056/NEJMoa2032183. PMID: 33567185. https://doi.org/10.1056/NEJMoa2032183 49. Wilding JPH, Batterham RL, Davies M, et al. Impact of semaglutide on body composition in adults with overweight or obesity: exploratory analysis of the STEP 1 study. J Endocr Soc. 2021;5(Suppl 1):A16-A17. doi:10.1210/jendso/bvab048.030. https://doi.org/10.1210/jendso/bvab048.030 50. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med. 2022;387(3):205-216. doi:10.1056/NEJMoa2206038. PMID: 35658024. https://doi.org/10.1056/NEJMoa2206038 51. Look M, Dunn JP, Kushner RF, et al. Body composition changes during weight reduction with tirzepatide in the SURMOUNT-1 study of adults with obesity or overweight. Diabetes Obes Metab. 2025;27(5):2720-2729. doi:10.1111/dom.16275. PMID: 39996356. https://doi.org/10.1111/dom.16275 52. Wang Z, Deurenberg P, Wang W, Pietrobelli A, Baumgartner RN, Heymsfield SB. Hydration of fat-free body mass: review and critique of a classic body-composition constant. Am J Clin Nutr. 1999;69(5):833-841. doi:10.1093/ajcn/69.5.833. PMID: 10232621. https://doi.org/10.1093/ajcn/69.5.833 53. Wang ZM, Pierson RN Jr, Heymsfield SB. The five-level model: a new approach to organizing body-composition research. Am J Clin Nutr. 1992;56(1):19-28. doi:10.1093/ajcn/56.1.19. PMID: 1609756. https://doi.org/10.1093/ajcn/56.1.19 54. Wadden TA, Neiberg RH, Wing RR, et al. Four-year weight losses in the Look AHEAD study: factors associated with long-term success. Obesity (Silver Spring). 2011;19(10):1987-1998. doi:10.1038/oby.2011.230. PMID: 21779086. https://doi.org/10.1038/oby.2011.230 55. Fildes A, Charlton J, Rudisill C, Littlejohns P, Prevost AT, Gulliford MC. Probability of an obese person attaining normal body weight: cohort study using electronic health records. Am J Public Health. 2015;105(9):e54-e59. doi:10.2105/AJPH.2015.302773. PMID: 26180980. https://doi.org/10.2105/AJPH.2015.302773 56. Alissou M, Demangeat T, Folope V, et al. Effect of semaglutide on sarcopenic obesity. Diabetes Obes Metab. 2026;28(1):112-121. doi:10.1111/dom.70141. PMID: 41068996. https://doi.org/10.1111/dom.70141 57. Bansal MB, Patton H, Morgan TR, Carr RM, Dranoff JA, Allen AM. Semaglutide therapy for metabolic dysfunction-associated steatohepatitis: November 2025 updates to AASLD Practice Guidance. Hepatology. 2025;83(5):1326-1340. doi:10.1097/HEP.0000000000001608. PMID: 41201884. https://doi.org/10.1097/HEP.0000000000001608 58. Sardeli AV, Komatsu TR, Mori MA, Gáspari AF, Chacon-Mikahil MPT. Resistance training prevents muscle loss induced by caloric restriction in obese elderly individuals: a systematic review and meta-analysis. Nutrients. 2018;10(4):423. doi:10.3390/nu10040423. PMID: 29596307. https://doi.org/10.3390/nu10040423 59. Rosenberg IH. Summary comments. Am J Clin Nutr. 1989;50(5):1231-1233. doi:10.1093/ajcn/50.5.1231. Not indexed in PubMed. https://doi.org/10.1093/ajcn/50.5.1231 60. Rosenberg IH. Sarcopenia: origins and clinical relevance. J Nutr. 1997;127(5 Suppl):990S-991S. doi:10.1093/jn/127.5.990S. PMID: 9164280. https://doi.org/10.1093/jn/127.5.990S 61. Kirk B, Cawthon PM, Arai H, et al. The conceptual definition of sarcopenia: Delphi consensus from the Global Leadership Initiative in Sarcopenia. Age Ageing. 2024;53(3):afae052. doi:10.1093/ageing/afae052. PMID: 38520141. https://doi.org/10.1093/ageing/afae052 62. Goodpaster BH, Park SW, Harris TB, et al. The loss of skeletal muscle strength, mass, and quality in older adults: the Health, Aging and Body Composition Study. J Gerontol A Biol Sci Med Sci. 2006;61(10):1059-1064. doi:10.1093/gerona/61.10.1059. PMID: 17077199. https://doi.org/10.1093/gerona/61.10.1059 63. Pascual-Fernández J, Fernández-Montero A, Córdova-Martínez A, Pastor D, Martínez-Rodríguez A, Roche E. Sarcopenia: molecular pathways and potential targets for intervention. Int J Mol Sci. 2020;21(22):8844. doi:10.3390/ijms21228844. PMID: 33266508. https://doi.org/10.3390/ijms21228844 64. Kwon YN, Yoon SS. Sarcopenia: neurological point of view. J Bone Metab. 2017;24(2):83-89. doi:10.11005/jbm.2017.24.2.83. PMID: 28642851. https://doi.org/10.11005/jbm.2017.24.2.83 65. Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol. 2018;14(9):513-537. doi:10.1038/s41574-018-0062-9. PMID: 30065268. https://doi.org/10.1038/s41574-018-0062-9 66. Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med. 2023;389(24):2221-2232. doi:10.1056/NEJMoa2307563. PMID: 37952131. https://doi.org/10.1056/NEJMoa2307563 67. Deanfield J, Lincoff AM, Kahn SE, et al. Impact of semaglutide on cardiovascular outcomes by adiposity measures in SELECT. Lancet. 2025;406(10516):2257-2268. doi:10.1016/S0140-6736(25)01375-3. PMID: 41138739. https://doi.org/10.1016/S0140-6736(25)01375-3 68. Perkovic V, Tuttle KR, Rossing P, et al. Effects of semaglutide on chronic kidney disease in patients with type 2 diabetes. N Engl J Med. 2024;391(2):109-121. doi:10.1056/NEJMoa2403347. PMID: 38785209. https://doi.org/10.1056/NEJMoa2403347 69. Obesity Medicine Association. Definition of obesity. https://obesitymedicine.org/blog/why-is-obesity-a-disease/ 70. Tomiyama AJ, Hunger JM, Nguyen-Cuu J, Wells C. Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005-2012. Int J Obes (Lond). 2016;40(5):883-886. doi:10.1038/ijo.2016.17. PMID: 26841729. https://doi.org/10.1038/ijo.2016.17 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Most men who start testosterone never needed it, and some who genuinely do never get treated. In the final episode of the Signal series, Dr. Jordan Feigenbaum and Dr. Austin Baraki work through who actually needs testosterone replacement, who got sold it, and what the evidence says about the risks that scared the field for a decade. We cover the blinded trial where men couldn't tell real testosterone from placebo, what the heart and prostate data actually show now that we have the trials, what testosterone does to fertility, and the framework we use to decide. We also close the story of Mark, the patient whose lab result started the series. This is educational content, not medical advice. Talk to your physician about your personal situation. Here we cover the real diagnosis of testosterone deficiency, primary versus secondary low testosterone, how the system both over- and under-prescribes, the SHBG trap that makes a normal level look low, the gray-zone crossover study, what replacement should actually target, why most men quit within a year, testosterone as a male contraceptive, the TRAVERSE cardiovascular results, the saturation model and prostate safety, the blood side effect worth monitoring, and when not to start at all. Timestamps: 00:00 The study almost nobody mentions 01:31 Who this episode is for 03:35 What a real testosterone diagnosis requires 07:18 Primary vs secondary low testosterone 10:12 How testosterone gets over-prescribed 11:35 The SHBG trap: when a low number misleads 18:10 Would GLP-1 plus testosterone work better? 22:19 Why genuine deficiency gets under-treated 24:15 The cardiovascular scare and where it came from 34:11 The gray-zone study, in full 41:02 What TRT should actually target, and the "900" myth 47:38 Running TRT as a trial, and why 70% quit 52:36 Testosterone as a contraceptive: the fertility cost 57:19 Does TRT cause heart problems? The TRAVERSE trial 01:01:40 Testosterone and the prostate 01:09:13 The blood side effect worth watching 01:12:02 When not to start testosterone 01:14:26 Who actually benefits from TRT 01:18:28 The Signal framework, and what happened to Mark 01:21:14 Five things to take away 01:23:33 Our conflict of interest, and the book Resources: Buy the book, Signal: https://www.barbellmedicine.com/shop/learning/signal/ Part 1: Is the testosterone crisis real? Part 2: Is you testosterone actually low? Part 3: What's actually driving your testosterone down? New Barbell Medicine Hybrid 5K and 10K Run + Lift Programs Barbell Medicine coaching and templates: https://www.barbellmedicine.com Testosterone Action Plan: https://www.barbellmedicine.com/testosterone-action-plan/ Mulligan T, Frick MF, Zuraw QC, Stemhagen A, McWhirter C. Prevalence of hypogonadism in males aged at least 45 years: the HIM study. Int J Clin Pract. 2006;60(7):762-769. doi:10.1111/j.1742-1241.2006.00992.x Baillargeon J, Urban RJ, Ottenbacher KJ, Pierson KS, Goodwin JS. Trends in androgen prescribing in the United States, 2001-2011. JAMA Intern Med. 2013;173(15):1465-1466. doi:10.1001/jamainternmed.2013.6895 Bhasin S, Brito JP, Cunningham GR, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744. doi:10.1210/jc.2018-00229 Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and management of testosterone deficiency: AUA guideline. J Urol. 2018;200(2):423-432. doi:10.1016/j.juro.2018.03.115 Corona G, Goulis DG, Huhtaniemi I, et al. European Academy of Andrology (EAA) and European Society of Endocrinology (ESE) recommendations on the diagnosis and management of male hypogonadism. Andrology. 2020;8(5):970-987. doi:10.1111/andr.12770 Morgentaler A, Zitzmann M, Traish AM, et al. Commentary: who is a candidate for testosterone therapy? A synthesis of international expert opinions. J Sex Med. 2014;11(7):1636-1645. doi:10.1111/jsm.12546 Mok SF, Fennell C, Savkovic S, et al. Testosterone for androgen deficiency-like symptoms in men without pathologic hypogonadism: a randomized, placebo-controlled cross-over with masked choice extension clinical trial. J Gerontol A Biol Sci Med Sci. 2020;75(9):1723-1731. doi:10.1093/gerona/glz195 Clift AK, Johnson H, Huang DR, Morgentaler A. Real-world outcomes and safety of testosterone therapy: a longitudinal, retrospective cohort study of over 9,000 men. World J Mens Health. 2026;44(2):438-450. doi:10.5534/wjmh.250245 Malik RD, Wang CE, Lapin B, Lakeman JC, Helfand BT. Characteristics of men undergoing testosterone replacement therapy and adherence to follow-up recommendations in a metropolitan multicenter health care system. Urology. 2015;85(6):1382-1388. doi:10.1016/j.urology.2015.01.027 Donatucci C, Cui Z, Fang Y, Muram D. Long-term treatment patterns of testosterone replacement medications. J Sex Med. 2014;11(8):2092-2099. doi:10.1111/jsm.12608 Saad F, Aversa A, Isidori AM, Zafalon L, Zitzmann M, Gooren L. Onset of effects of testosterone treatment and time span until maximum effects are achieved. Eur J Endocrinol. 2011;165(5):675-685. doi:10.1530/EJE-11-0221 Ly LP, Liu PY, Handelsman DJ. Rates of suppression and recovery of human sperm output in testosterone-based hormonal contraceptive regimens. Hum Reprod. 2005;20(6):1733-1740. doi:10.1093/humrep/deh834 Liu PY, Swerdloff RS, Christenson PD, Handelsman DJ, Wang C; Hormonal Male Contraception Summit Group. Rate, extent, and modifiers of spermatogenic recovery after hormonal male contraception: an integrated analysis. Lancet. 2006;367(9520):1412-1420. doi:10.1016/S0140-6736(06)68614-5 Ko EY, Siddiqi K, Brannigan RE, Sabanegh ES Jr. Empirical medical therapy for idiopathic male infertility: a survey of the American Urological Association. J Urol. 2012;187(3):973-978. doi:10.1016/j.juro.2011.10.137 Kohn TP, Louis MR, Pickett SM, et al. Age and duration of testosterone therapy predict time to return of sperm count after human chorionic gonadotropin therapy. Fertil Steril. 2017;107(2):351-357.e1. doi:10.1016/j.fertnstert.2016.10.004 Wenker EP, Dupree JM, Langille GM, et al. The use of HCG-based combination therapy for recovery of spermatogenesis after testosterone use. J Sex Med. 2015;12(6):1334-1337. doi:10.1111/jsm.12890 Basaria S, Coviello AD, Travison TG, et al. Adverse events associated with testosterone administration. N Engl J Med. 2010;363(2):109-122. doi:10.1056/NEJMoa1000485 Vigen R, O’Donnell CI, Barón AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA. 2013;310(17):1829-1836. doi:10.1001/jama.2013.280386 Basaria S, Harman SM, Travison TG, et al. Effects of testosterone administration for 3 years on subclinical atherosclerosis progression in older men with low or low-normal testosterone levels: a randomized clinical trial. JAMA. 2015;314(6):570-581. doi:10.1001/jama.2015.8881 Budoff MJ, Ellenberg SS, Lewis CE, et al. Testosterone treatment and coronary artery plaque volume in older men with low testosterone. JAMA. 2017;317(7):708-716. doi:10.1001/jama.2016.21043 Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular safety of testosterone-replacement therapy. N Engl J Med. 2023;389(2):107-117. doi:10.1056/NEJMoa2215025 Huggins C, Hodges CV. Studies on prostatic cancer. I. The effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. Cancer Res. 1941;1(4):293-297. Morgentaler A, Traish AM. Shifting the paradigm of testosterone and prostate cancer: the saturation model and the limits of androgen-dependent growth. Eur Urol. 2009;55(2):310-320. doi:10.1016/j.eururo.2008.09.024 Khera M, Crawford D, Morales A, Salonia A, Morgentaler A. A new era of testosterone and prostate cancer: from physiology to clinical implications. Eur Urol. 2014;65(1):115-123. doi:10.1016/j.eururo.2013.08.015 Bhasin S, Lincoff AM, Nissen SE, et al. Prostate safety events during testosterone replacement therapy in men with hypogonadism: a randomized clinical trial. JAMA Netw Open. 2023;6(12):e2348692. doi:10.1001/jamanetworkopen.2023.48692 Snyder PJ, Bhasin S, Cunningham GR, et al. Effects of testosterone treatment in older men. N Engl J Med. 2016;374(7):611-624. doi:10.1056/NEJMoa1506119 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

In 2004 a surgeon removed about ten kilograms of fat from fifteen women and measured everything that mattered. Nothing improved. Four years later, it still hadn't. That result should have ended an argument about body fat. Instead the argument got more specific, and the version you've heard most recently is that visceral fat, the fat around your organs, is the dangerous kind. I've said a version of that myself on this show, and in this episode I expand upon it. This one starts from the beginning: what your fat is actually for, what insulin is, and what insulin resistance means, in plain terms and assuming nothing. Then four experiments that all point the same direction. Fat removed surgically, and the disease doesn't follow. People born with no fat tissue at all, who get the entire disease anyway. A hormone that reversed a 48% fatty liver without adding a gram of fat. And a diabetes drug that made people heavier and healthier at the same time. The second half is practical. What a fatty liver actually does over twenty years, what BMI can and can't do, why the Lancet Commission changed the definition of obesity in 2025, and the exact order of tests I'd use, including the TyG index, FIB-4, and where each one stops working. Part one of two. Next episode is about muscle. Timestamps: 00:00 The Liposuction Experiment 02:06 The Visceral Fat Correction 05:47 What Fat Is For 08:14 The Carb Insulin Model 10:51 Filling The Garage 14:35 Taking The Fat Out 17:57 Born Without Fat Tissue 22:52 Heavier And Healthier 25:05 Neptune And Vulcan 29:57 The Patient Nobody Checked 33:59 What Every Ruler Missed 36:00 What To Actually Order 40:29 What Obesity Actually Is Resources: Vital 5 (TyG , waist to height, etc. discussion): https://www.barbellmedicine.com/vital-5-action-plan/ New Barbell Medicine Hybrid 5K and 10K Run + Lift Programs Barbell Medicine coaching and templates: https://www.barbellmedicine.com Plus podcast subscription: https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/ Barbell Medicine Premium: https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/ Signal (now shipping): https://www.barbellmedicine.com/shop/learning/signal/ Klein S, Fontana L, Young VL, et al. Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med. 2004;350(25):2549-2557. doi:10.1056/NEJMoa033179 Mohammed BS, Cohen S, Reeds D, Young VL, Klein S. Long-term effects of large-volume liposuction on metabolic risk factors for coronary heart disease. Obesity (Silver Spring). 2008;16(12):2648-2651. doi:10.1038/oby.2008.418 Sommer I, Teufer B, Szelag M, et al. The performance of anthropometric tools to determine obesity: a systematic review and meta-analysis. Sci Rep. 2020;10(1):12699. doi:10.1038/s41598-020-69498-7 Donnelly KL, Smith CI, Schwarzenberg SJ, Jessurun J, Boldt MD, Parks EJ. Sources of fatty acids stored in liver and secreted via lipoproteins in patients with nonalcoholic fatty liver disease. J Clin Invest. 2005;115(5):1343-1351. doi:10.1172/JCI23621 Spalding KL, Arner E, Westermark PO, et al. Dynamics of fat cell turnover in humans. Nature. 2008;453(7196):783-787. doi:10.1038/nature06902 Fabbrini E, Tamboli RA, Magkos F, et al. Surgical removal of omental fat does not improve insulin sensitivity and cardiovascular risk factors in obese adults. Gastroenterology. 2010;139(2):448-455. doi:10.1053/j.gastro.2010.04.056 Garg A. Acquired and inherited lipodystrophies. N Engl J Med. 2004;350(12):1220-1234. doi:10.1056/NEJMra025261 Al Yaarubi S, Alsagheir A, Al Shidhani A, et al. Analysis of disease characteristics of a large patient cohort with congenital generalized lipodystrophy from the Middle East and North Africa. Orphanet J Rare Dis. 2024;19(1):118. doi:10.1186/s13023-024-03084-2 Petersen KF, Oral EA, Dufour S, et al. Leptin reverses insulin resistance and hepatic steatosis in patients with severe lipodystrophy. J Clin Invest. 2002;109(10):1345-1350. doi:10.1172/JCI200215001 Miyazaki Y, Mahankali A, Matsuda M, et al. Effect of pioglitazone on abdominal fat distribution and insulin sensitivity in type 2 diabetic patients. J Clin Endocrinol Metab. 2002;87(6):2784-2791. doi:10.1210/jcem.87.6.8567 Cusi K, Orsak B, Bril F, et al. Long-term pioglitazone treatment for patients with nonalcoholic steatohepatitis and prediabetes or type 2 diabetes mellitus: a randomized trial. Ann Intern Med. 2016;165(5):305-315. doi:10.7326/M15-1774 Taylor R, Barnes AC, Hollingsworth KG, et al. Aetiology of type 2 diabetes in people with a 'normal' body mass index: testing the personal fat threshold hypothesis. Clin Sci (Lond). 2023;137(16):1333-1346. doi:10.1042/CS20230586 Martin S, Cule M, Basty N, et al. Genetic evidence for different adiposity phenotypes and their opposing influences on ectopic fat and risk of cardiometabolic disease. Diabetes. 2021;70(8):1843-1856. doi:10.2337/db21-0129 Martin S, Sorokin EP, Thomas EL, et al. Estimating the effect of liver and pancreas volume and fat content on risk of diabetes: a Mendelian randomization study. Diabetes Care. 2022;45(2):460-468. doi:10.2337/dc21-1262 Sanyal AJ, Kaplan LM, Frias JP, et al. Triple hormone receptor agonist retatrutide for metabolic dysfunction-associated steatotic liver disease: a randomized phase 2a trial. Nat Med. 2024;30(7):2037-2048. doi:10.1038/s41591-024-03018-2 Portillo-Sanchez P, Bril F, Maximos M, et al. High prevalence of nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus and normal plasma aminotransferase levels. J Clin Endocrinol Metab. 2015;100(6):2231-2238. doi:10.1210/jc.2015-1966 Hagström H, Nasr P, Ekstedt M, et al. Fibrosis stage but not NASH predicts mortality and time to development of severe liver disease in biopsy-proven NAFLD. J Hepatol. 2017;67(6):1265-1273. doi:10.1016/j.jhep.2017.07.027 Rubino F, Cummings DE, Eckel RH, et al. Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025;13(3):221-262. doi:10.1016/S2213-8587(24)00316-4 Guerrero-Romero F, Simental-Mendía LE, González-Ortiz M, et al. The product of triglycerides and glucose, a simple measure of insulin sensitivity: comparison with the euglycemic-hyperinsulinemic clamp. J Clin Endocrinol Metab. 2010;95(7):3347-3351. doi:10.1210/jc.2010-0288 Sánchez-García A, Rodríguez-Gutiérrez R, Mancillas-Adame L, et al. Diagnostic accuracy of the triglyceride and glucose index for insulin resistance: a systematic review. Int J Endocrinol. 2020;2020:4678526. doi:10.1155/2020/4678526 McLaughlin T, Abbasi F, Cheal K, Chu J, Lamendola C, Reaven G. Use of metabolic markers to identify overweight individuals who are insulin resistant. Ann Intern Med. 2003;139(10):802-809. doi:10.7326/0003-4819-139-10-200311180-00007 McPherson S, Hardy T, Dufour JF, et al. Age as a confounding factor for the accurate non-invasive diagnosis of advanced NAFLD fibrosis. Am J Gastroenterol. 2017;112(5):740-751. doi:10.1038/ajg.2016.453 Mózes FE, Lee JA, Selvaraj EA, et al. Diagnostic accuracy of non-invasive tests for advanced fibrosis in patients with NAFLD: an individual patient data meta-analysis. Gut. 2022;71(5):1006-1019. doi:10.1136/gutjnl-2021-324243 Bansal MB, Patton H, Morgan TR, Carr RM, Dranoff JA, Allen AM. Semaglutide therapy for metabolic dysfunction-associated steatohepatitis: November 2025 updates to AASLD practice guidance. Hepatology. 2025;83(5):1326-1340. doi:10.1097/HEP.0000000000001608 Tomiyama AJ, Hunger JM, Nguyen-Cuu J, Wells C. Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005-2012. Int J Obes (Lond). 2016;40(5):883-886. doi:10.1038/ijo.2016.17 Wildman RP, Muntner P, Reynolds K, et al. The obese without cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2 phenotypes among the US population (NHANES 1999-2004). Arch Intern Med. 2008;168(15):1617-1624. doi:10.1001/archinte.168.15.1617 Mongraw-Chaffin M, Foster MC, Anderson CAM, et al. Metabolically healthy obesity, transition to metabolic syndrome, and cardiovascular risk. J Am Coll Cardiol. 2018;71(17):1857-1865. doi:10.1016/j.jacc.2018.02.055 Gujral UP, Vittinghoff E, Mongraw-Chaffin M, et al. Cardiometabolic abnormalities among normal-weight persons from five racial/ethnic groups in the United States: a cross-sectional analysis of two cohort studies. Ann Intern Med. 2017;166(9):628-636. doi:10.7326/M16-1895 Ruderman NB, Schneider SH, Berchtold P. The "metabolically-obese," normal-weight individual. Am J Clin Nutr. 1981;34(8):1617-1621. doi:10.1093/ajcn/34.8.1617 Sims EA. Are there persons who are obese, but metabolically healthy? Metabolism. 2001;50(12):1499-1504. doi:10.1053/meta.2001.27213 National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication 98-4083. Bethesda, MD: National Institutes of Health; September 1998. American Medical Association House of Delegates. Resolution 420 (A-13): Recognition of Obesity as a Disease. Adopted June 18, 2013. American Medical Association Council on Science and Public Health. Report 3-A-13: Is Obesity a Disease? 2013. Rey-López JP, de Rezende LF, Pastor-Valero M, Tess BH. The prevalence of metabolically healthy obesity: a systematic review and critical evaluation of the definitions used. Obes Rev. 2014;15(10):781-790. doi:10.1111/obr.12198 Hinnouho GM, Czernichow S, Dugravot A, Batty GD, Kivimaki M, Singh-Manoux A. Metabolically healthy obesity and risk of mortality: does the definition of metabolic health matter? Diabetes Care. 2013;36(8):2294-2300. doi:10.2337/dc12-1654 Herman WH, Ye W, Griffin SJ, et al. Early detection and treatment of type 2 diabetes reduce cardiovascular morbidity and mortality: a simulation of the results of the Anglo-Danish-Dutch study of intensive treatment in people with screen-detected diabetes in primary care (ADDITION-Europe). Diabetes Care. 2015;38(8):1449-1455. doi:10.2337/dc14-2459 Le MH, Yeo YH, Cheung R, Wong VW, Nguyen MH. Ethnic influence on nonalcoholic fatty liver disease prevalence and lack of disease awareness in the United States, 2011-2016. J Intern Med. 2020;287(6):711-722. doi:10.1111/joim.13035 Sutin AR, Stephan Y, Terracciano A. Weight discrimination and risk of mortality. Psychol Sci. 2015;26(11):1803-1811. doi:10.1177/0956797615601103 Amy NK, Aalborg A, Lyons P, Keranen L. Barriers to routine gynecological cancer screening for White and African-American obese women. Int J Obes (Lond). 2006;30(1):147-155. doi:10.1038/sj.ijo.0803105 Kramer CK, Zinman B, Retnakaran R. Are metabolically healthy overweight and obesity benign conditions? A systematic review and meta-analysis. Ann Intern Med. 2013;159(11):758-769. doi:10.7326/0003-4819-159-11-201312030-00008 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

A popular paper claimed the longevity benefit of lifting disappears once you train more than an hour a week. It's a real paper, but the claim is a misread. This is the free cut of this month's Direct Line, where Drs. Feigenbaum and Baraki also take on whether GLP-1s affect your mood, the "same calories, more weight loss" protein argument, and what you can actually do in the gym when you have chronic fatigue syndrome. For education and infotainment, not medical advice. To become a member and have us answer YOUR questions, join today: https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/ Timestamps: 0:00 Intro 0:38 The paper: does lifting stop helping after an hour? 3:19 The newer 147,000-person, 30-year study 13:21 GLP-1s, mood, and motivation 14:50 The FDA reverses the suicide warning 19:29 What happened when they gave people a GLP-1 in a bar 24:54 Is a calorie just a calorie? 28:17 The "same calories, more weight loss" protein study 30:48 Does keto break the laws of physics? 34:56 Lifting with chronic fatigue syndrome 36:14 The identical-twin experiment 37:36 Can lifting in bed do anything? 45:33 Get the full Direct Line New Barbell Medicine Hybrid 5K and 10K Run + Lift Programs Barbell Medicine coaching and templates: https://www.barbellmedicine.com Barbell Medicine Premium: https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/ Signal (pre-order) https://www.barbellmedicine.com/shop/learning/signal/ 1. Momma H, Kawakami R, Honda T, Sawada SS. Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies. *Br J Sports Med*. 2022;56(13):755-763. doi:10.1136/bjsports-2021-105061 2. Dankel SJ, Loenneke JP, Loprinzi PD. Dose-dependent association between muscle-strengthening activities and all-cause mortality: prospective cohort study among a national sample of adults in the USA. *Arch Cardiovasc Dis*. 2016;109(11):626-633. doi:10.1016/j.acvd.2016.04.005 3. Zhang Y, Lee DH, Rezende LFM, Ma Y, Giovannucci E. Long-term resistance training with all-cause and cause-specific mortality: assessing dose-response and joint associations with aerobic physical activity. *Br J Sports Med*. Published online June 2, 2026. doi:10.1136/bjsports-2025-110503 4. US Food and Drug Administration. FDA requests removal of suicidal behavior and ideation warning from glucagon-like peptide-1 receptor agonist (GLP-1 RA) medications. Drug Safety Communication. January 13, 2026. Accessed August 12, 2026. https://www.fda.gov/drugs/drug-safety-communications/fda-requests-removal-suicidal-behavior-and-ideation-warning-glucagon-peptide-1-receptor-agonist-glp 5. Hendershot CS, Bremmer MP, Paladino MB, et al. Once-weekly semaglutide in adults with alcohol use disorder: a randomized clinical trial. *JAMA Psychiatry*. 2025;82(4):395-405. doi:10.1001/jamapsychiatry.2024.4789 6. Klausen MK, Justesen SK, Pedersen JN, et al. Once-weekly semaglutide versus placebo in patients with alcohol use disorder and comorbid obesity: a randomised, double-blind, placebo-controlled trial. *Lancet*. 2026;407(10540):1687-1698. doi:10.1016/S0140-6736(26)00305-3 7. Haghighat N, Ashtary-Larky D, Bagheri R, et al. The effect of 12 weeks of euenergetic high-protein diet in regulating appetite and body composition of women with normal-weight obesity: a randomised controlled trial. *Br J Nutr*. 2020;124(10):1044-1051. doi:10.1017/S0007114520002019 8. Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, Board on the Health of Select Populations, Institute of Medicine. *Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness*. National Academies Press; 2015. Accessed August 12, 2026. https://www.ncbi.nlm.nih.gov/books/NBK274235/ 9. Giloteaux L, Hanson MR, Keller BA. A pair of identical twins discordant for myalgic encephalomyelitis/chronic fatigue syndrome differ in physiological parameters and gut microbiome composition. *Am J Case Rep*. 2016;17:720-729. doi:10.12659/AJCR.900314 10. Rangan A, Brealey SD, Keding A, et al. Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial. *Lancet*. 2020;396(10256):977-989. doi:10.1016/S0140-6736(20)31965-6 11. Millar NL, Meakins A, Struyf F, et al. Frozen shoulder. *Nat Rev Dis Primers*. 2022;8(1):59. doi:10.1038/s41572-022-00386-2 12. US Department of Agriculture, US Department of Health and Human Services. *Dietary Guidelines for Americans, 2025-2030*. January 2026. Accessed August 12, 2026. https://www.dietaryguidelines.gov/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

An FDA advisory committee just voted to open a legal compounding supply line for six of seven peptides, including BPC-157 and TB-500, over the objection of the FDA's own scientists, who recommended against all seven. Dr. Jordan Feigenbaum walks through what the Pharmacy Compounding Advisory Committee actually voted on, why a vote about ulcerative colitis ends up governing tendon and joint use, what the single human BPC-157 trial does and doesn't show, and why "a pharmacy makes it safe" and "there's no money to study it" don't hold up. Evidence-based, no hype, no nocebo. Timestamps: | 00:00:00 | The FDA voted 8-6. What it actually means | 00:01:25 | What I am, and am not, claiming | 00:03:21 | How they got here: Category 2 and the paperwork | 00:07:17 | Who was in the room: the panel that flipped | 00:10:57 | What they voted on: compounding and the bulks list | 00:15:37 | "No money in it, you can't patent it" | 00:18:24 | The trials already run: Plevna and MK-677 | 00:22:55 | "I took it and it worked": placebo and fake surgery | 00:27:02 | The one human trial: Ruenzi 2005 | 00:32:28 | Is it natural? Is it even a drug? | 00:36:58 | Harm reduction, or follow the money? | 00:42:45 | Three times a missing trial went wrong | 00:50:58 | Safety: known, unknown, and unknowable | 00:55:22 | The other six peptides | 00:58:22 | What I'd actually tell you | 01:02:08 | What actually works, and what would change my mind Resources: Barbell Medicine coaching and templates: https://www.barbellmedicine.com Plus podcast subscription: https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/ Barbell Medicine Premium: https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/ Signal (book pre-order): https://www.barbellmedicine.com/shop/learning/signal/ 1. US Food and Drug Administration. FDA Briefing Document: Pharmacy Compounding Advisory Committee Meeting. July 23-24, 2026. Silver Spring, MD: FDA; 2026. 2. US Food and Drug Administration. FDA review of BPC-157-related bulk drug substances. PCAC Briefing Document. July 23-24, 2026. Media 193343. Accessed July 24, 2026. https://www.fda.gov/media/193343/download 3. US Food and Drug Administration. FDA review of TB-500-related bulk drug substances. PCAC Briefing Document. July 23-24, 2026. Media 193349. 4. US Food and Drug Administration. FDA review of KPV-, MOTS-c-, Semax-, Epitalon-, and Emideltide-related bulk drug substances. PCAC Briefing Documents. July 23-24, 2026. 5. US Food and Drug Administration. Questions for the Pharmacy Compounding Advisory Committee. July 23-24, 2026. 6. US Food and Drug Administration. Pharmacy Compounding Advisory Committee meeting roster. July 23-24, 2026. Media 193772. 7. US Food and Drug Administration. Pharmacy Compounding Advisory Committee meeting roster. 2022. Media 159040. 8. openFDA. FAERS adverse event reports for BPC-157. Accessed July 24, 2026. https://open.fda.gov 9. Pharmacy compounding; 503A bulk drug substances. 21 CFR §216.23 (2026). 10. Federal Food, Drug, and Cosmetic Act §503A, 21 USC §353a (pharmacy compounding). 11. Abigail Alliance for Better Access to Developmental Drugs v von Eschenbach, 495 F3d 695 (DC Cir 2007). 12. United States v Rutherford, 442 US 544 (1979). 13. Trickett Wendler, Frank Mongiello, Jordan McLinn, and Matthew Bellina Right to Try Act of 2017, Pub L No. 115-176, 132 Stat 1372 (2018). 14. US Food and Drug Administration. Regulatory considerations for human drug products containing peptides. Guidance for Industry (draft). 2020. 15. Ruenzi M, Stolte M, Veljaca M, et al. Efficacy and safety of PL 14736 (BPC 157) in patients with active ulcerative colitis [abstract]. Gastroenterology. 2005. Meeting abstract; full study not published. 16. Staresinic M, Petrovic I, Novinscak T, et al. Effective therapy of transected quadriceps muscle in rat: gastric pentadecapeptide BPC 157. J Orthop Res. 2006;24(5):1109-1117. doi:10.1002/jor.20089 17. Gwyer D, Wragg NM, Wilson SL. Gastric pentadecapeptide body protection compound BPC 157 and its role in accelerating musculoskeletal soft tissue healing. Cell Tissue Res. 2019;377(2):153-159. doi:10.1007/s00441-019-03016-8 18. Sikiric P, Skrtic A, Gojkovic S, et al. Stable gastric pentadecapeptide BPC 157 and hemorrhage/thrombosis. Pharmaceuticals (Basel). 2026;19(3):463. doi:10.3390/ph19030463 19. Stavchansky VV, Filippenkov IB, Dergunova LV, Limborska SA. The role of glyprolines in the regulation of gene expression: focus on Semax. Genes (Basel). 2022;13(12):2380. doi:10.3390/genes13122380 20. Mendias CL, Awan TM. The safety and efficacy of approved and unapproved peptides. Sports Med. 2026. doi:10.1007/s40279-026-02437-0 21. Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347(2):81-88. doi:10.1056/NEJMoa013259 22. Cobb LA, Thomas GI, Dillard DH, Merendino KA, Bruce RA. An evaluation of internal-mammary-artery ligation by a double-blind technic. N Engl J Med. 1959;260(22):1115-1118. 23. Dimond EG, Kittle CF, Crockett JE. Comparison of internal mammary artery ligation and sham operation for angina pectoris. Am J Cardiol. 1960;5:483-486. 24. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360-366. doi:10.1177/03635465980260030301 25. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790-802. doi:10.1111/j.1600-0838.2009.00949.x 26. Langberg H, Skovgaard D, Karamouzis M, Bulow J, Kjaer M. Metabolism and inflammatory mediators in the peritendinous space measured by microdialysis during intermittent isometric exercise in humans. J Physiol. 1999;515(Pt 3):919-927. doi:10.1111/j.1469-7793.1999.919ab.x 27. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-469. doi:10.1001/jama.2013.129 28. Kearney RS, Ji C, Warwick J, et al. Effect of platelet-rich plasma injection vs sham injection on tendon dysfunction in chronic midportion Achilles tendinopathy: a randomized clinical trial. JAMA. 2021;326(2):137-144. doi:10.1001/jama.2021.6986 29. Pavlova AV, Shim JSC, Moss R, et al. Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis. Br J Sports Med. 2023;57(20):1327-1334. doi:10.1136/bjsports-2022-105754 30. Weintraub M, Sundaresan PR, Madan M, et al. Long-term weight control study I (weeks 0 to 34): fenfluramine plus phentermine versus placebo. Clin Pharmacol Ther. 1992;51(5):586-594. doi:10.1038/clpt.1992.69 31. Connolly HM, Crary JL, McGoon MD, et al. Valvular heart disease associated with fenfluramine-phentermine. N Engl J Med. 1997;337(9):581-588. doi:10.1056/NEJM199708283370901 32. Centers for Disease Control and Prevention. Cardiac valvulopathy associated with exposure to fenfluramine or dexfenfluramine: interim public health recommendations, 1997. MMWR Morb Mortal Wkly Rep. 1997;46(45):1061-1066. 33. Bombardier C, Laine L, Reicin A, et al; VIGOR Study Group. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med. 2000;343(21):1520-1528. doi:10.1056/NEJM200011233432103 34. Graham DJ, Campen D, Hui R, et al. Risk of acute myocardial infarction and sudden cardiac death in patients treated with cyclo-oxygenase 2 selective and non-selective non-steroidal anti-inflammatory drugs: nested case-control study. Lancet. 2005;365(9458):475-481. doi:10.1016/S0140-6736(05)17864-7 35. Smith RM, Schaefer MK, Kainer MA, et al; Multistate Fungal Infection Outbreak Response Team. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med. 2013;369(17):1598-1609. doi:10.1056/NEJMoa1213978 36. Adunsky A, Chandler J, Heyden N, et al. MK-0677 (ibutamoren mesylate) for the treatment of patients recovering from hip fracture: a multicenter, randomized, placebo-controlled phase IIb study. Arch Gerontol Geriatr. 2011;53(2):183-189. doi:10.1016/j.archger.2010.10.004 [Trial terminated early for a congestive-heart-failure safety signal.] 37. Nass R, Pezzoli SS, Oliveri MC, et al. Effects of an oral ghrelin mimetic on body composition and clinical outcomes in healthy older adults: a randomized trial. Ann Intern Med. 2008;149(9):601-611. doi:10.7326/0003-4819-149-9-200811040-00003 38. Van Wagoner RM, Eichner A, Bhasin S, Deuster PA, Eichner D. Chemical composition and labeling of substances marketed as selective androgen receptor modulators and sold via the internet. JAMA. 2017;318(20):2004-2010. doi:10.1001/jama.2017.17069 39. ECRI and Institute for Safe Medication Practices. Unapproved peptide products: safety and quality concerns [white paper]. Plymouth Meeting, PA: ECRI; April 2026. 40. Center for Science in the Public Interest. What are injectable peptides, and are they safe? Accessed July 24, 2026. https://www.cspinet.org 41. World Anti-Doping Agency. The 2026 Prohibited List. Montreal, QC: WADA; 2026. Accessed July 24, 2026. https://www.wada-ama.org 42. US Anti-Doping Agency. BPC-157: a prohibited peptide. Accessed July 24, 2026. https://www.usada.org 43. FDA committee votes in favor of compounding several peptides. Time. July 23, 2026. Accessed July 24, 2026. https://time.com 44. FDA advisory committee backs controversial peptides. Regulatory Affairs Professionals Society (RAPS). 2026. Accessed July 24, 2026. https://www.raps.org 45. FDA panel okays peptides for compounding, including BPC-157 and KPV. STAT News. July 23, 2026. Accessed July 24, 2026. https://www.statnews.com 46. FDA panel recommends easing peptide restrictions over agency scientists' objections. NBC News. 2026. Accessed July 24, 2026. https://www.nbcnews.com 47. Associated Press. Financial ties reported among FDA peptide advisory panel members. 2026. Accessed July 24, 2026. 48. Leerink Partners. Equity research note: PCAC peptide vote and the telehealth compounding market. 2026. 49. Examine.com. BPC-157 research breakdown. Accessed July 24, 2026. https://examine.com/supplements/bpc-157/ 50. Jarry J. Body protection compound: no proof required. McGill Office for Science and Society. Accessed July 24, 2026. https://www.mcgill.ca/oss Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

A previously healthy 21-year-old shows up with seven months of headaches and 30-plus pounds of weight gain he can’t explain. He’s eating the same and training more, and the scale climbs anyway. We hand the case to Dr. Austin Baraki cold and work it in real time: the exam, the labs, the MRI, and two diagnoses that turn a headache workup into the clearest proof we’ve got that body weight is set by the brain, not by character. This is the capstone of our weight series (willpower, calories, protein), and it ends on the drug that, this year, did something for these patients that nothing had done before. Timestamps 00:00:00 Cold open: the man who couldn’t stop gaining weight 00:01:49 Meet the case (and the rules of the game) 00:02:36 The presentation: 21, headaches, unexplained weight gain 00:03:57 Austin’s one-liner and how a clinician builds a differential 00:05:10 Secondary headaches: what raises the red flag 00:13:12 The exam: vitals, and the eye findings that matter 00:14:37 The labs, one number at a time 00:16:08 Raised pressure and a visual-field clue (bitemporal hemianopia) 00:20:45 The MRI 00:21:54 First diagnosis: craniopharyngioma 00:25:32 The name: a tumor built from tooth tissue 00:25:50 Surgery, and what it costs 00:27:43 The new mystery: gaining weight faster than ever 00:33:41 Second diagnosis: acquired hypothalamic obesity 00:39:17 How your brain sets your weight: the POMC brake and the AgRP accelerator 00:42:07 What about leptin? 00:45:46 Monogenic vs common obesity 00:50:30 Why GLP-1 drugs still worked: the brainstem backdoor 00:52:11 Responders and non-responders 00:55:40 Setmelanotide: a drug for the broken circuit 00:56:53 TRANSCEND, and the new FDA approval 00:58:55 What it costs 01:01:32 Why we care about body fat at all: the garage 01:04:36 Flux: which fat is actually dangerous 01:09:15 Close Resources Barbell Medicine coaching and templates: https://www.barbellmedicine.com Plus podcast subscription: https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/ Barbell Medicine Premium: https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/ Signal (book pre-order): https://www.barbellmedicine.com/shop/learning/signal/ 1. Brijmohan A, et al. Acquired hypothalamic obesity following craniopharyngioma resection in a young adult [case report]. 2025. PMCID: PMC12268545; PMID: 40677794. 2. Miller JL, et al; TRANSCEND investigators. Setmelanotide in acquired hypothalamic obesity: a phase 3 randomized trial. N Engl J Med. 2026. 3. Rhythm Pharmaceuticals. FDA approves IMCIVREE (setmelanotide) for acquired hypothalamic obesity. News release. March 19, 2026. 4. US Food and Drug Administration. FDA approves first treatment for weight management for people with certain rare genetic conditions (setmelanotide). 2020. 5. Montague CT, Farooqi IS, Whitehead JP, et al. Congenital leptin deficiency is associated with severe early-onset obesity in humans. Nature. 1997;387(6636):903-908. 6. Farooqi IS, Jebb SA, Langmack G, et al. Effects of recombinant leptin therapy in a child with congenital leptin deficiency. N Engl J Med. 1999;341(12):879-884. 7. Krude H, Biebermann H, Luck W, et al. Severe early-onset obesity, adrenal insufficiency and red hair pigmentation caused by POMC mutations in humans. Nat Genet. 1998;19(2):155-157. 8. Farooqi IS, Keogh JM, Yeo GS, et al. Clinical spectrum of obesity and mutations in the melanocortin 4 receptor gene. N Engl J Med. 2003;348(12):1085-1095. 9. Clément K, Vaisse C, Lahlou N, et al. A mutation in the human leptin receptor gene causes obesity and pituitary dysfunction. Nature. 1998;392(6674):398-401. 10. Fabbrini E, Tamboli RA, Magkos F, et al. Surgical removal of omental fat does not improve insulin sensitivity and cardiovascular risk factors in obese adults. Gastroenterology. 2010;139(2):448-455. 11. Klein S, Fontana L, Young VL, et al. Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med. 2004;350(25):2549-2557. 12. Guyenet SJ. The Hungry Brain: Outsmarting the Instincts That Make Us Overeat. Flatiron Books; 2017. Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Every couple of years a new headline warns that the protein you eat is quietly hurting you. This year the target is your kidneys. Before that it was cancer, then your bones, then the claim that your body can only use twenty or thirty grams of protein at a meal. In this episode, Dr. Jordan Feigenbaum goes through the actual studies behind each scare: the kidney trials, the 2014 IGF-1 and cancer paper that started the panic, the acid-ash bone hypothesis, and the per-meal "cap." Each fear starts from a real mechanism, and each one was run straight to a frightening conclusion the clinical outcomes never supported. The take home is simple. For a healthy adult, protein is not the lever people think it is, and where a real signal exists (processed and red meat, or a kidney that is already diseased) it tracks the whole dietary pattern more than the protein number. The two things that actually decide your health here are whether you eat mostly real food and whether you train. Timestamps 00:00 The protein scare cycle 01:23 The four fears 01:59 Kidneys: healthy kidneys under higher protein 06:22 Kidney disease: does cutting protein help? 09:38 Red meat and the dietary pattern, not protein 12:00 Muscle, aging, and lifting on a restricted diet 13:54 Cancer: IGF-1 and the 2014 study everyone cites 16:22 The age reversal, and what travels with protein 18:48 Bigger data, processed meat, and the IGF-1 tell 22:15 Bones and the acid-ash myth 25:13 The 30-gram cap 27:17 What protein actually does, and how much you need 32:20 The two questions that matter Resources: Barbell Medicine coaching and templates: https://www.barbellmedicine.com Plus podcast subscription: https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/ Barbell Medicine Premium: https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/ Signal (book pre-order): https://www.barbellmedicine.com/shop/learning/signal/ Our Protein Content: https://www.barbellmedicine.com/blog/protein-and-weight-loss/ https://www.barbellmedicine.com/blog/protein-on-ozempic/ https://www.barbellmedicine.com/blog/barbell-medicine-protein-recommendations/ Studies Levine et al. Cell Metabolism 2014. doi:10.1016/j.cmet.2014.02.006 Naghshi et al. BMJ 2020. doi:10.1136/bmj.m2412 Devries et al. J Nutr 2018. doi:10.1093/jn/nxy197 Antonio et al. J Nutr Metab 2016. doi:10.1155/2016/9104792 Knight et al. Ann Intern Med 2003. doi:10.7326/0003-4819-138-6-200303180-00009 Klahr et al. (MDRD). NEJM 1994. doi:10.1056/NEJM199403313301301 Hahn, Hodson & Fouque. Cochrane 2020. doi:10.1002/14651858.CD001892.pub5 Obeid, Hiremath & Topf. Kidney360 2022. doi:10.34067/KID.0001002022 Lew et al. J Am Soc Nephrol 2017. doi:10.1681/ASN.2016030248 Castaneda et al. Ann Intern Med 2001. doi:10.7326/0003-4819-135-11-200112040-00008 Bauer et al. (PROT-AGE). JAMDA 2013. doi:10.1016/j.jamda.2013.05.021 Fenton et al. Nutrition Journal 2011. doi:10.1186/1475-2891-10-41 Shams-White et al. Am J Clin Nutr 2017. doi:10.3945/ajcn.116.145110 Witard et al. Am J Clin Nutr 2013. doi:10.3945/ajcn.112.055517 Macnaughton et al. Physiol Rep 2016. doi:10.14814/phy2.12893 Trommelen et al. Cell Reports Medicine 2023. doi:10.1016/j.xcrm.2023.101324 Wycherley et al. Am J Clin Nutr 2012. doi:10.3945/ajcn.112.044321 Moore et al. JAMA Intern Med 2016. doi:10.1001/jamainternmed.2016.1548 Larsson et al. Cancer Med 2020. doi:10.1002/cam4.3345 Brenner, Meyer & Hostetter. NEJM 1982. doi:10.1056/NEJM198209093071104 Chan et al. PLoS One 2011. doi:10.1371/journal.pone.0020456 Berryman et al. Am J Clin Nutr 2018. doi:10.1093/ajcn/nqy088 Morton et al. Br J Sports Med 2018. doi:10.1136/bjsports-2017-097608 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Is weight loss really just Calories in, Calories out? The equation is true, but "just count your Calories" is bad advice for most people, and almost every objection to it is pointing at something real. In part two of our energy balance series, Jordan Feigenbaum takes the biggest "it's not Calories, it's ___" claims (metabolism, thyroid, cortisol, PCOS, insulin, the type of food) and tests each against the best evidence. The verdict: none of them breaks the equation. Every one is a hand on a lever that moves Calories in or Calories out, not a hole in the math. In this episode: why your metabolism does not crash at 40, how small real metabolic adaptation actually is after weight loss, why hypothyroid weight is mostly water, what the cortisol and PCOS (now PMOS) data show, how absorption and cooking move Calories only at the edges, why even dietitians miscount their own intake, and why the carbohydrate-insulin model fails three tests, including the GLP-1 drugs that raise insulin and still produce the biggest weight loss we have ever approved. Part two of three: willpower, Calories in Calories out, then GLP-1 drugs. Next week: are GLP-1s cheating? Timestamps 0:00 Is it really just calories in, calories out? 0:18 The willpower episode and the through-line 2:10 Thermodynamics: what sets both sides 2:41 Your metabolism is three things 4:05 Claim 1: my metabolism crashed 4:24 No cliff at 40: the doubly labeled water study 5:33 Real metabolic adaptation after weight loss 6:56 Why your food diary lies 7:49 Claim 2: it's my hormones 8:07 Thyroid: mostly water 9:36 Cortisol: explains about 1 percent 11:12 PCOS is now PMOS 13:06 Menopause 14:18 Claim 3: a calorie isn't a calorie 16:48 Absorption: nuts, cooking, eggs 19:44 Why calorie counting fails 21:12 Claim 4: it's not Calories, it's insulin 22:02 Testing the carbohydrate-insulin model 25:52 The GLP-1 drugs that should end it 28:34 The whole list, claim by claim 29:53 What to actually do 30:42 Next week: are GLP-1s cheating? Resources: Barbell Medicine coaching and templates: https://www.barbellmedicine.com https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/ https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/ Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/ Pontzer et al., Science 2021. https://doi.org/10.1126/science.abe5017 Muller et al., Am J Clin Nutr 2015. https://doi.org/10.3945/ajcn.115.109173 Lichtman et al., N Engl J Med 1992. https://doi.org/10.1056/NEJM199212313272701 Karmisholt et al., J Clin Endocrinol Metab 2011. https://doi.org/10.1210/jc.2010-1521 Lee et al., Endocr Pract 2014. https://doi.org/10.4158/EP14072.OR van der Valk et al., Obes Rev 2022. https://doi.org/10.1111/obr.13376 Nikokavoura et al., Diabetes Metab Syndr Obes 2015. https://doi.org/10.2147/DMSO.S85134 Greendale et al., JCI Insight 2019. https://doi.org/10.1172/jci.insight.124865 Lejeune et al., Am J Clin Nutr 2006. https://doi.org/10.1093/ajcn/83.1.89 Bray et al., JAMA 2012. https://doi.org/10.1001/jama.2011.1918 Novotny et al., Am J Clin Nutr 2012. https://doi.org/10.3945/ajcn.112.035782 Baer et al., J Nutr 2016. https://doi.org/10.3945/jn.115.217372 Baer et al., Br J Nutr 2012. https://doi.org/10.1017/S0007114511002649 Evenepoel et al., J Nutr 1998. https://doi.org/10.1093/jn/128.10.1716 Hall et al., Cell Metabolism 2019. https://doi.org/10.1016/j.cmet.2019.05.008 Champagne et al., J Am Diet Assoc 2002. https://doi.org/10.1016/S0002-8223(02)90316-0 Hall et al., Cell Metabolism 2015. https://doi.org/10.1016/j.cmet.2015.07.021 Wilding et al., N Engl J Med 2021. https://doi.org/10.1056/NEJMoa2032183 Jastreboff et al., N Engl J Med 2022. https://doi.org/10.1056/NEJMoa2206038 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Obesity roughly tripled in about 60 years, and the genes didn't change in that time. So if body weight isn't a willpower problem, what is it? Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through what actually sets your weight: the adoption and twin studies behind the genetics, the "defended range" your biology fights to hold, the food environment that does most of the eating for you, and where GLP-1 medications actually work. Along the way — why diets regain after you white-knuckle them, what The Biggest Loser six-year data show about resting metabolism, and four willpower myths worth retiring. Hosted by Dr. Jordan Feigenbaum and Dr. Austin Baraki, co-founders of Barbell Medicine. Timestamps 00:00 Cold open: Danny Cahill and The Biggest Loser 01:03 What we mean by "willpower" 05:48 Obesity tripled in ~60 years: the one number 06:31 Adoption and twin studies: genes vs. household 09:37 Set point vs. the defended range 10:37 Gene–environment mismatch 14:03 In the clinic: a lifelong weight history 19:18 Losing weight vs. keeping it off 20:26 Appetite doesn't reset (Sumithran) 25:52 Metabolic adaptation and the Biggest Loser data 34:07 Part 2: eating on autopilot 35:10 Portion size runs the meal 39:12 What changed in the food supply 40:42 Same genes, new environment: Pima and immigrants 43:20 Why ultra-processed food is easy to overeat 50:28 Processing vs. calories: the Hall ward study 52:36 When the brain changes eating: gourmand syndrome 1:00:01 Why the willpower story stuck 1:01:08 Taft, Churchill, and the intelligence myth 1:02:43 Does intelligence predict weight? (sibling study) 1:11:16 Are GLP-1s cheating? What they actually do 1:15:10 Beyond the scale: muscle, health, nutrition 1:24:21 Myth-busting: lightning round 1:39:04 Three takeaways: what to actually do 1:41:00 Danny Cahill, revisited Resources Barbell Medicine coaching and templates: https://www.barbellmedicine.com https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/ https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/ Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/ Coaching, programs & templates: https://www.barbellmedicine.com/ Prevalence of Overweight, Obesity, and Severe Obesity Among Adults Age 20 and Older: United States, 1960-1962 Through August 2021-August 2023. NCHS Health E-Stats. 2024. https://www.cdc.gov/nchs/data/hestat/hestat111.htm Obesity and Severe Obesity Prevalence in Adults: United States, August 2021-August 2023. NCHS Data Brief No. 508. Hyattsville, MD: National Center for Health Statistics; 2024. https://www.cdc.gov/nchs/products/databriefs/db508.htm Hill JO, Peters JC. Environmental contributions to the obesity epidemic. Science. 1998;280(5368):1371-1374. https://doi.org/10.1126/science.280.5368.1371 Morton RW, Murphy KT, McKellar SR, et al. A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults. Br J Sports Med. 2018;52(6):376-384. https://doi.org/10.1136/bjsports-2017-097608 Stunkard AJ, Sorensen TIA, Hanis C, et al. An adoption study of human obesity. N Engl J Med. 1986;314(4):193-198. https://doi.org/10.1056/NEJM198601233140401 Stunkard AJ, Harris JR, Pedersen NL, McClearn GE. The body-mass index of twins who have been reared apart. N Engl J Med. 1990;322(21):1483-1487. https://doi.org/10.1056/NEJM199005243222102 Speakman JR, Levitsky DA, Allison DB, et al. Set points, settling points and some alternative models: theoretical options to understand how genes and environments combine to regulate body adiposity. Dis Model Mech. 2011;4(6):733-745. https://doi.org/10.1242/dmm.008698 Kalm LM, Semba RD. They starved so that others be better fed: remembering Ancel Keys and the Minnesota Experiment. J Nutr. 2005;135(6):1347-1352. https://doi.org/10.1093/jn/135.6.1347 Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. 2011;365(17):1597-1604. https://doi.org/10.1056/NEJMoa1105816 Fothergill E, Guo J, Howard L, et al. Persistent metabolic adaptation 6 years after 'The Biggest Loser' competition. Obesity (Silver Spring). 2016;24(8):1612-1619. https://doi.org/10.1002/oby.21538 Hall KD. Energy compensation and metabolic adaptation: 'The Biggest Loser' study reinterpreted. Obesity (Silver Spring). 2022;30(1):11-13. https://doi.org/10.1002/oby.23308 Cohen DA, Farley TA. Eating as an automatic behavior. Prev Chronic Dis. 2008;5(1):A23. https://www.cdc.gov/pcd/issues/2008/jan/07_0046.htm Rolls BJ, Morris EL, Roe LS. Portion size of food affects energy intake in normal-weight and overweight men and women. Am J Clin Nutr. 2002;76(6):1207-1213. https://doi.org/10.1093/ajcn/76.6.1207 Diliberti N, Bordi PL, Conklin MT, Roe LS, Rolls BJ. Increased portion size leads to increased energy intake in a restaurant meal. Obes Res. 2004;12(3):562-568. https://doi.org/10.1038/oby.2004.64 Hollands GJ, Shemilt I, Marteau TM, et al. Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco. Cochrane Database Syst Rev. 2015;(9):CD011045. https://doi.org/10.1002/14651858.CD011045.pub2 Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause excess calorie intake and weight gain: an inpatient randomized controlled trial of ad libitum food intake. Cell Metab. 2019;30(1):67-77.e3. https://doi.org/10.1016/j.cmet.2019.05.008 Pontzer H, Raichlen DA, Wood BM, et al. Hunter-gatherer energetics and human obesity. PLoS One. 2012;7(7):e40503. https://doi.org/10.1371/journal.pone.0040503 Careau V, Halsey LG, Pontzer H, et al. Energy compensation and adiposity in humans. Curr Biol. 2021;31(20):4659-4666.e2. https://doi.org/10.1016/j.cub.2021.08.016 Miller WC, Koceja DM, Hamilton EJ. A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention. Int J Obes Relat Metab Disord. 1997;21(10):941-947. https://doi.org/10.1038/sj.ijo.0800499 Gaesser GA, Angadi SS. Obesity treatment: weight loss versus increasing fitness and physical activity for reducing health risks. iScience. 2021;24(10):102995. https://doi.org/10.1016/j.isci.2021.102995 US Department of Agriculture, Economic Research Service. Food Availability (Per Capita) Data System, Loss-Adjusted Food Availability. https://www.ers.usda.gov/data-products/food-availability-per-capita-data-system/ Steele EM, Baraldi LG, Louzada ML, Moubarac JC, Mozaffarian D, Monteiro CA. Ultra-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study. BMJ Open. 2016;6(3):e009892. https://doi.org/10.1136/bmjopen-2015-009892 Wang L, Martinez Steele E, Du M, et al. Trends in consumption of ultraprocessed foods among US youths aged 2-19 years, 1999-2018. JAMA. 2021;326(6):519-530. https://doi.org/10.1001/jama.2021.10238 Schulz LO, Bennett PH, Ravussin E, et al. Effects of traditional and western environments on prevalence of type 2 diabetes in Pima Indians in Mexico and the US. Diabetes Care. 2006;29(8):1866-1871. https://doi.org/10.2337/dc06-0138 Goel MS, McCarthy EP, Phillips RS, Wee CC. Obesity among US immigrant subgroups by duration of residence. JAMA. 2004;292(23):2860-2867. https://doi.org/10.1001/jama.292.23.2860 Papavramidou NS, Papavramidis ST, Christopoulou-Aletra H. Galen on obesity: etiology, effects, and treatment. World J Surg. 2004;28(6):631-635. https://doi.org/10.1007/s00268-004-7458-5 Haslam DW, Haslam F. Fat, Gluttony and Sloth: Obesity in Literature, Art and Medicine. Liverpool: Liverpool University Press; 2009. https://www.liverpooluniversitypress.co.uk/9781846311734/fat-gluttony-and-sloth/ Townend L. The moralizing of obesity: a new name for an old sin? Crit Soc Policy. 2009;29(2):171-190. https://doi.org/10.1177/0261018308101625 Levine DI. Corpulence and correspondence: President William H. Taft and the medical management of obesity. Ann Intern Med. 2013;159(8):565-570. https://doi.org/10.7326/0003-4819-159-8-201310150-00012 Wright L, Davies NM, Bann D. The association between cognitive ability and body mass index: a sibling-comparison analysis in four longitudinal studies. PLoS Med. 2023;20(4):e1004207. https://doi.org/10.1371/journal.pmed.1004207 Mechanisms of GLP-1 receptor agonist-induced weight loss: a review of central and peripheral pathways. Am J Med. 2025 (review of hypothalamic arcuate nucleus and brainstem area postrema action). https://www.sciencedirect.com/science/article/pii/S0002934325000592 Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity (STEP 1). N Engl J Med. 2021;384(11):989-1002. https://doi.org/10.1056/NEJMoa2032183 Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide once weekly for the treatment of obesity (SURMOUNT-1). N Engl J Med. 2022;387(3):205-216. https://doi.org/10.1056/NEJMoa2206038 Grannell A, Fallon F, Al-Najim W, le Roux C. Obesity and responsibility: is it time to rethink agency? Obes Rev. 2021;22(8):e13270. https://doi.org/10.1111/obr.13270 Al Khatib HK, Harding SV, Darzi J, Pot GK. The effects of partial sleep deprivation on energy balance: a systematic review and meta-analysis. Eur J Clin Nutr. 2017;71(5):614-624. https://doi.org/10.1038/ejcn.2016.201 Helms ER, Aragon AA, Fitschen PJ. Evidence-based recommendations for natural bodybuilding contest preparation: nutrition and supplementation. J Int Soc Sports Nutr. 2014;11:20. https://doi.org/10.1186/1550-2783-11-20 Garthe I, Raastad T, Refsnes PE, Koivisto A, Sundgot-Borgen J. Effect of two different weight-loss rates on body composition and strength and power-related performance in elite athletes. Int J Sport Nutr Exerc Metab. 2011;21(2):97-104. https://doi.org/10.1123/ijsnem.21.2.97 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Once a month we answer Barbell Medicine Plus subscribers’ questions on the Direct Line. This is a free look at June’s episode. We start with GLP-1 drugs and muscle: why DEXA overstates the loss, what resistance training actually does, and whether creatine is worth taking. Then whether bulking and cutting does anything the scale can’t already tell you, how to get real benefit from one training hour a week, and what happens to your muscle, strength, tendons, and bone when you take time off, including why muscle memory brings it back faster than you built it. What we cover: • GLP-1s and muscle: the DEXA problem, resistance training, and creatine • Bulking vs cutting vs just maintaining, and a health-first way to choose • Training on one hour a week: the least that still moves the needle • How fast you lose muscle when you stop, and why it comes back fast The full two-hour episode and every back episode are on Barbell Medicine Plus, which can bundled with Premium. Resources and full references below. Timestamps 0:00 Intro + GLP-1 and the DEXA muscle-loss myth 3:00 Do GLP-1s spare or waste muscle? 8:03 Does creatine help on a GLP-1? 10:45 Does bulking and cutting do anything? 13:18 Health first: when to lose fat before gaining 22:30 Training on one hour a week 36:22 How fast you lose muscle when you stop 43:19 Muscle memory: why it comes back 48:25 The full episode on Plus Resources Barbell Medicine coaching and templates: https://www.barbellmedicine.com https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/ https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/ Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/ https://www.barbellmedicine.com/blog/glp-1-muscle-loss/ https://www.barbellmedicine.com/blog/creatine-on-ozempic-does-it-prevent-muscle-loss/ https://www.barbellmedicine.com/blog/novice-intermediate-advanced-strength-training/ Lundgren JR, et al. Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined (S-LITE). N Engl J Med 2021;384:1719-1730. nejm.org · NEJMoa2028198 T-REX trial: tirzepatide with or without resistance training (Univ. of Western Australia). Preliminary. ANZCTR ACTRN12623001236684 Creatine + GLP-1 pilot (Univ. of Saskatchewan). Ongoing, results expected 2027. ClinicalTrials.gov NCT07625202 Momma H, et al. Muscle-strengthening activities and lower risk/mortality in major non-communicable diseases. Br J Sports Med 2022. PubMed 35228201 Wall BT, et al. 2014. Immobilization and disuse muscle atrophy (quadriceps −3.5% at 5 days, −8% at 14 days). PubMed 24168489 Gaffney CJ, et al. 2021. Grip strength loss with short-term arm immobilization. PMC8107283 Farthing JP, et al. 2009. Cross-education and preservation of the immobilized limb. PubMed 19150859 Marusic U, et al. 2021. Bed rest: strength loss outpaces size loss. PMC8325614 Yoshihara, et al. 2023. Sepsis-associated muscle wasting (−26% in a week). PMC10003568 Warren GL, et al. 2017. Strength loss and recovery after muscle injury (meta-analysis). PMC5214801 Hortobágyi T, et al. 1993. Short-term detraining in strength athletes. PubMed 8371654 Gavanda S, et al. 2020. Training cessation in previously untrained adolescents. PMC7241623 Lovell DI, et al. 2010. Detraining strength loss in older adults. PubMed 20140683 Mujika I, Padilla S. 2001. Physiology of detraining (review). PubMed 11474330 Smith K, et al. 2003. Two years of training, then detraining, in older adults. PubMed 12955872 Staron RS, et al. 1991. Detraining and muscle cross-sectional area in women. PubMed 1827108 Ivey FM, et al. 2000. Detraining across age and sex. PubMed 10795719 Taaffe DR, et al. 2009. Training and detraining in older adults. PMC2756799 Grgic J, et al. 2022. Muscle size loss with detraining (meta-analysis). PubMed 36360927 Bosquet L, et al. 2013. Detraining effects on strength and power. PubMed 23347054 Bruusgaard JC, et al. 2010. Myonuclei acquired by overload persist after detraining (muscle memory). PMC2930527 Weakley J, et al. 2017. Day-to-day variation in strength performance. PubMed 28277425 McGuigan MR, et al. 2004. Strength performance variability. PubMed 15320651 Andreoli A, et al. 2009. DEXA precision and assumptions. PMC9263164 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Is there really a “menopause-specific” way to train, eat, and supplement — or is most of it marketing? In the finale of our 4-part menopause series, Drs. Jordan Feigenbaum and Austin Baraki go straight to the evidence on building muscle and bone before, during, and after the transition. We cover whether menopause blunts your response to lifting (the Isenmann 2023 head-to-head trial and the 2026 meta-analysis of ~4,000 women say it doesn’t), the one-index-card prescription that actually works. Then we work through the loudest claims in the space — cortisol “wrecking” your fat loss, anabolic resistance, the protein and creatine hype, hormone therapy as a cure-all, and “you need a different paradigm” — steelmanning each before we push back. We close with the strongest case in the whole space: heavy lifting for bone density (the LIFTMOR trial), the pelvic-floor evidence, your three biggest fears answered, and how to tell a good coach or clinician from a bad one. Claims discussed are associated with Stacey Sims, Mary Claire Haver, Mindy Pelz, and the broader functional-medicine space. We push back on the claims, not the people. Timestamps: 0:00 The 90-year-olds who tripled their strength 1:10 Why this matters: heart disease and falls, not vanity 2:28 Can women still build muscle after menopause? (Isenmann 2023) 7:31 Does menopause blunt your gains? The 2026 meta-analysis 8:49 Is it menopause, or just individual variation? 14:42 The estrogen "shield" and the mechanical override 18:31 Does hormone therapy replace training? (the 2021 estradiol trial) 22:44 What actually works: the whole prescription 24:18 Program details: frequency, volume & insulin sensitivity 30:22 Nutrition: protein and the 2026 review 35:06 Creatine, vitamin D & calcium 43:29 Anabolic resistance: mostly overstated 47:22 Clinical case: the supplement-stack patient 52:23 A short history of wrong advice for women 53:38 Claim 1: "Lift heavy or lose your bones" (Stacey Sims) 1:01:09 Claim 2: the cortisol myth 1:15:18 Clinical case: the cortisol-anxious patient 1:18:20 Claim 3: "It's all hormonal, HRT fixes it" (Mary Claire Haver) 1:20:45 Testosterone in women: what it does and doesn't do 1:21:51 Claim 4: "Menopause needs its own paradigm" & the SWAN data 1:24:48 Bone density done right: the LIFTMORE trial 1:33:07 Does heavy lifting wreck your pelvic floor? 1:38:59 Your three biggest fears, answered 1:40:44 Green flags & red flags Resources: Menopause Series Part 1 : https://www.youtube.com/watch?v=yzk0IkTy0WM Menopause Series Part 2 — https://www.youtube.com/watch?v=YKAlamIOiwU Menopause Series Part 3 — https://www.youtube.com/watch?v=jzoNMQaBAcI Hypercortisolism episode - https://open.spotify.com/episode/7tDdUi8dDFWjMYx0fRJdOz Barbell Medicine coaching and templates: https://www.barbellmedicine.com Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/ Isenmann (2023) https://doi.org/10.1186/s12905-023-02671-y Isenmann (2026) https://doi.org/10.1016/j.jsams.2026.01.004 Fiatarone (1990) https://doi.org/10.1001/jama.1990.03440220053029 Fiatarone (1994) https://doi.org/10.1056/NEJM199406233302501 Dam (2021) https://doi.org/10.3389/fphys.2020.596130 Markofski (2015) https://doi.org/10.1016/j.exger.2015.02.015 Orsatti (2022) https://doi.org/10.1016/j.exger.2022.111904 Walter (2026) https://doi.org/10.1186/s40798-025-00954-2 dos Santos (2021) https://doi.org/10.3390/nu13113757 Myung (2021) https://doi.org/10.3390/nu13020368 Dote-Montero (2021) https://doi.org/10.1111/sms.13999 Ravussin (2015) https://doi.org/10.1093/gerona/glv057 Cadegiani (2016) https://doi.org/10.1186/s12902-016-0128-4 Greising (2009) https://doi.org/10.1093/gerona/glp082 Islam (2019) https://doi.org/10.1016/S2213-8587(19)30189-5 Testosterone in women review (2026) https://doi.org/10.1080/09513590.2025.2592402 NAMS nonhormone position statement (2023) https://doi.org/10.1097/GME.0000000000002200 Vasomotor exercise meta-analysis (2022) https://doi.org/10.1080/13697137.2022.2097865 Greendale (2019) https://doi.org/10.1172/jci.insight.124865 Watson, LIFTMOR (2018) https://doi.org/10.1002/jbmr.3284 Skaug (2024) https://doi.org/10.1249/MSS.0000000000003278 Skaug (2021) https://doi.org/10.1007/s00192-021-04739-5 Dumoulin (2018) https://doi.org/10.1002/14651858.CD005654.pub4 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Most women in 2026 are told menopause affects everything, the weight, the belly fat, the bones, the heart, the brain, and that the fix is hormones, supplements, and a proprietary protocol. The data tell a different story. Menopause does some of it, but not all of it. In this episode, Dr. Jordan Feigenbaum and Dr. Austin Baraki, with OB-GYN Dr. Loraine Baraki at the clinical handoffs, put real numbers on what menopause actually changes, e.g. body composition, the cardiometabolic shift around the final menstrual period, bone, cognition and sleep — and on the single biggest modifiable lever against what actually kills postmenopausal women. This is Episode 3 of Barbell Medicine's four-part menopause series. Timestamps: 01:23 Intro 02:45 Body composition & the SWAN study 04:16 How much weight gain is really menopause? 06:55 The answer: about 1.5 kg 08:14 Subcutaneous vs visceral fat 11:08 Why waist beats weight (and body-fat %) 17:21 Does menopause crash your metabolism? 19:02 Clinic: MHT for body composition 23:51 Dr. Loraine Baraki — MHT, weight & testosterone 27:29 The cardiometabolic shift: cholesterol at the FMP 30:18 Insulin resistance & metabolic syndrome 33:12 Blood pressure & 10-year heart risk 34:54 Clinic: the "estrogen crisis" lipid panic 39:13 Bone: the advice vs the data 40:34 Why DXA misses most fractures 41:24 LIFTMOR: lifting heavy with low bone density 44:47 The LIFTMOR results 46:53 Lifting vs Pilates, and falls 52:17 Clinic: "Should I be deadlifting?" 56:14 Cognition & brain fog 57:50 Why brain fog is mostly a sleep problem 59:17 Clinic: brain fog, night sweats, broken sleep 1:03:06 Depression & dementia in midlife 1:05:43 Does hormone therapy protect the brain? 1:08:53 Clinic: "Am I getting early dementia?" 1:13:19 Dr. Loraine Baraki — the timing hypothesis & the brain 1:16:15 What actually kills postmenopausal women 1:17:31 Fitness: the biggest mortality lever 1:20:21 Strength, power & grip 1:25:15 Clinic: where to start when you're overwhelmed 1:30:41 The detraining problem 1:32:38 Trained vs untrained: what's recoverable 1:34:53 The actual plan 1:39:48 Takeaways Resources: Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/ Barbell Medicine coaching and templates: https://www.barbellmedicine.com/ Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/ Body composition & metabolism Greendale et al., SWAN body composition, JCI Insight 2019: https://doi.org/10.1172/jci.insight.124865 Lovejoy et al., visceral fat across the transition, Int J Obes 2008: https://doi.org/10.1038/ijo.2008.25 Pontzer et al., daily energy expenditure across life, Science 2021: https://doi.org/10.1126/science.abe5017 Karppinen et al., metabolism in midlife women, Eur J Prev Cardiol 2023: https://doi.org/10.1093/eurjpc/zwad177 Cardiometabolic Matthews et al., lipid changes & the menopause transition, JACC 2009: https://doi.org/10.1016/j.jacc.2009.10.009 Janssen et al., menopause & metabolic syndrome (SWAN), Arch Intern Med 2008: https://doi.org/10.1001/archinte.168.14.1568 El Khoudary et al., AHA Scientific Statement on midlife women, Circulation 2020: https://doi.org/10.1161/CIR.0000000000000912 Bone Greendale et al., SWAN bone loss across the FMP, JBMR 2012: https://doi.org/10.1002/jbmr.534 Siris et al., undiagnosed low BMD & fractures (NORA), JAMA 2001: https://doi.org/10.1001/jama.286.22.2815 Watson et al., LIFTMOR, JBMR 2018: https://doi.org/10.1002/jbmr.3284 Kemmler et al., EFOPS 16-year, Menopause 2017: https://doi.org/10.1097/GME.0000000000000720 Kistler-Fischbacher et al., MEDEX-OP, JBMR 2021: https://doi.org/10.1002/jbmr.4334 Sherrington et al., exercise for preventing falls, Cochrane 2019: https://doi.org/10.1002/14651858.CD012424.pub2 ACSM Position Stand: Osteoporosis and Exercise, Med Sci Sports Exerc 1995;27(4):i–vii (no DOI) Cognition & mood Greendale et al., SWAN cognition, Neurology 2009: https://doi.org/10.1212/WNL.0b013e3181a71193 Kravitz et al., sleep in midlife women, Obstet Gynecol Clin North Am 2018: https://doi.org/10.1016/j.ogc.2018.07.008 Cohen et al., Harvard Study of Moods and Cycles, Arch Gen Psychiatry 2006: https://doi.org/10.1001/archpsyc.63.4.385 Bromberger & Kravitz, mood and menopause (SWAN), Obstet Gynecol Clin North Am 2011: https://doi.org/10.1016/j.ogc.2011.05.011 Livingston et al., Lancet Commission on dementia 2024: https://doi.org/10.1016/S0140-6736(24)01296-0 Shumaker et al., WHIMS (estrogen+progestin & dementia), JAMA 2003: https://doi.org/10.1001/jama.289.20.2651 Espeland et al., WHIMS (estrogen-alone & cognition), JAMA 2004: https://doi.org/10.1001/jama.291.24.2959 Gleason et al., KEEPS-Cog, PLoS Med 2015: https://doi.org/10.1371/journal.pmed.1001833 Henderson et al., ELITE (timing hypothesis & cognition), Neurology 2016: https://doi.org/10.1212/WNL.0000000000002980 USPSTF, hormone therapy for primary prevention, JAMA 2022: https://doi.org/10.1001/jama.2022.18625 Fitness & mortality Mandsager et al., cardiorespiratory fitness & mortality, JAMA Netw Open 2018: https://doi.org/10.1001/jamanetworkopen.2018.3605 Kodama et al., fitness & mortality meta-analysis, JAMA 2009: https://doi.org/10.1001/jama.2009.681 Sui et al., fitness & adiposity in older adults, JAMA 2007: https://doi.org/10.1001/jama.298.21.2507 Momma et al., muscle-strengthening activity & mortality, Br J Sports Med 2022: https://doi.org/10.1136/bjsports-2021-105061 Araújo et al., muscle power vs strength & mortality (CLINIMEX), Mayo Clin Proc 2025: https://doi.org/10.1016/j.mayocp.2025.02.015 Leong et al., grip strength & mortality (PURE), Lancet 2015: https://doi.org/10.1016/S0140-6736(14)62000-6 Detraining & trained-vs-untrained Troiano et al., accelerometer-measured activity, Med Sci Sports Exerc 2008: https://doi.org/10.1249/mss.0b013e31815a51b3 Fleg et al., aerobic-capacity decline (BLSA), Circulation 2005: https://doi.org/10.1161/CIRCULATIONAHA.105.545459 Ratley et al. aerobic-capacity changes during menopause, 2025 https://pmc.ncbi.nlm.nih.gov/articles/PMC12358808/ Janssen et al., skeletal muscle mass across adulthood, J Appl Physiol 2000: https://doi.org/10.1152/jappl.2000.89.1.81 Pollock et al., master athletes & aerobic capacity, J Appl Physiol 1987: https://doi.org/10.1152/jappl.1987.62.2.725 Latella et al., strength across ages in powerlifters, Sports Med 2024: https://doi.org/10.1007/s40279-023-01962-6 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor 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The story goes that hard exercise is risky for women, and that the idea is ancient. Both halves fall apart on contact. In this solo episode, Dr. Jordan Feigenbaum follows the claim that physical effort harms the female body across twenty centuries, and shows that almost every version of it arrived as a verdict first, with the science bolted on afterward. It runs from antiquity to the present: what Galen actually wrote, why Sparta trained its women on purpose, the Victorian “vital force” panic and Edward Clarke’s claim that studying would sterilize girls, the doctor who prescribed bed rest to women and the wilderness to men, and the 1928 Olympic 800m that was erased for 32 years over a collapse that never happened. Then the correction: the research that finally tested heavy training in older women and women with low bone mass, and what it found. The episode closes on 2026, where the guidelines say lift and the menopause market often says don’t. What we cover • Why the “ancient Greeks” origin story for the no-hard-exercise rule doesn’t hold up. • How a Victorian energy-budget idea became a medical case against women lifting and studying. • The real story of the 1928 Olympic women’s 800m and the 32-year ban. • The strong women who were relabeled as freaks or exceptions instead of counted. • What Fiatarone’s nonagenarians and LIFTMOR actually showed about lifting heavy later in life. • The cortisol panic, the fasting scare, and cycle syncing, examined against the data. • Why the cautious messaging now comes from the market, not the medical guidelines. Timestamps 00:00 The 1928 Olympic “massacre” that never happened 03:37 Antiquity: what the Greeks actually said 06:50 The Victorians and “vital force” 10:02 Mary Putnam Jacobi tests the claim, and is ignored 11:53 1928 in full: who killed the women’s 800m 13:53 The double standard, and Alice Milliat 15:39 The strong women history relabeled 20:26 The correction: what the evidence shows 22:27 LIFTMOR: lifting heavy with low bone mass 24:35 2026: guidelines, the market, and cortisol 28:34 Cycle syncing, and naming the pattern 30:40 What to take away Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/ Barbell Medicine coaching and templates: https://www.barbellmedicine.com/ Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/ References Cahn S. Coming on Strong: Gender and Sexuality in Twentieth-Century Women's Sport. Harvard University Press; 1994. Clarke EH. Sex in Education; or, A Fair Chance for the Girls. Boston: James R. Osgood and Company; 1873. Colenso-Semple LM, McKendry J, Lim C, et al. Menstrual cycle phase does not influence muscle protein synthesis or whole-body myofibrillar proteolysis in response to resistance exercise. J Physiol. 2025. PMID: 39630025. Daly W, Hackney AC. Is exercise cortisol response of endurance athletes similar to levels of Cushing's syndrome? J Sports Med Phys Fitness. 2019. PMID: 31371847. Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. PMID: 30907953. Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans WJ. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA. 1990;263(22):3029-3034. PMID: 2342214. Fiatarone MA, O'Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med. 1994;330(25):1769-1775. Galen. On the Preservation of Health (De Sanitate Tuenda). 2nd century CE. Various translations. Jacobi MP. The Question of Rest for Women During Menstruation. New York: G.P. Putnam's Sons; 1877. (Awarded the Harvard Boylston Prize.) Latella C, Teo WP, Spathis J, et al. Using powerlifting athletes to determine strength adaptations across ages in males and females: a longitudinal growth modelling approach. Sports Med. 2024;54(3):753-774. Maudsley H. Sex in mind and in education. Fortnightly Review. 1874;15:466-483. Plutarch. Life of Lycurgus. Approx. 75 CE. Various translations. Schultz J. Qualifying Times: Points of Change in U.S. Women's Sport. Urbana: University of Illinois Press; 2014. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984;65(10):593-596. PMID: 6487063. Soranus of Ephesus. Gynecology. Approx. 2nd century CE. Translated by Temkin O. Baltimore: Johns Hopkins University Press; 1991. Switzer K. Marathon Woman: Running the Race to Revolutionize Women's Sports. Cambridge, MA: Da Capo Press; 2007. Todd J. Various publications. Iron Game History. Stark Center for Physical Culture and Sports, University of Texas at Austin. Tunis JR. Women and the Olympic Games. Harper's Magazine. July 1929. (And contemporaneous press coverage.) Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018;33(2):211-220. PMID: 30861219. Xenophon. Constitution of the Lacedaemonians. Approx. 4th century BCE. Various translations. 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In 1889 a French physiologist injected himself with guinea pig and dog testicle extract and published a claim of self-rejuvenation in The Lancet. That announcement kicked off a 200-year medicalization of menopause that ran through leeches and bromides, Premarin, the 2002 Women's Health Initiative, and the contemporary menopause-content space. In Episode 1 of our three-part menopause series, Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through what menopause actually is at the hormonal level, which midlife symptoms are menopause-driven and which are not, the KNDy neuron mechanism behind hot flashes (and the new medication that blocks it), and the 24-year follow-up on the WHI that substantially revised the original conclusions. OB-GYN Dr. Loraine Baraki walks the clinical workup, the lab panel she actually orders, and how she handles patients arriving with DUTCH panels and compounded hormone protocols. If you have heard contradictory things about menopause hormone therapy from your primary care, your menopause coach, and your sister, that is not your fault. The evidence base has been revised in significant ways since the 2002 publication, and most patient-facing summaries are out of date. Timestamps 00:00 Cold open: 200 years of menopause medicine 03:23 Welcome and roadmap 04:20 The HPG axis, follicles, and the FSH lag 09:11 STRAW+10 staging and the timing of perimenopause 13:47 Austin: the 49-year-old with a hormone panel 20:00 Loraine: the OB-GYN workup 28:00 Symptom attribution: what menopause actually causes 33:46 Austin: the all-estrogen patient 37:58 VMS duration and the KNDy mechanism (Avis, SKYLIGHT) 43:53 Austin: who actually gets fezolinetant 47:22 The WHI 24-year correction (Manson, Chlebowski, Boardman) 01:00:15 Modern prescribing today 01:06:52 Where the menopause-content space gets it right and wrong 01:11:50 Testosterone, compounded bioidenticals, and DUTCH panels 01:24:13 Takeaways What we cover The HPG axis and the estrogen shield: what is happening across the 35-year reproductive era and what changes at perimenopause. STRAW+10 staging: how long perimenopause actually lasts and where most women fall in the timeline. Symptom attribution: hot flashes and genitourinary syndrome are menopause. Weight gain, sleep, and joint pain are mostly other things. The KNDy neuron mechanism behind hot flashes and the new pharmacology that blocks it (fezolinetant, elinzanetant). The Women's Health Initiative: what the trial actually tested, what the 2002 result said, and what 24 years of follow-up have shown since then. The estrogen-alone arm reduced breast cancer incidence by 22% and mortality by 40% over 20 years. The timing hypothesis: hormone therapy started within 10 years of the final menstrual period vs more than 10 years out. Modern prescribing today: transdermal estradiol plus micronized progesterone, and why the formulations matter. Where the contemporary menopause-content space gets it right and wrong: the undertreatment problem, the zone-of-chaos framing, and the testosterone-for-everything marketing. Testosterone in women: one guideline-supported indication. Compounded bioidenticals and DUTCH panels. Resources Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/ Barbell Medicine coaching and templates: https://www.barbellmedicine.com/ Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal Manson JE et al. 18-year mortality from the WHI. JAMA, 2017. https://pubmed.ncbi.nlm.nih.gov/28898378/ Chlebowski RT et al. WHI estrogen-alone arm at 20 years. JAMA, 2020. https://pubmed.ncbi.nlm.nih.gov/32706854/ Boardman HMP et al. Hormone therapy for cardiovascular prevention. Cochrane, 2015. https://pubmed.ncbi.nlm.nih.gov/25754617/ Avis NE et al. Duration of VMS in the SWAN cohort. JAMA Intern Med, 2015. https://pubmed.ncbi.nlm.nih.gov/25686030/ Lederman S et al. SKYLIGHT 1, fezolinetant. The Lancet, 2023. https://pubmed.ncbi.nlm.nih.gov/36924778/ Johnson KA et al. SKYLIGHT 2, fezolinetant. JCEM, 2023. https://pubmed.ncbi.nlm.nih.gov/37410020/ USPSTF. Hormone therapy for primary prevention. JAMA, 2022. https://pubmed.ncbi.nlm.nih.gov/36318127/ Davis SR et al. Global Consensus on testosterone in women. JCEM, 2019. https://pubmed.ncbi.nlm.nih.gov/31498871/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

This is the free preview of the May 2026 Direct Line, our monthly AMA for Barbell Medicine Plus subscribers. Three reader questions answered in full. We open with a mid-30s woman with bilateral shin pain and exertional foot numbness who started creatine a month ago and is asking whether the supplement is the cause. We walk through the compartment syndrome literature, the 2025 case report being passed around online and misinterpreted, what creatine actually does to total body water (and what it doesn’t), the four compartment pressure studies that exist, the Waterman 2013 demographic data on who actually gets chronic exertional compartment syndrome, and the workup we would actually run if this person walked into clinic. Next, whether splitting your resistance training across the day affects strength and hypertrophy. We cover BBM’s general heuristic on frequency as a distribution tool for training load, the Schoenfeld meta-analyses on frequency (2016 and 2019), the wrinkle on cardiorespiratory fitness and exercise snacks, and where we go off the reservation compared to a strict evidence-based read. We close with endometriosis for the lifter, including the seven-year average diagnostic delay, the 2022 ESHRE guideline shift away from required laparoscopy, what the menstrual cycle and performance literature actually says (McNulty 2020), why the anti-inflammatory diet narrative is mostly noise, the iron and protein levers that matter, post-operative return-to-lifting timelines, the meet-timing question, and Austin’s clinical case walk on supplement stacks and GLP-1 anti-inflammatory effects. A dedicated full episode on endometriosis is coming this summer. The full unabridged Direct Line covers ten more questions, including where the GLP-1 strength trials actually are, why DEXA misleads on muscle mass loss, how we arrived at the Vital 5 weightings, the salt sermon for strongman, running shoes for casual runners, hernias and crunches in older lifters, the Bristol Stool Chart, Austin on coaching his residents, and a fresh reading list. Full episode on BBM Plus. Timestamps: Question 1 · Creatine and shin pain01:2713:21 Question 2 · Splitting your workout across the day13:2120:29 Question 3 · Endometriosis for the lifter20:29 What we cover: The clinical workup for chronic exertional compartment syndrome and why creatine is rarely the culprit. The Schoenfeld frequency literature and why training load matters more than the day it’s distributed across. Endometriosis basics including diagnostic delay, prevalence, and the 2022 ESHRE guideline change. Why most endometriosis “diets” don’t have evidence behind them, and which nutrition levers actually matter (iron, protein, energy availability). Post-operative return to training, meet-timing options, supplement stacks, and the role of GLP-1 receptor agonists in chronic anti-inflammatory effects. Resources: Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/ Barbell Medicine coaching and templates: https://www.barbellmedicine.com/ Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/ Waterman B.R. et al. 2013. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med 41(11):2545-2552. https://pubmed.ncbi.nlm.nih.gov/24036570/ Powers M.E. et al. 2003. Creatine supplementation increases total body water without altering fluid distribution. J Athl Train 38(1):44-50. https://pubmed.ncbi.nlm.nih.gov/12937471/ Antonio J. et al. 2021. Common questions and misconceptions about creatine supplementation (ISSN position). J Int Soc Sports Nutr 18(1):13. https://pubmed.ncbi.nlm.nih.gov/33557850/ Bruneau A. et al. 2025. Creatine supplementation associated with chronic exertional compartment syndrome: case report. [TO ADD: PMID once indexed] Schoenfeld B.J. et al. 2016. Effects of resistance training frequency on measures of muscle hypertrophy: a systematic review and meta-analysis. Sports Med 46(11):1689-1697. https://pubmed.ncbi.nlm.nih.gov/27102172/ Schoenfeld B.J. et al. 2019. How many times per week should a muscle be trained to maximize hypertrophy? J Sports Sci 37(11):1286-1295. https://pubmed.ncbi.nlm.nih.gov/30558493/ ESHRE Endometriosis Guideline Development Group. 2022. ESHRE guideline: endometriosis. Hum Reprod Open 2022(2):hoac009. https://pubmed.ncbi.nlm.nih.gov/35350465/ McNulty K.L. et al. 2020. The effects of menstrual cycle phase on exercise performance in eumenorrheic women: systematic review and meta-analysis. Sports Med 50(10):1813-1827. https://pubmed.ncbi.nlm.nih.gov/32661839/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Most cases of low testosterone in modern men are not a problem with the testes. The number is downstream of body composition, sleep, and energy availability. The wellness-clinic algorithm walks past every one of them. Jordan and Austin walk through what actually drives men’s testosterone down, the mechanisms behind it, and the modifiable levers that bring it back up. MOSH, the leptin and Kisspeptin pathway, the aromatase loop, the sleep apnea picture most clinics never ask about, the GLP-1 and weight-loss data on testosterone recovery, the low energy availability case that hits high-volume lifters harder than they realize, and the closing question of when a standard-dose TRT prescription actually functions as a PED. This is Episode 3 of our four-part Signal book launch series. Mark, the patient we have been threading from Episode 1, finally gets his diagnosis revealed. Timestamps 00:00 The 9x stat and Mark's diagnosis revealed 02:10 How body fat suppresses testosterone (MOSH) 07:26 Primary vs secondary causes, and Klinefelter 11:35 Leptin and the Kisspeptin pathway 14:38 Mark: the body-composition picture 16:10 The 40-inch-waist case 20:01 Weight loss, GLP-1s, and does Ozempic raise testosterone? 24:21 T4DM: adding testosterone to lifestyle 28:35 Sleep, OSA, and Mark's diagnosis 38:39 TRT in untreated sleep apnea 41:47 Can you train your testosterone down? (LEA / EHMC) 50:12 Replacement dose vs PED 55:47 Four takeaways 57:46 Episode 4 preview and book pre-order What we cover: • How body fat suppresses testosterone at two different points in the HPG axis, and why the loop is self-reinforcing • The leptin and Kisspeptin pathway most clinics never address • Mark’s case: a 45-year-old with a 240 ng/dL afternoon draw, no workup, and an immediate prescription • Primary versus secondary causes, and why Klinefelter syndrome is the under-recognized one to not miss • Weight loss dose-response: how much testosterone climbs on lifestyle alone, with GLP-1 agonists, and after bariatric surgery • T4DM: why adding testosterone to a structured weight-loss program produced no extra quality-of-life benefit over placebo • One week of sleep restriction drops testosterone by about 15 percent in healthy young men; eight days of military field exercises drop it by 50 percent • Why CPAP for obstructive sleep apnea reliably improves symptoms but does not always move the lab number • The opposite extreme: low energy availability, relative energy deficiency in sport, and the exercise-hypogonadal male condition • The lifter calculus: when a textbook replacement dose is functionally a PED in a chronically underfueled trainee Resources mentioned: Signal book pre-order: https://barbellmedicine.com/signal Training Plateau Action Plan (free): https://www.barbellmedicine.com/training-plateau-action-plan/ Barbell Medicine programs and coaching: https://www.barbellmedicine.com/ Episode 1 (Is the Testosterone Crisis Real?) Episode 2 (Is Your Testosterone Actually Low? Referenced studies: Wu F.C.W. et al. 2010. Identification of late-onset hypogonadism in middle-aged and elderly men (EMAS). N Engl J Med 363(2):123-135. https://pubmed.ncbi.nlm.nih.gov/20554979/ Travison T.G. et al. 2011. The natural history of symptomatic androgen deficiency in men. J Am Geriatr Soc. https://pubmed.ncbi.nlm.nih.gov/18454751/ Corona G. et al. 2013. Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: systematic review and meta-analysis. Eur J Endocrinol 168(6):829-843. https://pubmed.ncbi.nlm.nih.gov/23482592/ Kounatidis D. et al. 2025. The impact of GLP-1 receptor agonists on erectile function. Biomolecules 15(9):1284. https://doi.org/10.3390/biom15091284 Grossmann M. et al. 2024. Testosterone treatment, weight loss, and health-related quality of life and psychosocial function in men: 2-year RCT (T4DM QoL arm). J Clin Endocrinol Metab 109(8):2019-2028. https://pubmed.ncbi.nlm.nih.gov/38311835/ Leproult R., Van Cauter E. 2011. Effect of 1 week of sleep restriction on testosterone levels in young healthy men. JAMA 305(21):2173-2174. https://pubmed.ncbi.nlm.nih.gov/21632481/ Penev P.D. 2007. Association between sleep and morning testosterone levels in older men. Sleep 30(4):427-432. https://pubmed.ncbi.nlm.nih.gov/17520785/ Wittert G. 2014. The relationship between sleep disorders and testosterone in men. Asian J Androl 16(2):262-265. https://pubmed.ncbi.nlm.nih.gov/24435056/ Alemany J.A. et al. 2008. Effects of dietary protein content on IGF-I, testosterone, and body composition during 8 days of severe energy deficit and arduous physical activity. J Appl Physiol 105(1):58-64. https://pubmed.ncbi.nlm.nih.gov/18450989/ Mountjoy M., Sundgot-Borgen J.K., Burke L.M. et al. 2018. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med 52:687-697. https://pubmed.ncbi.nlm.nih.gov/29773536/ Areta J.L. et al. 2021. Low energy availability: history, definition and evidence of its endocrine, metabolic and physiological effects in prospective studies in females and males. Eur J Appl Physiol 121(1):1-21. https://pubmed.ncbi.nlm.nih.gov/33095376/ Mäestu J. et al. 2010. Anabolic and catabolic hormones and energy balance of the male bodybuilders during the preparation for the competition. J Strength Cond Res 24(4):1074-1081. https://pubmed.ncbi.nlm.nih.gov/20300023/ Hooper D.R. et al. 2018. Treating exercise-associated low testosterone (EHMC). Phys Sportsmed 46(4):427-434. https://pubmed.ncbi.nlm.nih.gov/30074435/ Hackney A.C. 2020. Hypogonadism in exercising males: dysfunction or adaptive-regulatory adjustment? Front Endocrinol 11:11. https://pubmed.ncbi.nlm.nih.gov/32082252/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Three weeks of stalled squats. The conventional answer is to switch programs because you've crossed into intermediate territory. The data says something else. In Part 3 of the Progressive Loading series, Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through why the standard novice / intermediate / advanced framework runs into trouble in real training, what the four adaptive systems are actually doing across a training career, and why most of what gets called a stall is impatience with the noise floor at your current strength level. This is Part 3 of the Progressive Loading series. Part 1 covered why loading should react to demonstrated adaptation. Part 2 covered RPE-based autoregulation and the artificial-momentum approach. Today is the mechanism layer. Pre-order our book, Signal: barbellmedicine.com/signal Timestamps 0:00 - Why your lifts aren't moving 1:52 - The novice / intermediate / advanced framework, three claims to test 13:23 - What 17 years of powerlifting data show about how long you keep getting stronger 32:28 - How getting stronger actually works (four systems on four clocks) 38:00 - What early growth is actually made of (the Damas 2016 deuterium study) 50:33 - The connective tissue lag and why early-training injuries happen 58:32 - Why heavy lifting works for bone density (and why "walk on a treadmill" advice misses) 1:05:10 - Why new lifters get hurt 3 to 10 times more than experienced lifters 1:12:56 - Fatigue is at least four different things (and most coaches treat it as one) 1:26:19 - The CNS fatigue myth (and what the data actually says) 1:33:52 - When the bar isn't moving: how to actually diagnose a stall 1:45:51 - Takeaways and next week's tease: leptin and low testosterone What we cover - The novice / intermediate / advanced framework: three claims and why each one fails the data test - The 17-year IPF strength curve and what the no-kink finding does and does not establish (Latella 2024) - The four adaptive systems and their separate timescales (neural, muscle, connective tissue, bone) - What early growth actually is, including the deuterium-oxide finding that most week-3 size is fluid (Damas 2016) - Why connective tissue lags muscle by six to eight weeks, and why that produces patellar tendinopathy four months in - The 9.5 vs 0.74 to 3.3 injury rate gap between novice and experienced CrossFit participants - The CNS fatigue myth and the Skarabot 2018 finding that locates the fatigue in the muscle, not the brain - Why the LIFTMOR trial result (heavy lifting for bone density in women in their 60s and 70s) is being missed by primary care - A practical decision tree for stalls: environment first, then load, then program - Tease for next week: leptin, the HPG axis, and the metabolic driver of low testosterone almost nobody connects Resources Training Plateau Action Plan (free): https://www.barbellmedicine.com/training-plateau-action-plan/ Progressive Loading article series: https://www.barbellmedicine.com/blog/progressive-loading/ Beyond Progressive Overload (Part 2 article): https://www.barbellmedicine.com/blog/beyond-progressive-overload/ BBM Programs and Coaching: https://www.barbellmedicine.com/ Support our work on barbellmedicine.supercast.com Latella C et al. Using powerlifting athletes to determine strength adaptations across ages in males and females. Sports Med. 2024. https://pubmed.ncbi.nlm.nih.gov/ Del Vecchio A et al. The increase in muscle force after 4 weeks of strength training is mediated by adaptations in motor unit recruitment and rate coding. J Physiol. 2019. https://pubmed.ncbi.nlm.nih.gov/30644584/ Lecce E et al. Resistance training-induced adaptations in the neuromuscular system. J Physiol. 2025. Balshaw TG et al. Neural adaptations after 4 years vs 12 weeks of resistance training. Scand J Med Sci Sports. 2019. https://pubmed.ncbi.nlm.nih.gov/30474171/ Skarabot J et al. Voluntary activation and agonist EMG amplitude in resistance-trained men. J Appl Physiol. 2021. Roberts MD et al. Mechanisms of mechanical overload-induced skeletal muscle hypertrophy. Physiol Rev. 2023. Damas F et al. Resistance training-induced changes in integrated myofibrillar protein synthesis are related to hypertrophy only after attenuation of muscle damage. J Physiol. 2016. https://pubmed.ncbi.nlm.nih.gov/27219125/ Damas F et al. Early resistance training-induced increases in muscle cross-sectional area are concomitant with edema-induced muscle swelling. Eur J Appl Physiol. 2016. https://pubmed.ncbi.nlm.nih.gov/26280652/ Lazarczuk SL et al. Mechanical, material and morphological adaptations of healthy lower limb tendons. Sports Med. 2022. https://pubmed.ncbi.nlm.nih.gov/35657492/ Kubo K et al. Time course of changes in the human Achilles tendon properties. Eur J Appl Physiol. 2012. https://pubmed.ncbi.nlm.nih.gov/22105708/ Watson SL et al. High-intensity resistance and impact training improves bone mineral density in postmenopausal women: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018. https://pubmed.ncbi.nlm.nih.gov/28975661/ Aasa U et al. Injuries among weightlifters and powerlifters: a systematic review. Br J Sports Med. 2017. https://pubmed.ncbi.nlm.nih.gov/27445362/ Prieto-Gonzalez P et al. Injuries in novice participants during an eight-week start-up CrossFit program. Int J Environ Res Public Health. 2020. https://pubmed.ncbi.nlm.nih.gov/32155747/ Kanayama G et al. Tendon rupture in body builders. Sports Med. 2015. Enoka RM, Duchateau J. Translating fatigue to human performance. Med Sci Sports Exerc. 2016. https://pubmed.ncbi.nlm.nih.gov/27015386/ Behrens M et al. Fatigue and human performance: an updated framework. Sports Med. 2023. https://pubmed.ncbi.nlm.nih.gov/ Halperin I et al. Accuracy in predicting repetitions to task failure: scoping review. Sports Med. 2022. https://pubmed.ncbi.nlm.nih.gov/ Skarabot J et al. Neuromuscular fatigue and recovery after heavy resistance, jump, and sprint training. Eur J Appl Physiol. 2018. Garcia-Ramos A et al. Greater neuromuscular and perceptual fatigue after low-load to failure than heavy-load to failure. 2024. Minor, Brian MS, CSCS1; Helms, Eric PhD, CSCS2; Schepis, Jacob3. RE: Mesocycle Progression in Hypertrophy: Volume Versus Intensity. Strength and Conditioning Journal 42(5):p 121-124, October 2020. | DOI: 10.1519/SSC.0000000000000581 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Out of 32 symptoms commonly attributed to low testosterone, only 3 actually correlate with it. All three are sexual. The other 29 — fatigue, brain fog, low mood, weight you can't lose, feeling not quite like yourself — are real, but they are produced by something else, and the wellness-clinic funnel runs on getting that wrong. Episode 2 of our Signal book launch series. Dr. Jordan Feigenbaum and Dr. Austin Baraki cover how testosterone actually works, what the number on your lab report is really measuring, and what a real evaluation of low T looks like. Pre-order our book, Signal: barbellmedicine.com/signal Timestamps: 00:00 Mark, revisited (cold open) 02:00 How testosterone actually works (HPG axis) 06:14 Why "in range" can still be abnormal 09:24 What your lab number actually measures 12:25 Case: total 230, low SHBG — does this guy need TRT? 17:04 The saturation model — why higher isn't better 21:11 A patient at 480 wants 900: how the conversation goes 28:57 What "in range" actually means (and why 264 is the cutoff) 34:41 The 3 symptoms that matter (out of 32) 37:16 Walking back a 10-symptom checklist 42:31 How a real testosterone workup gets done 46:42 Chasland trial — TRT vs. exercise at low-normal T 49:31 A warning for hard-training men 58:48 Takeaways, tease, and what's coming next What we cover: The HPG axis explained — and why one low total testosterone reading tells you almost nothing about where the problem actually sits. The difference between total, free, and bioavailable testosterone — and why SHBG, the binding protein the wellness-clinic workup almost always ignores, is what determines whether the number on your lab report is misleading you in either direction. The saturation model: above roughly 250 ng/dL, the prostate androgen receptor is saturated. Libido follows the same plateau. Pushing a normal man from 500 to 900 isn't doing what the marketing implies. The EMAS study finding: of 32 symptoms men commonly attribute to low testosterone, only 3 actually correlate. Every other symptom needs a different workup. How a real testosterone workup gets done — morning sample, fasted, repeat draw, LH/FSH/SHBG to localize and contextualize. The Chasland 2021 trial: when standard TRT is prescribed properly to middle-aged men with low-normal levels, does it beat exercise? The answer is what most of the wellness-clinic industry is built on getting wrong. A note for hard-training men: the exercise-hypogonadal-male pattern, what "low-normal" means in someone whose levels are an adaptation to training load rather than a baseline deficit, and why a textbook TRT dose in that man may functionally act as a performance enhancer. If you have a lab report on your kitchen counter right now, this is what we wrote for you. Signal, the book, drops in May. Pre-order available soon at barbellmedicine.com. Resources & links Signal — Feigenbaum & Baraki (Barbell Medicine, 2026): coming soon Episode 1 (Is the Testosterone Crisis Real?): https://stream.redcircle.com/episodes/b25a8006-57e5-4dc3-b74c-203f6fbcebc1/stream.mp3 Training Plateau Action Plan (free): barbellmedicine.com/training-plateau-action-plan Barbell Medicine programs and consultations: barbellmedicine.com To support us and get ad free listening, plus special product discounts, and exclusive content, go to supercast.barbellmedicine.com Referenced studies Wu FCW et al. 2010 - Identification of late-onset hypogonadism in middle-aged and elderly men. NEJM 363(2):123-135. [The EMAS 3-of-32 finding] https://pubmed.ncbi.nlm.nih.gov/20554979/ Bhasin S et al. 2018 - Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. JCEM 103(5):1715-1744. [264 ng/dL threshold; first-draw protocol] https://pubmed.ncbi.nlm.nih.gov/29562364/ Travison TG et al. 2008 - The natural history of symptomatic androgen deficiency in men. JAGS 56(5):831-839. [MMAS: ~50% of initially low values normalize on repeat] https://pubmed.ncbi.nlm.nih.gov/18308002/ Travison TG et al. 2006 - The relationship between libido and testosterone levels in aging men. JCEM 91(7):2509-2513. [Libido plateau data, Framingham + HIM] https://pubmed.ncbi.nlm.nih.gov/16670164/ Brambilla DJ et al. 2009 - The effect of diurnal variation on clinical measurement of serum testosterone. JCEM 94(3):907-913. [Why morning, fasted matters] https://pubmed.ncbi.nlm.nih.gov/19112025/ Morgentaler A & Traish AM. 2009 - Shifting the paradigm of testosterone and prostate cancer: the saturation model and the limits of androgen-dependent growth. Eur Urol 55(2):310-320. [The saturation model] https://pubmed.ncbi.nlm.nih.gov/18838208/ Trost LW & Mulhall JP. 2016 - Challenges in Testosterone Measurement, Data Interpretation, and Methodological Appraisal of Interventional Trials. J Sex Med 13(7):1029-1046. [Free T unreliability at the low end; equilibrium dialysis as the reference method] https://pubmed.ncbi.nlm.nih.gov/27210182/ Vermeulen A et al. 1999 - A critical evaluation of simple methods for the estimation of free testosterone in serum. JCEM 84(10):3666-3672. [Calculated free T methodology] https://pubmed.ncbi.nlm.nih.gov/10523012/ Chasland LC et al. 2021 - Testosterone and exercise: effects on fitness, body composition, and strength in middle-to-older aged men with low-normal serum testosterone levels. Am J Physiol Heart Circ Physiol 320(5):H1985-H1998. [The 12-week trial] https://pubmed.ncbi.nlm.nih.gov/33739153/ Arun AS et al. 2025 - Reevaluating the Threshold for Low Total Testosterone. Clin Chem 71(5):609-611. [2025 NHANES strength-dissociation reference] https://pubmed.ncbi.nlm.nih.gov/40066943/ Baillargeon J et al. 2015 - Trends in Androgen Prescribing in the United States, 2001-2011. JAMA Intern Med 175(8):1413-1415. [25% no preceding lab; the 50% no follow-up monitoring gap - referenced from Episode 1] https://pubmed.ncbi.nlm.nih.gov/26075486/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Stop a GLP-1 and about two thirds of the weight loss comes back within a year. Three randomized withdrawal trials (SURMOUNT-4, STEP 1 extension, STEP 4) and a new BMJ 2026 systematic review of 37 RCTs and nearly 10,000 adults all land on the same signal. The cardiometabolic benefits, blood pressure, fasting glucose, lipids, drift back in parallel with the weight. The framing that actually fits the data: GLP-1s behave like a statin. There is a cumulative benefit during exposure, but this does not extend indefinitely, This month's Direct Line covers two subscriber questions. The first asks what the new BMJ paper on GLP-1 cardiovascular protection after cessation actually shows, and how GLP-1 durability compares to lifestyle-only interventions. The second asks how a postmenopausal woman newly diagnosed with osteopenia should structure her lifting. Studies referenced: SURMOUNT-4 (Jastreboff, JAMA 2024), STEP 1 extension (Wilding, Diabetes Obes Metab 2022), STEP 4 (Rubino, JAMA 2021), West et al. BMJ 2026 systematic review, Budini 2026 eClinicalMedicine regain meta-analysis, SELECT cardiovascular outcomes, FLOW renal outcomes, the Diabetes Prevention Program, Look AHEAD, POUNDS Lost, and LIFTMOR (Watson, JBMR 2018). Full episode on BBM+ covers 8 additional subscriber questions. Join at https://barbellmedicine.supercast.com/ Timestamps 0:00 Intro 1:52 Q1: What happens when you stop a GLP-1 5:33 Lifestyle-only comparators: DPP, Look AHEAD, POUNDS Lost 8:15 Austin on the cessation conversation 1 2:41 BMJ 2026: weight and cardiometabolic regression 17:59 The statin framing 23:41 Austin: first 6 months off GLP-1 28:07 Q2: Osteopenia and heavy lifting 35:28 LIFTMOR protocol 38:00 Outro Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com Resources Aronne, Louis J., et al. "Continued Treatment With Tirzepatide for Maintenance of Weight Reduction in Adults With Obesity: The SURMOUNT-4 Randomized Clinical Trial." JAMA, vol. 331, no. 1, 2024, pp. 38–48. https://jamanetwork.com/journals/jama/fullarticle/2812936 Wilding, John P. H., et al. "Weight Regain and Cardiometabolic Effects After Withdrawal of Semaglutide: The STEP 1 Trial Extension." Diabetes, Obesity and Metabolism, vol. 24, no. 8, Aug. 2022, pp. 1553–1564. https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14725 Rubino, Domenica, et al. "Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity: The STEP 4 Randomized Clinical Trial." JAMA, vol. 325, no. 14, 2021, pp. 1414–1425. https://jamanetwork.com/journals/jama/fullarticle/2777886 West, Sam, et al. "Weight Regain After Cessation of Medication for Weight Management: Systematic Review and Meta-Analysis." BMJ, vol. 392, 7 Jan. 2026, article e085304. https://www.bmj.com/content/392/bmj-2025-085304 Budini, Brajan, et al. "Trajectory of Weight Regain After Cessation of GLP-1 Receptor Agonists: A Systematic Review and Nonlinear Meta-Regression." eClinicalMedicine, vol. 93, 4 Mar. 2026, article 103796. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(26)00043-X/fulltext Lincoff, A. Michael, et al. "Semaglutide and Cardiovascular Outcomes in Obesity Without Diabetes." New England Journal of Medicine, vol. 389, no. 24, 11 Nov. 2023, pp. 2221–2232. https://www.nejm.org/doi/full/10.1056/NEJMoa2307563 Perkovic, Vlado, et al. "Effects of Semaglutide on Chronic Kidney Disease in Patients with Type 2 Diabetes." New England Journal of Medicine, vol. 391, no. 2, 24 May 2024, pp. 109–121. https://www.nejm.org/doi/full/10.1056/NEJMoa2403347 Knowler, William C., et al. "Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin." New England Journal of Medicine, vol. 346, no. 6, 7 Feb. 2002, pp. 393–403. https://www.nejm.org/doi/full/10.1056/NEJMoa012512 Look AHEAD Research Group. "Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes." New England Journal of Medicine, vol. 369, no. 2, 11 July 2013, pp. 145–154. https://www.nejm.org/doi/full/10.1056/NEJMoa1212914 Sacks, Frank M., et al. "Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates." New England Journal of Medicine, vol. 360, no. 9, 26 Feb. 2009, pp. 859–873. https://www.nejm.org/doi/full/10.1056/NEJMoa0804748 Watson, Shelley L., et al. "High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial." Journal of Bone and Mineral Research, vol. 33, no. 2, 2018, pp. 211–220. https://onlinelibrary.wiley.com/doi/10.1002/jbmr.3284 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Every week there's a new headline saying men are losing testosterone. A quarter of men now start testosterone replacement therapy without ever getting their blood tested. The supplement aisle is full of boosters that either do nothing or contain undisclosed steroids. And the lab test that gets everybody to the pharmacy? Half of low results normalize on their own. In Episode 1 of the Signal launch series, Dr. Jordan Feigenbaum and Dr. Austin Baraki (both MDs and strength coaches) walk through the three-layer problem with how testosterone gets diagnosed and treated in 2026, then take apart the "testosterone is crashing" headline with the most current data available, including a 2025 meta-analysis of more than one million men. Pre-order our book, Signal: barbellmedicine.com/signal Timestamps 0:00 Mark's story: treating the number, not the patient 1:18 Welcome to the Barbell Medicine Podcast 1:41 Problem 1: A quarter of men start TRT with no lab work 3:36 Problem 2: Why testosterone boosters do not work (and what is in them) 13:40 Problem 3: Why one low testosterone lab is not a diagnosis 19:19 Setup: Is the testosterone crisis headline real? 20:04 The MMAS data and the 1%-per-year number 20:52 The 2025 meta-analysis of over 1 million men 22:02 Why the headline is inflated: three causes 22:27 Cause 1: The testing method changed (immunoassay to mass spec) 25:58 Cause 2: BMI cannot see visceral fat 29:37 The Nyante study: when you fix both problems, the decline vanishes 33:58 What this actually means for you 37:05 The broken testosterone system, summarized 38:24 Five takeaways from this episode 39:14 Next week: How testosterone actually works 39:39 About Signal and credits What you'll learn in this episode: Why 25% of new TRT prescriptions are written without any pre-treatment lab work (JAMA, 2015) What actually happens when researchers test 50+ "testosterone booster" supplements (spoiler: 12% are contaminated with undisclosed steroids) Why a single low testosterone reading is not a diagnosis, and the Massachusetts Male Aging Study data that proves it The real size of the population-level testosterone decline (much smaller than 1% per year) Why BMI cannot see the visceral fat that is driving most of the genuine decline The Nyante study that shows the decline essentially vanishes when you use an accurate test and measure waist circumference Five practical takeaways you can apply before your next lab draw This is Episode 1 of a four-part series built around our upcoming book, Signal. Over the next four weeks we cover what testosterone actually is, how to tell when it is genuinely low, what is really driving population-level changes, and what the evidence says you can do about it. Next Steps Check out our new book, Signal (coming soon) For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com To support us and get ad free listening, plus special product discounts, and exclusive content, go to supercast.barbellmedicine.com Resources Baillargeon, J., et al. (2015). Trends in Androgen Prescribing in the United States, 2001–2011. JAMA Intern Med, 175(8), 1413–1415. — 25% no preceding lab; post-prescription monitoring gap. Rao, P.K., et al. (2017). Trends in Testosterone Replacement Therapy Use from 2003 to 2013 among Reproductive-Age Men in the United States. J Urol, 197(4), 1121–1126. — Prescription volume growth. Selinger, S., & Thallapureddy, A. (2024). Cross-sectional analysis of national testosterone prescribing through prescription drug monitoring programs, 2018–2022. PLoS One, 19(8), e0309160. — Recent prescribing data, 3-4 million estimate. Vesper, H.W., et al. (2015). Serum Total Testosterone Concentrations in the US Household Population from the NHANES 2011–2012 Study Population. Clin Chem, 61(12), 1495–1504. — Population testosterone levels, NHANES data. Clemesha, C.G., et al. (2020). "Testosterone Boosting" Supplements Composition and Claims Are Not Supported by the Academic Literature. World J Men's Health, 38(1), 115–122. — 62% no published data, 10% decreased T. Tucker, J., et al. (2018). Unapproved Pharmaceutical Ingredients Included in Dietary Supplements Associated With US FDA Warnings. JAMA Network Open, 1(6), e183337. — 12% adulterated with undisclosed steroids. Trost, L.W., & Mulhall, J.P. (2016). Challenges in Testosterone Measurement, Data Interpretation, and Methodological Appraisal of Interventional Trials. J Sex Med, 13(7), 1029–1046. — Half of low results normalize on repeat. Travison, T.G., et al. (2008). The Natural History of Symptomatic Androgen Deficiency in Men: Onset, Progression, and Spontaneous Remission. JCEM. MMAS data — 50%+ spontaneous normalization. Travison, T.G., et al. (2007). A Population-Level Decline in Serum Testosterone Levels in American Men. JCEM, 92(1), 196–202. — Original MMAS secular decline, 15–20% lower across cohorts. Santi, D., et al. (2025). Meta-analysis of secular trend in total testosterone levels, 1971–2024. 1,256 studies, N > 1,000,000. — 0.56%/year adjusted; LH parallel decline; mass spec subgroup no significant decline. Methods note on the ~0.56% per year figure cited in this episode: the Santi paper does not report a single percentage rate. The headline adjusted meta-regression coefficient (−0.6 nmol/L/year) is inflated by the random-effects weighting scheme and is not a biological rate. The 0.5–0.6% per year approximation comes from the pre-2000 stratified subgroup (Fig. 5, coefficient −0.1 nmol/L/year) divided by the dataset mean of 18.5 nmol/L. The post-2000 stratum runs larger (~1.1%), and the age-stratified coefficients in Table 5 cluster in the 0.4–0.9% range. The mass spectrometry subgroup (Table 3, Group 4) showed no significant trend (p = 0.845). The episode uses the conservative end of this range as the most defensible estimate of the real population-level rate after accounting for assay drift. Nyante, S.J., Graubard, B.I., Li, Y., McQuillan, G.M., Platz, E.A., Rohrmann, S., Bradwin, G., & McGlynn, K.A. (2012). Trends in sex hormone concentrations in US males: 1988–1991 to 1999–2004. Int J Androl, 35(3), 456–466. doi: 10.1111/j.1365-2605.2011.01230.x. — Archived NHANES samples, same platform, waist circumference added; no significant decline in total or free testosterone. Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

A 43-year-old man starts exercising and ends up in the ER with a CK over 100x the upper limit of normal. His doctor says it’s from training. We don’t think so. In this episode, Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through the full case — history, labs, diagnosis, and what actually went wrong — then break down the mechanisms behind the answer, the nocebo research, and what the brand-new 2026 guidelines mean for the 40 million Americans on a drug class you’ve definitely heard of. We also cover the STOMP trial (do statins actually impair strength gains?), the SAMSON trial (how much of statin intolerance is nocebo?), the difference between myalgia, myositis, and rhabdomyolysis, Austin’s clinical approach to a patient whose strength is declining on a statin, and the treatment escalation pathway for statin-intolerant patients including bempedoic acid, PCSK9 inhibitors, and inclisiran. Plus, where GLP-1 receptor agonists like tirzepatide fit into the cardiovascular risk picture. Timestamps 0:00 — A 43-year-old man is getting weaker, not stronger 2:09 — Taking the history: Medications, lifestyle, and red flags 12:53 — The labs come back: CK at 18,979 16:05 — Metabolic syndrome and the modern treatment approach 23:15 — Rhabdomyolysis: What it is and why it’s dangerous 29:50 — Final diagnosis and what went wrong with the medications 37:15 — 2026 ACC lipid guidelines: What changed 40:32 — Three mechanisms: How statins affect muscle 47:02 — The nocebo effect and the SAMSON trial 54:17 — Do statins impair training? The STOMP trial 1:00:30 — Who’s at highest risk for statin muscle problems 1:07:36 — What happened to the patient and options if this is you 1:14:12 — Five takeaways Five Takeaway Statin myopathy is real but relatively uncommon. The excess symptom rate above placebo is roughly 1–5% in controlled trials. But in exercising patients, especially on combination therapy, the risk can be higher. There are three proposed mechanisms: reduced energy production from CoQ10 depletion, compromised muscle cell membranes from isoprenoid loss, and accelerated protein breakdown from calcium leak via the ryanodine receptor. Exercise amplifies all three, but the vast majority of people compensate. If you’re on a statin and your strength is going down, talk to your doctor before stopping the medication or changing your training. A CK test can help separate a drug problem from a programming problem The 2026 ACC guidelines list vigorous exercise as a risk factor for statin-associated muscle symptoms for the first time. They also provide statin-intolerant patients a clear escalation pathway: bempedoic acid, ezetimibe, PCSK9 inhibitors, and more. Lower is better for LDL. There’s a 33% relative reduction in cardiovascular events at <55 vs. 70 mg/dL. Lower for longer. Healthy lifestyle changes plus effective lipid-lowering therapy are among the best things you can do for cardiovascular risk. Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com To support us and get ad free listening, plus special product discounts, and exclusive content, go to supercast.barbellmedicine.com Resources Training Plateau Action Plan (free): https://www.barbellmedicine.com/training-plateau-action-plan/ Fish oil episode: https://open.spotify.com/episode/4kRtXZBMZWKkZPDdIKpu1S Lp(a): https://www.barbellmedicine.com/blog/lipoprotein-a-testing-and-treatment/ Guidelines Blumenthal RS, Morris PB, et al. 2026 ACC/AHA Guideline on the Management of Dyslipidemia. Circulation. 2026. DOI: 10.1161/CIR.0000000000001423 Case László A, et al. Exercise and Statin-Fibrate Combination Therapy-Caused Myopathy. BMC Research Notes. 2013;6:52. https://pubmed.ncbi.nlm.nih.gov/23388500/ LDL Targets Lee YJ, et al. (Ez-PAVE) Intensive LDL Cholesterol Targeting in Atherosclerotic Cardiovascular Disease. NEJM. 2026. PMID: 41910315 Mechanisms of Statin Myopathy Meador BM, Huey KA. Statin-Associated Myopathy and Its Exacerbation with Exercise. Muscle Nerve. 2010;42(4):469–479. https://pubmed.ncbi.nlm.nih.gov/20878737/ Safitri N, et al. Statin-Induced Rhabdomyolysis: Mechanisms, Risk Factors, Management. Drug Healthc Patient Saf. 2021. https://pmc.ncbi.nlm.nih.gov/articles/PMC8593596/ Molinarolo S, et al. Cryo-electron microscopy reveals sequential binding and activation of Ryanodine Receptors by statin triplets. Nat Commun. 2025;16(1):11508. doi:10.1038/s41467-025-66522-0 Thompson PD, et al. Lovastatin Increases Exercise-Induced Skeletal Muscle Injury. Metabolism. 1997;46(10):1206–1210 Nocebo Effect and Statin Intolerance Wood FA, et al. N-of-1 Trial of a Statin, Placebo, or No Treatment to Assess Side Effects (SAMSON). NEJM. 2020;383(22):2182–2184. https://pmc.ncbi.nlm.nih.gov/articles/PMC8453640/ Khan S, et al. Does Googling Lead to Statin Intolerance? Int J Cardiol. 2018;262:25–27. https://pubmed.ncbi.nlm.nih.gov/29706390/ Gupta A, et al. Adverse Events Associated with Unblinded, but Not with Blinded, Statin Therapy in the ASCOT-LLA. Lancet. 2017;389(10088):2473–2481. https://pubmed.ncbi.nlm.nih.gov/28476288/ Moon JC, et al. Examining the Nocebo Effect of Statins through the FDA AERS. Circ Cardiovasc Qual Outcomes. 2021;14(1):e007480. https://pubmed.ncbi.nlm.nih.gov/33161769 Statins and Exercise Outcomes Parker BA, et al. Effect of Statins on Skeletal Muscle Function (STOMP). Circulation. 2013;127(1):96–103. https://pubmed.ncbi.nlm.nih.gov/23183941/ Parker BA, Thompson PD. Effect of Statins on Skeletal Muscle: Exercise, Myopathy, and Muscle Outcomes. Exerc Sport Sci Rev. 2012;40(4):188–194. https://pmc.ncbi.nlm.nih.gov/articles/PMC3463373/ Mikus CR, et al. Simvastatin Impairs Exercise Training Adaptations. JACC. 2013;62(8):709–714. https://pubmed.ncbi.nlm.nih.gov/23583255/ Slade JM, et al. The Impact of Statin Therapy and Aerobic Exercise Training. Am Heart J Plus. 2021;10:100028. https://pmc.ncbi.nlm.nih.gov/articles/PMC8477381/ Gui Y, et al. Efficacy and Safety of Statins and Exercise Combination Therapy. Eur J Prev Cardiol. 2017;24(9):907–916. DOI: 10.1177/2047487317691874 Genetic Susceptibility SEARCH Collaborative Group. SLCO1B1 Variants and Statin-Induced Myopathy — A Genomewide Study. NEJM. 2008;359(8):789–799 Autoimmune Myopathy Barkhordarian M, et al. Statin-Induced Autoimmune Myopathy. Am J Case Rep. 2024;25:e944261. https://pubmed.ncbi.nlm.nih.gov/39219126/ Statin-Fibrate Interactions Jones PH, Davidson MH. Reporting Rate of Rhabdomyolysis with Fenofibrate + Statin vs Gemfibrozil + Any Statin. Am J Cardiol. 2005;95(1):120–122 Bruckert E, et al. Mild to Moderate Muscular Symptoms with High-Dosage Statin Therapy (PRIMO Study). Cardiovasc Drugs Ther. 2005;19(6):403–414 Sinzinger H, O’Grady J. Professional Athletes Suffering from Familial Hypercholesterolaemia Rarely Tolerate Statin Treatment. Br J Clin Pharmacol. 2004;57(4):525–528 Tirzepatide and GLP-1 Agonists Al-kuraishy HM, et al. The mechanistic role of tirzepatide in atherosclerosis. Int J Biol Macromol. 2025;329(1). https://doi.org/10.1016/j.ijbiomac.2025.147734 Effects of Tirzepatide on Lipid Profile: A Systematic Review and Meta-Analysis. 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11704219/ Hamidi H, et al. Effect of tirzepatide on coronary atherosclerosis progression (T-Plaque trial design). Am Heart J. 2024;278:24–32. doi:10.1016/j.ahj.2024.08.015 Fish Oil and Omega-3 Fatty Acids Bhatt DL, et al. Cardiovascular Risk Reduction with Icosapent Ethyl (REDUCE-IT). NEJM. 2019;380:11–22. https://pubmed.ncbi.nlm.nih.gov/30415628/ Abdelhamid AS, et al. Omega-3 Fatty Acids for Prevention of Cardiovascular Disease. Cochrane Database Syst Rev. 2020. https://pubmed.ncbi.nlm.nih.gov/32114706/ Manson JE, et al. Marine n-3 Fatty Acids and Prevention of CVD and Cancer (VITAL). NEJM. 2019;380:23–32. https://pubmed.ncbi.nlm.nih.gov/30415637/ Myopathy Classification Selva-O’Callaghan A, et al. Statin-Induced Myalgia and Myositis: Pathogenesis and Clinical Recommendations. Expert Rev Clin Immunol. 2018;14(3):215–224. https://pmc.ncbi.nlm.nih.gov/articles/PMC6019601/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

In 2022, researchers conducted the most rigorous systematic review ever performed on overtraining syndrome — looking specifically for controlled studies that documented a human transitioning from a healthy training state to an overtrained state. Zero studies met those criteria. The word "overtrained" appears in coaching certifications, wearable device dashboards, and clinical sports medicine guidelines — and in each context it means something different. That definitional chaos has consequences: it delays real diagnoses, produces nocebo effects with measurable physiological outcomes, and leads athletes to reduce training they didn't need to reduce. In this episode, Drs. Jordan Feigenbaum and Austin Baraki work through the full evidence base on overtraining syndrome — the taxonomy, the attempted studies, the six competing mechanistic theories, the biomarker failures, and what's actually happening when a lifter can't make progress. Timestamps: 0:00 Cold open — the zero-studies finding 1:21 Why "overtrained" does four different jobs simultaneously 16:10 The FOR / NFOR / OTS taxonomy 19:43 The supercompensation model — borrowed from endurance, never validated for resistance training 32:28 Austin's clinical differential for fatigue and declining performance 36:17 RT evidence — what happens when researchers try to induce OTS through lifting 43:19 Austin — what actually drives the complaints he sees in practice 47:30 Six theories for what causes overtraining syndrome 1:01:09 The biomarker problem — why the T:C ratio and cortisol don't work 1:05:09 What your wearable is actually measuring (and what it isn't) 1:09:28 Austin — testosterone levels in trained athletes and when to act 1:13:40 Heart rate variability — limitations for strength training 1:15:36 Session RPE — the monitoring tool that actually works 1:17:31 How common is overtraining syndrome, really? 1:23:04 Three failure modes — what's actually happening when lifters say they feel overtrained 1:32:14 Austin — what a proper medical workup looks like 1:34:22 Outro What we cover: The definition problem — why a single word is doing four incompatible jobs simultaneously, and why that matters clinically and practically. The taxonomy — functional overreaching, nonfunctional overreaching, and overtraining syndrome as points on a continuous variable that can only be identified after the fact, not at presentation. The supercompensation model — where it came from, why it fails to describe how resistance training adaptation actually works, and how applying it too literally produces both overloading and underloading errors at the same time. Austin's clinical differential — what a physician actually works through when a patient presents with fatigue and declining performance, and where overtraining syndrome actually sits on that list. What resistance training research shows — including 140 maximal singles, 90 working sets per week, and daily 1-rep max attempts. No study has cleanly induced overtraining syndrome through resistance training. The hormonal data went in the opposite direction from what the endurance overtraining model predicts. Six mechanistic theories — glycogen depletion, serotonin/BCAA, autonomic imbalance, central governor, HPA axis dysregulation, and Armstrong's complex systems framework. Each one is partially supported and each falls short. The biomarker problem — resting cortisol is normal in 75%+ of OTS cases, the testosterone to cortisol ratio has never been validated against clinical outcomes as an individual diagnostic, and HRV recovery in strength training lags physical recovery by up to 30 hours. Austin on wearables — including a clinical pattern he's seeing with GLP-1 receptor agonists: wearable scores indicating deterioration when the clinical picture is actually fine. Session RPE as the real tool — why session RPE trending upward at stable training load is a more reliable signal of load-recovery mismatch than any biomarker currently used. Prevalence and confounders — the 60% figure, why it almost certainly captures all three FOR/NFOR/OTS categories plus REDS, depression, and illness, and why the residual true training-load-induced OTS in an otherwise healthy athlete may be vanishingly rare. Three failure modes — the three things Jordan actually sees in practice when lifters present saying they feel overtrained, and how to distinguish between them using session RPE. The medical workup — Austin's practical walkthrough of what to assess when programming and lifestyle changes don't move the needle, including iron deficiency (ferritin testing caveats, lab reference range problems), sleep apnea, post-viral syndromes, and hormone panels done correctly. Next Steps: For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com For ad free listening and exclusive discounts, become a Barbell Medicine Plus subscriber at https://barbellmedicine.supercast.com/ Resources Taxonomy / Definitions Meeusen et al. (2013) European College of Sport Science / ACSM consensus statement on FOR, NFOR, and OTS taxonomy. Defines OTS as a diagnosis of exclusion. https://pubmed.ncbi.nlm.nih.gov/23247672/ Meeusen et al. (2006) "Often only after a period of complete rest" — the retrospective nature of distinguishing NFOR from OTS. https://pubmed.ncbi.nlm.nih.gov/23016079/ Nocebo Effects in Sport 2024 Systematic Review Nocebo effects in sport were approximately twice the magnitude of placebo effects on performance across 20 studies. https://pubmed.ncbi.nlm.nih.gov/38999724/ Stress-Recovery-Adaptation Model Original general adaptation syndrome / stress physiology work in Nature. Foundational source the SRA model was derived from — not a sports science paper. https://www.nature.com/articles/138032a0 Multi-system adaptation timescales; critique of single-wave supercompensation model. https://pubmed.ncbi.nlm.nih.gov/3057313/ Multi-system adaptation timescales; further critique of the SRA "window of opportunity" model. https://pubmed.ncbi.nlm.nih.gov/15044685/ Lack of empirical support for the supercompensation "window of opportunity" in real training scenarios. https://pubmed.ncbi.nlm.nih.gov/29189930/ Resistance Training and OTS Grandou et al. (2020) Systematic review: 22 studies on resistance training overtraining. 10 showed zero performance decline under deliberate overload. No reliable biomarker established for RT overtraining; sustained performance drop is the only consistent signal. https://pubmed.ncbi.nlm.nih.gov/31313309/ Coleman et al. (2024) 9-week supervised high-volume RT protocol (~90 sets/week). No OTS criteria met. Ceiling for resistance training-induced OTS is considerably higher than commonly implied. https://pmc.ncbi.nlm.nih.gov/articles/PMC10809978/ Zourdos et al. (2016) Case series: 3 competitive strength athletes performed daily 1RM squat for 30 consecutive days. All three improved. https://pubmed.ncbi.nlm.nih.gov/26816276/ Daily 1RM Bench Press Study 7 athletes attempted a true 1RM bench press every day for 38 days. All improved despite day-to-day fluctuation. https://www.thefreelibrary.com/Efficacy+of+Daily+One-Repetition+Maximum+Bench+Press+Training+in...-a0828317501 3 weeks of daily loading; volume arm hypertrophied. Daily frequency did not produce overtraining; volume drives hypertrophy, not frequency alone. https://pubmed.ncbi.nlm.nih.gov/27875635/ Fry et al. (1994) — Overreaching Protocol Original resistance overreaching induction: 10×1 at 100% 1RM daily for 14 days. 1RM dropped ~12 kg. Hormonal response was opposite to endurance OTS profile (cortisol decreased, testosterone slightly increased). https://pubmed.ncbi.nlm.nih.gov/7808252/ Fry et al. (1994) — Endurance Biomarkers Endurance OTS biomarkers (T:C ratio) do not apply to high-intensity resistance training overreaching. https://pubmed.ncbi.nlm.nih.gov/9843563/ Fry et al. (2006) Same overreaching protocol with muscle biopsies. Beta-2 adrenergic receptor density in vastus lateralis decreased 37%. Orthopedic ceiling hypothesis: structural limits intervene before neuroendocrine axis fully desensitizes. https://pubmed.ncbi.nlm.nih.gov/16888042/ Raastad et al. (2001) Daily submaximal leg training for 2 weeks; 1RM increased 6%. Intensity (not frequency) is the necessary ingredient for overreaching in resistance training. https://pubmed.ncbi.nlm.nih.gov/11394254/ Margonis et al. (2007) 12-week progressive RT peaking at ~14 tonnes/week. Significant 1RM decrements not restored after 6-week taper — the only resistance training study to approach true OTS criteria. https://pubmed.ncbi.nlm.nih.gov/17697935/ HPA Axis / Biomarkers Cadegiani & Kater (2017) — EROS Study Resting cortisol is normal in ≥75% of OTS studies. Reduced pituitary ACTH output (not adrenal failure) is the upstream dysregulation in OTS. "Adrenal fatigue" is mechanistically backwards. https://pmc.ncbi.nlm.nih.gov/articles/PMC5722782/ EROS Study — Extended Findings Further EROS study data on HPA axis dysregulation patterns in OTS. https://pmc.ncbi.nlm.nih.gov/articles/PMC6590962/ Testosterone: acute 30% drops occur routinely after a marathon and normalize within days. Never validated as an individual OTS diagnostic. https://pubmed.ncbi.nlm.nih.gov/3744643/ Saw et al. (2016) 56-study systematic review of athlete monitoring tools. Subjective measures (mood, perceived fatigue, sleep quality) tracked training load changes with greater sensitivity than objective markers including hormones, resting HR, and HRV. https://pmc.ncbi.nlm.nih.gov/articles/PMC4789708/ Meeusen et al. (2004/2010) — Two-Bout Exercise Protocol Two maximal incremental tests 4 hours apart with serial blood draws. OTS athletes show blunted ACTH/prolactin response to second bout; NFOR athletes show exaggerated response. Most validated objective test available; not a field tool. https://pubmed.ncbi.nlm.nih.gov/18703548/ HRV as a Monitoring Tool HRV for OTS detection: weak data, foundational work done in cyclists and triathletes only. https://pubmed.ncbi.nlm.nih.gov/23852425/ Strength recovery occurred ~30 hours after heavy loading; HRV had not normalized at 60 hours. Using HRV as a daily training prescription tool in strength athletes is an untested assumption. https://pubmed.ncbi.nlm.nih.gov/21273908/ Session RPE and Monitoring Foster et al. (1998) Session RPE method: training load quantified as RPE × session duration. Key monitoring metric throughout the episode. https://pubmed.ncbi.nlm.nih.gov/9662690/ Soreness, mood, and motivation relative to training load as monitoring signals. https://pubmed.ncbi.nlm.nih.gov/38321325/ Prevalence Morgan et al. (1987) The commonly cited 60% OTS prevalence figure. Retrospective self-report using the term "staleness," conducted before the current taxonomy existed. Almost certainly captures all three tiers of the FOR/NFOR/OTS continuum. https://pubmed.ncbi.nlm.nih.gov/3676635/ Confounders: PED Use Anonymous Survey Data (2011) 29% of Track and Field World Championship athletes admitted PED use; 45% at Pan-Arab Games. https://core.ac.uk/download/pdf/109992897.pdf Lippi et al. (2015) WADA detects PED use in only 1–2% of samples; USADA detection rate <1%. Elite athlete PED use is substantially underreported in the OTS literature. https://www.nature.com/articles/517529a Confounders: Psychiatric Conditions Armstrong & VanHeest (2002) Overlap between OTS and major depression. Depression can produce every OTS symptom; any OTS workup without a formal depression screen is incomplete. https://pubmed.ncbi.nlm.nih.gov/11839081/ Confounders: Energy Availability Cadegiani et al. (2021) 86% of OTS studies showed co-occurrence of reduced energy availability with OTS-like presentation. https://pubmed.ncbi.nlm.nih.gov/34181189/ Autoregulation and RPE — Part I Barbell Medicine blog post on autoregulation and RPE-based programming. https://www.barbellmedicine.com/blog/autoregulation-and-rpe-part-i/ Training Plateau Action Plan Barbell Medicine practical guide for diagnosing and addressing training plateaus. https://www.barbellmedicine.com/training-plateau-action-plan/ Injury / Rehab Coaching Questionnaire https://www.barbellmedicine.com/coaching-questionnaire-injury-rehab/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

In this free preview of the March 2026 Direct Line AMA. Drs. Feigenbaum and Baraki cover: VO2 max versus cardiorespiratory fitness for longevity (are Peter Attia’s targets evidence-based? — with Goodhart’s Law and the JAMA evidence), what GLP-1 medications actually cost now via manufacturer programs ($149–449/month), and whether 7,000–10,000 daily steps actually meet the bar for cardiovascular training. Full episode for Barbell Medicine Plus subscribers at https://barbellmedicine.supercast.com/ Timestamps: 0:00 — Introduction 3:26 — VO2 Max vs. Cardiorespiratory Fitness for Longevity 14:11 — GLP-1 Costs: What you should actually be paying now 21:43 — Is Walking Enough for Cardiovascular Health? Next Steps: For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com Resources: JAMA Network Open — Cardiorespiratory Fitness & Long-term Mortality (Mandsager et al.) — Exercise capacity (METs) and longevity — the foundational CRF/mortality study cited in the episode https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2707428 JAMA — Blair et al. — Physical fitness and all-cause mortality: a prospective study of healthy men and women https://jamanetwork.com/journals/jama/fullarticle/379243 Barbell Medicine Vital Five — Multi-modal CRF benchmarks and longevity targets https://www.barbellmedicine.com/vital-5-action-plan/ Lilly Direct — Zepbound (tirzepatide) — Manufacturer direct program ($299–449/month) https://www.lillydirect.com/zepbound NovoCare — Wegovy (semaglutide) — Manufacturer savings program ($149–349/month) https://www.novocare.com/patient/medicines/wegovy.html Orforglipron — Eli Lilly oral GLP-1 — What to know about orforglipron (small-molecule oral GLP-1 agonist, pending FDA approval) https://www.lilly.com/news/stories/what-to-know-about-orforglipron Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

You can have a completely normal BMI and be on your way to cardiovascular disease, type 2 diabetes, and metabolic syndrome without triggering a single alert on a standard health screening. The fat that predicts metabolic risk most accurately isn't the fat your scale or your doctor is tracking. Dr. Jordan Feigenbaum breaks down the science of visceral fat — what it is, how it causes disease, how to measure it correctly at home for free, and what the evidence actually shows about exercise, GLP-1 medications, and testosterone. Timestamps: 00:00:00 Cold Open: The Visceral Fat Finding 00:00:49 The Scale Problem — What Body Weight Actually Measures 00:03:50 What Is Visceral Fat — and Why It's Not Just "Belly Fat" 00:05:04 Three Competing Theories: How Visceral Fat Actually Causes Disease 00:08:35 Adipokines: PAI-1, Angiotensinogen, and What Happens When Adiponectin Drops 00:09:52 How to Measure: Three Sites That Don't Give the Same Number 00:14:30 Clinical Thresholds, Ethnic Adjustments, and the Waist-to-Height Ratio 00:15:45 The Weight-to-Waist Ratio: Tracking the Quality of Your Fat Loss 00:19:20 Sleep, Cortisol, and Why the Hormonal Environment Has to Support the Work 00:21:24 Why Exercise Reduces Visceral Fat 6× More Than Diet Alone 00:22:02 Mechanism 1 — Beta-3 Adrenergic Receptors and Preferential Visceral Fat Mobilization 00:24:10 Mechanism 2 — Myokines: The Fat-Burning Signal Only Contracting Muscle Can Send 00:26:21 GLP-1 Agonists and Body Composition: What the Clinical Trials Actually Show 00:28:05 DXA's Blind Spot: Myosteatosis, Glycogen, and Why Lean Mass Numbers Are Inflated 00:30:10 SEMALEAN, the BELIEVE Trial, and the 1-in-10 Reality of Long-Term Lifestyle Programs 00:33:15 Testosterone, Visceral Fat, and the Aromatase Feed-Forward Loop 00:36:05 Three Testosterone Ranges: Deficient, Eugonadal, and Supraphysiological 00:38:05 The Bhasin 4-Group Study — and Why AAS Are a Class, Not a Synonym for TRT 00:39:33 Tesamorelin: The GHRH Analogue That Selectively Targets Visceral Fat 00:40:53 Practical Framework: What to Measure, When, and What to Do 00:43:20 Key Takeaways Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com Barbell Medicine Vital 5 Action Plan: https://www.barbellmedicine.com/vital-5-action-plan/ Resources: https://pubmed.ncbi.nlm.nih.gov/11502820/ https://pubmed.ncbi.nlm.nih.gov/33567185/ https://pubmed.ncbi.nlm.nih.gov/35658024/ https://pubmed.ncbi.nlm.nih.gov/40318682/ https://pubmed.ncbi.nlm.nih.gov/41068996/ https://pubmed.ncbi.nlm.nih.gov/41772149/ https://pubmed.ncbi.nlm.nih.gov/23944298/ https://pubmed.ncbi.nlm.nih.gov/20948519/ https://pubmed.ncbi.nlm.nih.gov/27213481/ https://pubmed.ncbi.nlm.nih.gov/23303913/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

A fit, healthy 39-year-old was nearly sent for a liver biopsy. The cause? Was it that he went to the gym before every blood draw or because his supplement was throwing his labs off?. Dr. Jordan Feigenbaum and Dr. Austin Baraki break down the blind spot that sends thousands of healthy athletes down an expensive, potentially unnecessary diagnostic rabbit hole every year. Timestamps: 00:01:09 Introducing the Case 00:03:44 How to Read a Liver Panel: ALT, AST, GGT, Alk Phos, Albumin Explained 00:10:50 What Is GGT and Why Does It Matter Clinically? 00:16:38 Why Exercise, Protein, and Creatine Aren't on the Differential (Yet) 00:17:35 The Workup: Hepatitis Panels, Abdominal Ultrasound, and More 00:19:42 Second Set of Labs — The Mystery Deepens 00:25:25 Updated Differential: What's Still on the List? 00:27:08 The Labs Normalize — A Critical Clue Appears 00:31:40 The Reveal: Exercise Was the Cause All Along 00:32:18 The Mechanism: How Exercise Elevates 'Liver' Enzymes 00:32:54 Point 1 — ALT & AST Are Not Exclusively Liver Enzymes 00:33:49 Point 2 — It's Unavoidable: 100% of Lifters Are Affected 00:36:02 Point 3 — It Takes 10–12 Days to Normalize 00:37:00 Point 4 — It's Mostly Harmless 00:38:27 56% of Physicians Miss This Diagnosis 00:38:48 Why Clinicians Overlook Exercise History 00:44:01 Point 5 — GGT as the Differentiator (And Its Limits) 00:46:42 Why Alkaline Phosphatase Also Rises Post-Workout 00:48:51 The Cost of Missing Lifestyle Context: Over- and Under-Diagnosis 00:53:29 What to Say to Your Doctor: 3 Patient Scripts 00:59:31 5 Key Takeaways 01:00:25 Final Advice from Dr. Baraki Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com Barbell Medicine Vital 5 Action Plan: https://www.barbellmedicine.com/vital-5-action-plan/ Resources: Case: https://pubmed.ncbi.nlm.nih.gov/37025214/ https://pubmed.ncbi.nlm.nih.gov/29059178/ https://pmc.ncbi.nlm.nih.gov/articles/PMC7438350/ https://pubmed.ncbi.nlm.nih.gov/18557801/ https://pubmed.ncbi.nlm.nih.gov/19209234/ https://pubmed.ncbi.nlm.nih.gov/11476029/ https://pmc.ncbi.nlm.nih.gov/articles/PMC11165564/ https://pmc.ncbi.nlm.nih.gov/articles/PMC12460594/ https://pmc.ncbi.nlm.nih.gov/articles/PMC2291230/ https://pmc.ncbi.nlm.nih.gov/articles/PMC11319523/ https://pmc.ncbi.nlm.nih.gov/articles/PMC3936967/ https://pmc.ncbi.nlm.nih.gov/articles/PMC12188904/ https://pmc.ncbi.nlm.nih.gov/articles/PMC7969109/ https://pmc.ncbi.nlm.nih.gov/articles/PMC11498664/ https://pmc.ncbi.nlm.nih.gov/articles/PMC3104191/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

In this special preview of the Barbell Medicine Plus Direct Line, Dr. Jordan Feigenbaum and Dr. Austin Baraki move past the fitness basics to tackle high-level technical nuances. We dive into the persistent myth of "muscle imbalances" and why your asymmetry might actually be a functional feature of your training. We also address the "meat" of the cardiovascular debate: is red meat and saturated fat consumption still risky if you are highly active and have a high-fiber diet? Finally, we explore the Dual Intervention Point Model to explain why the body defends its energy stores and how our environment has shifted the biological "set point" for body fat. Timestamps 00:00 – Barbell Medicine Plus: Special Annual Membership Promotion 01:03 – Muscle Imbalances: A Reliable Predictor of Pain? 03:59 – Acuted vs. Gradually Acquired Asymmetries 08:55 – How Coaches Should Manage "Alignment" Beliefs 11:54 – Is Red Meat Necessary to Limit if You Are Otherwise Healthy? 15:36 – The Role of Substitution: Plant vs. Animal Protein 19:50 – Analyzing the Lean Mass Hyper-Responder (LMHR) Phenotype 26:20 – The Dual Intervention Point Model of Body Fatness 30:26 – Lipostat, Gravistat, and the Regulation of Energy Stores Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com Barbell Medicine Vital 5 Action Plan: https://www.barbellmedicine.com/vital-5-action-plan/ Key Takeaways Asymmetry as a Feature: Human bodies are not naturally symmetrical. In many athletes—such as tennis players, pitchers, or rowers—asymmetry is a functional adaptation to the sport's demands. The Pathological vs. The Normal: Acutely acquired asymmetries (post-surgery or trauma) require specific clinical attention. Long-standing or gradually acquired asymmetries are rarely the primary driver of pain. Saturated Fat & The Healthy User Bias: While fit individuals have a lower overall risk profile, elevated LDL and ApoB particles represent a "time-volume" exposure risk that should not be ignored based solely on lifestyle. The Lean Mass Hyper-Responder (LMHR): We analyze the bold claims surrounding the LMHR phenotype and discuss why mechanistic hypothesizing currently lacks the "hard human outcome receipts" to prove long-term safety. Body Fat Regulation: The Dual Intervention Point Model suggests the body defends a lower boundary (starvation) and an upper boundary (predation). In the modern environment, the "predation pressure" has vanished, leading to a genetic drift upward in body fat set points. Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Most doctors, trainers, and "safety-first" influencers warn that holding your breath while lifting is a dangerous habit that could lead to a stroke or heart failure. By looking back at the 300-year history of the Valsalva maneuver—from a 1704 ear treatment to the "boogeyman" blood pressure studies of the 1980s—we dismantle the myth of the "fragile tube." Discover the science of the "pressurized suit" and why your body is actually designed to handle extreme internal pressure during heavy exertion. Key Takeaways The 'Ear Trick' Origins: Originally described in 1704 by Antonio Maria Valsalva as a way to clear middle-ear infections, the maneuver wasn't linked to cardiovascular risk until the 1850s "Weber experiments." The MacDougall 480/350 Study: Why the finding of massive blood pressure spikes during leg presses may have created a "villain arc" for the Valsalva maneuver in modern medicine. Transmural Pressure Protection: A blood vessel fails when internal pressure significantly exceeds external support; during a Valsalva, the internal spike is matched by an external "cradle" of intra-thoracic and cerebrospinal fluid pressure. Reflexive vs. Intentional Bracing: The Valsalva maneuver is a hard-wired reflex that triggers involuntarily at approximately 80% of a maximal voluntary contraction to stabilize the trunk. Vascular Safety and Stroke Risk: Evidence suggests that for healthy populations, the risk of a vascular "pop" is negligible because the pressure gradient across the vessel wall (transmural pressure) remains stable. Pregnancy and Fetal Safety: Clinical data on pregnant athletes shows that heavy, braced lifting up to 90% of a 10-rep max does not cause fetal distress or compromised uterine blood flow. The 'Hissing' Safety Valve: For those prone to lightheadedness or pelvic floor symptoms, using a slow, active exhalation (a hiss) during the concentric phase can help manage pressure transitions. Timestamps [00:00] History: From the 1704 Ear Treatise to the Weber Fainting Experiments [05:26] The 1985 MacDougall Study: Origin of the "480/350" Blood Pressure Boogeyman [06:22] The Anatomy of a Breath-Hold: The 4 Phases of the Valsalva Maneuver [12:59] Reflexive Bracing: Why You Can’t Stop Yourself from Holding Your Breath [28:24] The Pressurized Suit: Transmural Pressure and Vascular Safety [31:00] The Brain and the Box: CSF Protection and Intracranial Pressure [35:27] Heart Health: Does Lifting Cause Pathological Heart Thickening? [41:17] Special Populations: Strokes, Aneurysms, and the 'Pop' Theory [46:15] The Pelvic Floor: Stress Incontinence and the Weightlifter's Paradox [49:34] Pregnancy: Monitoring Fetal Heart Rates During Heavy Braced Lifting [56:42] Contraindications: When is the Valsalva Maneuver Actually Dangerous? Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com Barbell Medicine Vital 5 Action Plan: https://www.barbellmedicine.com/vital-5-action-plan/ References Middle Cerebral Artery and Valsalva Valsalva During Resistance Training Valsalva and Force Production and Weight IAP During Coughing Lifting Belt’s Effects Leg Press Training and Heart Adaptations Powerlifter’s Hearts Valsalva Maneuver and Cerebrovascular Dynamics RT, VM, and Cerebrovascular Pressures Women’s Pelvic Floors Pregnancy and RT and Again Fetal Heart Rate Injury Risk Hernia SUI Podcast Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

The longevity industry is now worth over $100 billion per year. From DNA methylation clocks to multi-cancer blood tests and GLP-1 medications, the promises are bold. But what actually predicts lifespan? In this episode, Dr. Jordan Feigenbaum and Dr. Austin Baraki break down the science behind biological clocks, the real story on GLP-1–related muscle loss, and introduce the Barbell Medicine “Vital Five” — a clinically grounded framework for health and longevity. Key Points: The Three Generations of Biological Clocks: Understanding the evolution of DNA methylation tests from simple chronological markers (Horvath) to sophisticated predictors of mortality (GrimAge) and functional decline (DunedinPACE). Descriptive vs. Prescriptive Metrics: Why a biological age score acts as a lagging indicator rather than a tool for clinical decision-making, compared to traditional risk factors like blood pressure and ApoB. GLP-1s and Sarcopenia Reality: A nuanced look at lean mass loss during semaglutide and tirzepatide treatment, emphasizing the difference between total lean mass and actual skeletal muscle quality. Weight-Independent Benefits of Incretins: Analyzing data from the SELECT and FLOW trials regarding the direct cardioprotective and renal benefits of GLP-1 receptor agonists. The Limitations of Early Detection: Why multi-cancer early detection (MCED) tests can lead to diagnostic loops and how clinical utility differs from marketing promises. The Barbell Medicine Vital Five: A definitive framework for longevity focusing on blood pressure, ApoB, VO2 max, relative strength, and body composition. Neurodegenerative Research Outlook: A critical review of the EVOKE trials and the potential (or lack thereof) for current weight-loss medications in treating established Alzheimer's disease. Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.com Timestamps: 00:00 Overview: longevity industry and proxy metrics 01:06 Biological age and DNA methylation clocks 08:18 Clinical usefulness and limitations of biological age testing 16:16 Multi-cancer early detection tests: screening tradeoffs 30:39 Exercise prescription for longevity (treat-to-target) 54:39 Protein intake and longevity: evidence and recommendations 1:07:23 GLP-1 receptor agonists: outcomes, misconceptions, and use cases 1:34:24 Hormone therapy (women and men): risks, benefits, evidence 1:49:19 Practical longevity tracking: “Vital Five” markers 1:58:15 Closing References: Biological Clock https://pmc.ncbi.nlm.nih.gov/articles/PMC8853656/ https://pmc.ncbi.nlm.nih.gov/articles/PMC12038942/ https://pmc.ncbi.nlm.nih.gov/articles/PMC11424583/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6366976/ Cancer Screening https://ascopubs.org/doi/10.1200/JCO.2019.37.15_suppl.5574 https://www.thelancet.com/article/S1470-2045(23)00277-2/fulltext https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01700-2/fulltext https://www.nhs-galleri.org/ Exercise https://bjsm.bmj.com/content/56/13/755 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2807854 https://pubmed.ncbi.nlm.nih.gov/35442242/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8915309/?mc_cid=87bfcaaa3a&mc_eid=8786146256 https://pmc.ncbi.nlm.nih.gov/articles/PMC9012529/ https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2707428 https://pubmed.ncbi.nlm.nih.gov/35228201/ https://pubmed.ncbi.nlm.nih.gov/35662329/ https://academic.oup.com/biomedgerontology/article/77/4/781/6354429 https://www.sciencedirect.com/science/article/abs/pii/S0025619625001004 https://pmc.ncbi.nlm.nih.gov/articles/PMC12131147/ https://pubmed.ncbi.nlm.nih.gov/18595904/ https://pubmed.ncbi.nlm.nih.gov/12242311/ Protein https://pubmed.ncbi.nlm.nih.gov/40418846/ https://pmc.ncbi.nlm.nih.gov/articles/PMC7250948/ https://pubmed.ncbi.nlm.nih.gov/39110456/ https://pubmed.ncbi.nlm.nih.gov/24606898/ https://www.bmj.com/content/370/bmj.m2412 GLP-1 https://www.cell.com/cell-metabolism/abstract/S1550-4131(26)00008-2 https://www.nejm.org/doi/full/10.1056/NEJMoa2307563 https://www.nejm.org/doi/abs/10.1056/NEJMoa2403347 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01296-0/fulltext https://link.springer.com/article/10.1007/s11154-025-09991-4 https://pmc.ncbi.nlm.nih.gov/articles/PMC12338914/ HRT https://pubmed.ncbi.nlm.nih.gov/25754617/ https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(25)00211-6/abstract https://www.nejm.org/doi/full/10.1056/NEJMoa2215025 https://pmc.ncbi.nlm.nih.gov/articles/PMC4527564/ https://www.mdpi.com/1422-0067/25/22/12221 Body Roundness Index (BRI) : https://www.barbellmedicine.com/blog/should-bri-replace-bmi/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Lifting more weight doesn't always mean you've gotten stronger. In this foundational session, Dr. Jordan Feigenbaum and Dr. Austin Baraki introduce the Fitness-Fatigue Model to explain why "stalled" progress is often just a temporary masking of strength by accumulated fatigue. By learning to differentiate between a lack of fitness adaptation and a lack of recovery, you can avoid the "panic pivot" and maintain the long-term signal necessary for elite-level gains. Supercast Sign-Up For the 6-part audio series and Training Plateau Action Plan, sign-up for Barbell Medicine Plus: https://barbellmedicine.supercast.com/ Key Learning Points The Fitness-Fatigue Model: Understand the physiological duality of every workout—while a session builds your "fitness" (potential), it also creates "fatigue" that temporarily suppresses your performance. Strength vs. Effort: Performance must be measured relative to RPE. If the weight on the bar increases but the RPE climbs disproportionately (e.g., jumping from RPE 8 to RPE 10 for a 5lb gain), your absolute strength has not actually improved. Noise vs. Signal: A one-week stall is statistical "noise." Constant program hopping in response to a single bad session destroys the cumulative stimulus (the "signal") required for actual tissue adaptation. The Root Cause Audit: Determining the "Why" behind a plateau. Lack of Fitness: The stimulus is no longer sufficient to drive a new adaptation (Needs more volume/intensity). Lack of Recovery: The fatigue is overwhelming the adaptation (Needs a deload or volume reduction). Autoregulation as a Diagnostic Tool: Using RPE not just to prescribe load, but to "interrogate" your current state of recovery and readiness. Timestamps [00:00] Intro: Introducing the Barbell Medicine Plus Exclusive Series [02:15] The Thought Experiment: 310x6 @ 8 vs. 315x6 @ 10 [05:30] Deep Dive: Defining the Fitness-Fatigue Model [09:45] Interpreting the Stall: Is it a Stimulus Problem or a Recovery Problem? [14:20] The Danger of "Short-Termism": Why Panicking Destroys the Signal [18:50] Introduction to the 6-Part Audio Course & Actionable PDF Pearls The Pivot Rule: Never change a successful program based on a single week of data. Look for a 3-week trend of stagnant or declining performance (at the same RPE) before initiating a program pivot. Peaking Mechanics: Most "peaking" protocols do not build new strength; they simply reduce fatigue to reveal the strength you've already built. The stimulus-Recovery Trap: If you feel "beat up" but the weights are moving well, you likely don't need a deload yet. If you feel "great" but the weights are stuck, you likely need a stronger stimulus. Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Can a simple one-second squeeze predict your risk of cardiovascular disease, cognitive decline, and all-cause mortality? Dr. Jordan Feigenbaum and Dr. Austin Baraki explore why grip strength has become the go-to metric for the longevity industry and why most people are interpreting the data incorrectly. Timestamps: [00:00] Intro: The Longevity Industry’s Thermometer Error [01:42] The Neuro-Axis: Anatomy of a Maximal Squeeze [06:43] The 35-3-5 Rule: Biomechanics of Grip [09:12] Asymmetries and Clinical Red Flags [17:31] Dynapenia vs. Sarcopenia: Why the Hand Fails First [18:41] Normative Data and the PURE Study Statistics [27:16] Genetics, Lean Body Mass, and Predictive Power [31:44] Absolute vs. Relative Grip Strength (The Metabolic Signal) [37:03] Bro-Science Beatdown: Neural Jitter and Training Readiness [42:19] The Extensor Training and "Grip Maxing" Myth [45:13] Programming: Systemic Training vs. Indirect Grip Work [48:10] The Straps Debate: Are You Killing Your Gains? [52:03] Final Verdict: Hierarchy and Health Priorities Key Takeaways: Grip is Systemic: Handgrip strength tests the integrity of the entire system, from the motor cortex in the brain down to the tendons and bones. It is a proxy for overall muscular quality and neurological health. Predictive Power: According to the PURE study, for every 5 kg decrease in grip strength, there is a 17% increased risk of cardiovascular death and a 7% increased risk of non-cardiovascular death. The Sarcopenia Floor: Clinical "red zones" for probable sarcopenia are <27 kg for men and <16 kg for women. Relative Strength Matters: Relative grip strength (Grip Strength ÷ BMI) is a more accurate predictor of hypertension, diabetes, and dyslipidemia than absolute grip strength alone. Don't Chase the Test: Direct grip training (crushers, etc.) obscures the predictive power of the test. To improve health, focus on indirect systemic resistance training (training the whole body) rather than "gaming" the thermometer. Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized medical and training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ RESOURCES: https://europepmc.org/article/med/1538102 https://pubmed.ncbi.nlm.nih.gov/12188074/#/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6322506/ https://pmc.ncbi.nlm.nih.gov/articles/PMC10777545/#/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6322506/#/ https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0113637#/ https://pubmed.ncbi.nlm.nih.gov/31499496/#/ https://pubmed.ncbi.nlm.nih.gov/25982160/#/ https://www.sciencedirect.com/science/article/pii/S2095254620300752?via%3Dihub#/ https://pubmed.ncbi.nlm.nih.gov/27701433/#/ https://pmc.ncbi.nlm.nih.gov/articles/PMC5517526/#/ https://pubmed.ncbi.nlm.nih.gov/18271028/#/ https://pmc.ncbi.nlm.nih.gov/articles/PMC7344191/#/ https://pmc.ncbi.nlm.nih.gov/articles/PMC7244054/#/ https://www.sciencedirect.com/science/article/abs/pii/S1388245710003561#/ https://pubmed.ncbi.nlm.nih.gov/25653226/#/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6306785/#/ https://pubmed.ncbi.nlm.nih.gov/27619723/#/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Dr. Feigenbaum and Dr. Baraki walk through the clinical workup of a 24 year old male presented with persistent weakness in his foot following weight loss of 22 pounds in two weeks. What could've possibly caused this? The discussion pivots to the science of how fast one should lose weight. While athletes should prioritize slow loss to preserve performance and lean mass, the data for individuals with obesity suggests that the speed of loss may be less critical than protein intake and resistance training. Timestamps: 00:00 - The Case of the Paralyzed Personal Trainer 03:48 - How Doctors Build a Differential for Weakness 12:08 - Interpreting Negative Labs and MRI Results 15:04 - Identifying Foot Drop and Nerve Distribution 20:53 - Understanding Nerve Conduction and EMG Studies 26:06 - The Diagnosis: Slimmers Paralysis Explained 32:56 - Are GLP-1 Medications Increasing Nerve Injury Risks? 35:01 - Rapid vs Slow Weight Loss: Muscle Mass and Performance 41:27 - The Truth About Metabolic Adaptation and Weight Regain 52:33 - New Research on Weight Regain After Stopping Medications 58:32 - Clinical Recommendations for Sustainable Weight Management Key Learning Points (SPOILER ALERT) Slimmer’s Paralysis (Dieting Palsy): Discover how rapid fat loss depletes the protective structural fat pads at the fibular head, leaving the common peroneal nerve vulnerable to compression. The "Two-Hit" Model: Understand how the combination of biological depletion (rapid weight loss) and mechanical provocation (aggressive stretching or squatting) triggers focal weakness. Speed vs. Quality for Athletes: Evidence suggests that for trainees, a slower weight loss rate of $\sim$0.7% of body weight per week is superior for maintaining lean mass compared to faster rates. Metabolic Adaptation as a Signature of Success: Why a reduction in resting metabolic rate is an unavoidable adaptive response to weight loss and not necessarily a predictor of future weight regain. Diagnosing Focal Weakness: A step-by-step look at how clinicians differentiate between lumbar spine issues and peripheral nerve entrapment using physical exams and electrodiagnostic testing. Resources: Case: https://pubmed.ncbi.nlm.nih.gov/39809480/ https://pubmed.ncbi.nlm.nih.gov/29503139/ https://pmc.ncbi.nlm.nih.gov/articles/PMC12157737/ https://pmc.ncbi.nlm.nih.gov/articles/PMC11273815/ https://pubmed.ncbi.nlm.nih.gov/32576318/ https://pubmed.ncbi.nlm.nih.gov/20443094/ https://pubmed.ncbi.nlm.nih.gov/24372837/ https://pubmed.ncbi.nlm.nih.gov/25459211/ https://www.bmj.com/content/392/bmj-2025-085304 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

In this episode, Dr. Jordan Feigenbaum and Dr. Austin Baraki dissect the federal government’s 2026 Food Pyramid Reset and its radical shift in nutrition policy. They explore the history of industry lobbying that shaped previous guidelines and evaluate whether the new emphasis on protein and animal fats aligns with current clinical evidence. Finally, the doctors provide the framework for the Barbell Medicine Dietary Guidelines, offering a practical, evidence-based framework for managing the modern food environment. Timestamps 00:00 - Introduction: The 1992 Food Pyramid vs. the 2026 Reset 03:11 - A History of Lobbying: From the McGovern Committee to the USDA 09:44 - Big Food and Big Tobacco: How the American pantry was engineered 17:15 - The Good: Protein floors and the official war on ultra-processed foods 27:13 - The Bad: Saturated fat, beef tallow, and the dairy hall pass 44:02 - The Ugly: The 25-gram fiber gap and the retreat on alcohol guidelines 54:10 - Economic barriers and the Healthy Eating Index scores 01:06:18 - The Barbell Medicine Dietary Guidelines: A practical framework Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized medical and training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ Key Learning Points Environment over Willpower: Weight gain is an emergent process caused by an engineered food environment that adds nearly 500 passive calories to the average American's daily intake compared to 1977. The New Protein Floor: The 2026 Reset finally acknowledges that the old 0.8g/kg RDA was a "survival dose." The new range of 1.2–1.6g/kg is a victory for skeletal muscle health, though doesn't really change intake for many (if they even read the guidelines). Incoherent Fat Logic: There is a fundamental conflict in guidelines that recommend beef tallow and butter while simultaneously advising that saturated fat stay below 10% of total calories. The Fiber Gap: By emphasizing animal proteins over legumes, the new guidelines risk widening the already massive fiber deficiency in the U.S. The 10:1 Rule: For better metabolic health, aim for a carbohydrate-to-fiber ratio of 10:1 (acceptable) or 5:1 (elite). References Barbell Medicine Guidelines Coming Soon! https://www.youtube.com/watch?v=inCEbKyWYwg (Trial of Big Food) https://pmc.ncbi.nlm.nih.gov/articles/PMC12027923/ https://www.govinfo.gov/content/pkg/CPRT-95SPRT98364O/pdf/CPRT-95SPRT98364O.pdf https://pubmed.ncbi.nlm.nih.gov/31462476/ https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001050 https://pubmed.ncbi.nlm.nih.gov/6841553/ https://pubmed.ncbi.nlm.nih.gov/7068846/ https://pubmed.ncbi.nlm.nih.gov/6841553/ https://pubmed.ncbi.nlm.nih.gov/7068846/ https://pmc.ncbi.nlm.nih.gov/articles/PMC10552423/ https://pubmed.ncbi.nlm.nih.gov/26980437/ https://pubmed.ncbi.nlm.nih.gov/26843151/ https://pmc.ncbi.nlm.nih.gov/articles/PMC10552423/ https://pubmed.ncbi.nlm.nih.gov/26980437/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6124841/ https://pubmed.ncbi.nlm.nih.gov/28889851/ https://www.ers.usda.gov/data-products/chart-gallery/chart-detail?chartId=58372#:~:text=As%20their%20incomes%20rise%2C%20U.S.,of%20after%2Dtax%20income). https://www.ers.usda.gov/data-products/food-price-outlook/summary-findings#:~:text=Beef%20and%20veal%20prices%20are,higher%20than%20in%20August%202024. https://pmc.ncbi.nlm.nih.gov/articles/PMC4733413/ https://pubmed.ncbi.nlm.nih.gov/26843151/ https://www.barbellmedicine.com/blog/how-to-eat-a-healthy-diet/ https://www.barbellmedicine.com/resources/calorie-calculator/ https://www.barbellmedicine.com/resources/macronutrient-calculator/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Fiber is the most underutilized tool in human nutrition. While the internet is currently buzzing about the new food pyramid and debating processed foods versus beef tallow, most people are missing the actual structural levers that dictate health and performance. Today, we are launching the Barbell Medicine Fiber Action Plan to bridge the gap between clinical science and your next trip to the grocery store. If you are a Barbell Medicine Plus subscriber, you can binge the entire 4-part audio series and download the full Action Plan right now in the Plus feed. If you are not a subscriber, head to the link below to sign up for early access to the Action Plan and exclusive content. Join Barbell Medicine Plus: https://barbellmedicine.supercast.com/ In this series, we move beyond the simple soluble versus insoluble labels and discuss how fiber can lower cholesterol, manage blood sugar, and regulate satiety. Nutrition should not be a social media shouting match; it should be a deliberate strategy for your health. Stop guessing, get the guide, and let us get to work. Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

For decades, the health and fitness industry has blamed rising obesity rates on a lack of individual willpower and "poor choices." However, a landmark lawsuit in San Francisco argues that the modern food environment is a public nuisance engineered by food giants using a literal tobacco playbook. By manipulating "Bliss Points" and dismantling the natural food matrix, these companies have created an environment where healthy choices are the path of highest resistance. Understanding the shift from personal responsibility to environmental accountability is the first step in reclaiming your health. Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized medical and training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ Timestamps 00:00 - The San Francisco Lawsuit vs. Big Food 01:46 - Legal Shift: Personal Choice vs. Public Nuisance 08:02 - Probabilistic Automaticity: Why Environment Wins 13:40 - The 500-Calorie Shift: The Rise of Energy Toxicity 16:11 - The Tobacco Playbook & The Bliss Point 22:33 - The Potato Continuum & The Food Matrix 28:09 - Yale Food Addiction Scale (YFAS) Data 33:48 - The BMJ Umbrella Review on UPF Risks 52:35 - Practical Strategy: Playing Offense at Home Key Points The Public Nuisance Shift: Why legal strategy is moving away from "individual choice" toward holding corporations accountable for creating a toxic health environment. Probabilistic Automaticity: Human willpower hasn't decreased since the 1970s; instead, the probability of making a "bad" choice has been engineered to increase through environmental cues. The Bliss Point: How food scientists precisely calibrate salt, sugar, and fat to create a transient "nirvana" that mutes the brain's satiety signals. The Potato Continuum: A framework for understanding how processing transforms a simple, satiating food into an energy-dense, hyper-palatable "drug." Food Addiction Data: Why 14% of adults meeting the Yale Food Addiction Scale criteria suggests a systemic design flaw in our food supply, not a character flaw in the consumer. The Tobacco Playbook: The historical link between cigarette manufacturers buying food companies and the subsequent optimization of addictive "mouthfeel" and delivery systems. Clinical Pearls Master Your Micro-Environment: Spend your "willpower budget" only once—at the grocery store. If hyper-palatable foods aren't in your pantry, they cannot exploit your fatigue at 9 p.m. Prioritize the Food Matrix: Aim for foods high in protein and fiber that have "built-in stoplights," rather than ultra-processed items where the matrix has been dismantled. Distraction-Free Feeding: Eliminate "subconscious eating" by removing screens during meals, allowing your brain to accurately register hormonal satiety signals like leptin and ghrelin. References: https://sfcityattorney.org/san-francisco-city-attorney-chiu-sues-largest-manufacturers-of-ultra-processed-foods/ https://www.lawforhoas.com/civil-code-section-3479-nuisance-defined https://www.naag.org/our-work/naag-center-for-tobacco-and-public-health/the-master-settlement-agreement/ https://pmc.ncbi.nlm.nih.gov/articles/PMC3667220/ https://pubmed.ncbi.nlm.nih.gov/22551473/ https://linkinghub.elsevier.com/retrieve/pii/S0195666325000819 https://psycnet.apa.org/record/2006-22447-006 Maimati 2018 Stephen 2020 Machado 2019 Young 2002 Zlatevska 2014 https://pubmed.ncbi.nlm.nih.gov/37250387/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6550161/ https://pubmed.ncbi.nlm.nih.gov/30040431/ https://pubmed.ncbi.nlm.nih.gov/31105044/ https://pubmed.ncbi.nlm.nih.gov/37813420/ https://ajcn.nutrition.org/article/S0002-9165(22)00584-6/fulltext https://pubmed.ncbi.nlm.nih.gov/38418082/ https://www.fao.org/3/ca5644en/ca5644en.pdf https://www.mdpi.com/2674-0311/3/3/25 Powell 2013 Bhutani 2018 Fernandez 2021 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

A 23-year-old soldier presents with hypertensive urgency and acute kidney injury. He thought he was doing everything right for his health—so what caused his system to fail? Dr. Feigenbaum and Dr. Baraki break down the clinical evidence and the surprising lab results. Timestamps [00:00] Introduction to the Case: The Fit Soldier’s Failure [01:07] Welcome and Mystery Case Framework [02:05] Patient History: The River and the GI Symptoms [03:53] Building the Differential: Infection vs. Dehydration [08:20] Initial Workup and the Hypercalcemia Discovery [14:14] The Medical Student’s Reveal: Supplement Reconciliation [18:05] Final Diagnosis: Severe Hypervitaminosis D [22:20] Metastatic Calcification and Permanent Vascular Damage [25:23] The Mechanism of Jaw Pain: Bone Resorption [28:34] Science Review: Debunking the Pilz (2011) Study [32:27] Fat-Soluble vs. Water-Soluble Risks [43:06] The Free Vitamin D Hypothesis [48:06] Updated 2024 Endocrine Society Guidelines [55:16] Final Thoughts: Vitamin D and the Endurance Population Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized medical and training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ Key Learning Points The Testosterone Fallacy: Meta-analyses confirm that Vitamin D supplementation has no significant effect on testosterone levels in men who are not clinically deficient. The Fat-Soluble Risk: Unlike water-soluble vitamins, Vitamin D is stored in adipose tissue, meaning toxicity can persist for months or years after cessation. Metastatic Calcification: Severe Vitamin D toxicity causes calcium phosphate to deposit in arterial walls, potentially turning flexible vessels into rigid pipes. 2024 Endocrine Guideline Shift: Updated medical standards now recommend against routine Vitamin D screening and universal high-target levels for healthy adults. The Natural Blind Spot: Patients often fail to categorize supplements as "medication," leading to dangerous diagnostic delays when clinicians do not ask specifically about over-the-counter products. The Mechanism of Bone Pain: Toxic Vitamin D levels can drive aggressive bone resorption, effectively "stealing" calcium from the skeleton and causing severe pain. Clinical Pearls Screening Protocol: Avoid routine Vitamin D blood testing for healthy, asymptomatic adults under 75 unless a specific condition like malabsorption or osteoporosis is present. Dosing Guidelines: For the general population, stick to the daily recommended intake (600–800 IU) rather than using high-dose bolus therapy or chasing a serum level of 30 ng/mL. Medication Reconciliation: Always disclose all "natural," "herbal," or "gym-based" supplements to your medical provider, as these can interact with other medications or cause direct toxicity. Timestamps [00:00] Introduction to the Case: The Fit Soldier’s Failure [01:07] Welcome and Mystery Case Framework [02:05] Patient History: The River and the GI Symptoms [03:53] Building the Differential: Infection vs. Dehydration [08:20] Initial Workup and the Hypercalcemia Discovery [14:14] The Medical Student’s Reveal: Supplement Reconciliation [18:05] Final Diagnosis: Severe Hypervitaminosis D [22:20] Metastatic Calcification and Permanent Vascular Damage [25:23] The Mechanism of Jaw Pain: Bone Resorption [28:34] Science Review: Debunking the Pilz (2011) Study [32:27] Fat-Soluble vs. Water-Soluble Risks [43:06] The Free Vitamin D Hypothesis [48:06] Updated 2024 Endocrine Society Guidelines [55:16] Final Thoughts: Vitamin D and the Endurance Population References https://pmc.ncbi.nlm.nih.gov/articles/PMC9478588/ https://link.springer.com/article/10.1007/s12020-020-02482-3 https://pubmed.ncbi.nlm.nih.gov/32446600/ https://pubmed.ncbi.nlm.nih.gov/21154195/ https://academic.oup.com/jcem/article/109/8/1907/7685305?login=false https://academic.oup.com/edrv/article/45/5/625/7659127 https://academic.oup.com/milmed/article/189/1-2/e417/7218964 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Biohackers and longevity clinics claim peptides are a side-effect-free sniper rifle for fat loss and injury recovery, but the reality is often buried in failed clinical trials and regulatory bans. Many popular compounds like BPC-157 have never undergone a single randomized controlled trial in humans, despite their reputation for Wolverine-like healing. This episode dismantles the hype surrounding the gray market, exposing the significant risks of immunogenicity and heavy metal contamination. Learn why modern load management and evidence-based medicine beat a research chemical bought with Bitcoin every time. Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized medical and training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ Key Points The FDA Category 2 Crackdown: Federal regulators restricted many peptides because of the risk of immunogenicity where the body creates antibodies that attack its own proteins. BPC-157 Has Zero Human Data: Despite being marketed for tendon repair, there is not a single published human randomized controlled trial for this molecule. The MK-677 Prediabetes Tax: While it increases lean mass, human trials show zero improvement in strength or power while frequently causing insulin resistance. Retatrutide as the Weight Loss Godzilla: This triple agonist is achieving nearly 29 percent weight loss in trials by increasing energy expenditure through thermogenesis. Sourcing and Safety Realities: A study of 44 research chemicals found that only 18 actually contained the labeled compound, with many containing heavy metals. The 40-Amino-Acid Rule: The legal distinction between a peptide and a protein is based on size, which dictates how the FDA regulates these substances and how your body absorbs them. Timestamps 00:03 Intro: The CJC-1295 Heart Attack Case 05:39 Defining a Peptide: The 40-Amino-Acid Bright Line 15:14 GH Secretagogues: CJC-1295 and Ipamorelin 23:51 MK-677: The Oral Hunger Mimetic and Prediabetes Risk 32:56 BPC-157 and the Lack of Human Data 38:12 Immunogenicity: Why the FDA Banned BPC-157 49:46 Retatrutide: The Triple Agonist Weight Loss Godzilla 01:11:24 Summary: Peptides vs. Anabolic Steroids 01:16:12 The Sourcing Spectrum: Pharmaceutical vs. Research Chemicals Clinical Pearls Use load management and progressive resistance training as the primary intervention for tendon and muscle injuries rather than unproven peptides. If choosing to use metabolic modulators, monitor fasting blood glucose and insulin sensitivity to avoid drug-induced prediabetes or metabolic dysfunction. Avoid the research chemical gray market entirely due to the high prevalence of under-dosing, contamination, and incorrect active ingredients found in third-party testing. Resources https://pubmed.ncbi.nlm.nih.gov/16352683/ https://pubmed.ncbi.nlm.nih.gov/18347346/ https://pmc.ncbi.nlm.nih.gov/articles/PMC2657499/ https://pubmed.ncbi.nlm.nih.gov/9849822/ https://pubmed.ncbi.nlm.nih.gov/10496658/ https://pubmed.ncbi.nlm.nih.gov/21298258/ https://pubmed.ncbi.nlm.nih.gov/18981485/ https://pubmed.ncbi.nlm.nih.gov/9467542/ https://pubmed.ncbi.nlm.nih.gov/18981485/ https://pubmed.ncbi.nlm.nih.gov/20554713/ https://pubmed.ncbi.nlm.nih.gov/39813152/ Duzel 2007 Strinic 2017 Sikiric 1993 He 2022 https://pmc.ncbi.nlm.nih.gov/articles/PMC2289708/ https://pubmed.ncbi.nlm.nih.gov/10469335/ https://pubmed.ncbi.nlm.nih.gov/23050815/ https://pubmed.ncbi.nlm.nih.gov/20536454/ https://pubmed.ncbi.nlm.nih.gov/29986520/ https://pmc.ncbi.nlm.nih.gov/articles/PMC4508379/ https://pubmed.ncbi.nlm.nih.gov/41090431/ https://pubmed.ncbi.nlm.nih.gov/38858523/ https://pubmed.ncbi.nlm.nih.gov/20445536/ https://pmc.ncbi.nlm.nih.gov/articles/PMC3136748/#R41 https://pubmed.ncbi.nlm.nih.gov/25738459/ https://pubmed.ncbi.nlm.nih.gov/33473109/ https://pmc.ncbi.nlm.nih.gov/articles/PMC5826726/ https://pubmed.ncbi.nlm.nih.gov/31599840/ https://pubmed.ncbi.nlm.nih.gov/18206919/ https://pmc.ncbi.nlm.nih.gov/articles/PMC5820696/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Experiencing a pins-and-needles sensation on a run or fearing the straight bar deadlift shouldn't be your fitness journey's bingo card. Many trainees abandon effective habits due to false narratives regarding physiological signals or myths regarding back safety. We break down the clinical reality of exercise-induced sensations, the ethics of modern metabolic medicine, and why your choice of imlpement is more about preference than peril. Resources and Next Steps For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized medical and training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ Topics The Hemodynamic Itch: Why vasodilation and increased blood flow to capillaries can cause mechanical stimulation of nerve endings during a run. Exercise-Induced Anaphylaxis: The critical difference between benign "runner’s itch" and a systemic medical emergency involving hives and hemodynamic instability. Medical Paternalism: Why withholding GLP-1 medications from patients who drink alcohol is a flawed clinical approach that ignores aggregate health risk reduction. The Seatbelt Analogy: Treating one health risk (obesity) is objectively better than leaving it untreated, even if other risks (alcohol) remain constant. The EMG Trap: Why electrical muscle activity data is a poor predictor of long-term strength and hypertrophy outcomes compared to longitudinal studies. Biomechanical Distribution: How the trap bar shifts load toward the quadriceps while the straight bar emphasizes the hamstrings and erectors without changing "safety." Clinical Pearls Identify Red Flags: If itching is accompanied by wheezing, nausea, or dizziness, stop exercise immediately and seek emergency medical care. Prioritize Habituation: For benign runner’s itch, consistent training typically leads to physiological adaptation and symptom resolution within a few weeks. Shared Decision-Making: When choosing between deadlift variations, select the tool that aligns with your specific goals—use the straight bar for powerlifting prep and the trap bar for general strength or power development. Timestamps 00:00 – Intro to the Direct Line AMA series 00:43 – The Mystery of "Runner’s Itch": Mechanisms and Hemodynamics 04:19 – Case Study: 24-year-old Marine and Exercise-Induced Anaphylaxis 06:22 – Summary: Benign Itching vs. Cholinergic Urticaria vs. Anaphylaxis 07:24 – GLP-1 Receptor Agonists and Heavy Alcohol Use 10:57 – Beyond the Stomach: How GLP-1s Impact Brain Reward Pathways 15:32 – Avoiding Paternalism in Medicine: Shared Decision-Making 18:12 – The Great Deadlift Debate: Trap Bar vs. Straight Bar 21:31 – Why EMG Data is Often Misleading for Trainees 24:54 – Debunking the "Save Your Back" Myth Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Welcome to the Barbell Medicine Cholesterol Action Plan. Cardiovascular disease is the #1 killer globally. We just released a massive 6-part audio series and written guide to fix that. It covers ApoB vs LDL, the CAC score paradox, the P:S diet ratio, and Plaque Regression. The full series is available INSTANTLY for Barbell Medicine Plus subscribers. If you're not a subscriber, start here: https://barbellmedicine.supercast.com/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

The wellness industry wants you to believe that menopause renders you fragile, fasting creates "cortisol belly," and birth control is silently destroying your skeletal health. These claims aren't just scientifically inaccurate; they act as "nocebo" barriers that scare women away from effective training and healthcare. We brought in the heavy artillery—Dr. Lauren Colenso-Semple, Dr. Loraine Baraki, and Dr. Spencer Nadolsky—to dissect the physiology behind these viral fears. Discover why your body remains resilient through hormonal transitions and why lifestyle or GLP-1s is a false dichotomy, Dr. Colenso-Semple: @drlaurencs1 Dr. Loraine Baraki: @loraine_barbellmedicine Dr. Spencer Nadolsky: @drnadolsky Key Learning Points The Menopause "Cliff" Myth: Menopause does not destroy your ability to recover or adapt to exercise.1 While aging may require programming adjustments, your muscles do not stop responding to tension and progressive overload simply because estrogen levels change. Cortisol Fear-mongering: There is no evidence that intermittent fasting or skipping breakfast causes pathological "cortisol belly" or visceral fat storage in women. Fasting is simply a tool for Calorie restriction, not a hormonal wrecking ball. IUDs & Bone Density: Levonorgestrel IUDs (hormonal) work primarily via local action on the uterus, not systemic suppression. Contrary to viral claims, they do not "eat your bones," and most users continue to ovulate and produce protective estrogen. The "Masking" Fallacy: Amenorrhea (lack of period) on an IUD is a known, harmless side effect of a thinned uterine lining. It is rarely "masking" a dangerous underlying condition like premature ovarian insufficiency. Birth Control & Performance: Population-level data shows that hormonal contraceptives do not clinically impair strength or athletic performance. While they increase SHBG and lower free testosterone, women are not "little men" dependent solely on testosterone for performance. GLP-1 Agonists (Ozempic/Mounjaro): Using medication to treat the appetite dysregulation of obesity is not "cheating." Muscle loss on these drugs is primarily a function of the Caloric deficit, not the drug itself, and can be mitigated with resistance training. Get More Value: Exclusive Content and Resources Want to support the show and get early, ad-free access to all episodes plus exclusive bonus content? Subscribe to Barbell Medicine Plus and get ad-free listening, product discounts, and more. Try it free for 30-days. Unsure which training plan is right for you? Take the free Barbell Medicine Template Quiz to be matched with the ideal program for your goals and experience level. For media, support, or general questions, please contact us at support@barbellmedicine.com Clinical Pearls & Takeaways Programming for Menopause: Stop treating menopause as a disability. Continue to lift heavy (RPE 6-9) and perform conditioning. If recovery lags, adjust volume (sets/reps) before blaming hormones. Protein Simplified: Ignore the complex "ideal body weight" math. Aim for ~1.6g/kg of total body weight, or simply add one extra serving of protein (like a shake) to your current daily intake. Medical Decisions: Do not remove an IUD or avoid birth control solely due to social media fear-mongering about bone density or "low T." These choices should be based on your contraceptive needs and symptom management (e.g., PCOS, endometriosis). Timestamps 00:00 Intro: The "Fragile Female" Narrative 01:00 Does Menopause Destroy Recovery? 11:00 Muscle Fiber Types: Fact vs. Fiction 24:00 Fasting, "Cortisol Belly," and Visceral Fat 34:00 Protein Intake: Survival vs. Optimal 41:40 Dr. Lorraine Baraki: Do IUDs Cause Bone Loss? 50:00 Birth Control, Acne, and Athletic Performance 59:00 Dr. Spencer Nadolsky: The Truth About GLP-1s & Muscle Loss 01:05:00 Final Verdict: You Are Not Fragile References Thomas, Ewan et al. “The effect of resistance training programs on lean body mass in postmenopausal and elderly women: a meta-analysis of observational studies.” Aging clinical and experimental research vol. 33,11 (2021): 2941-2952. doi:10.1007/s40520-021-01853-8 TWO Roberts, Brandon M et al. “Sex Differences in Resistance Training: A Systematic Review and Meta-Analysis.” Journal of strength and conditioning research vol. 34,5 (2020): 1448-1460. doi:10.1519/JSC.0000000000003521 Khalafi, Mousa et al. “The effects of exercise training on body composition in postmenopausal women: a systematic review and meta-analysis.” Frontiers in endocrinology vol. 14 1183765. 14 Jun. 2023, doi:10.3389/fendo.2023.1183765 Staron, R S et al. “Fiber type composition of the vastus lateralis muscle of young men and women.” The journal of histochemistry and cytochemistry : official journal of the Histochemistry Society vol. 48,5 (2000): 623-9. doi:10.1177/002215540004800506 Hunter, Sandra K. “The Relevance of Sex Differences in Performance Fatigability.” Medicine and science in sports and exercise vol. 48,11 (2016): 2247-2256. doi:10.1249/MSS.0000000000000928 Nuzzo, James L. “Narrative Review of Sex Differences in Muscle Strength, Endurance, Activation, Size, Fiber Type, and Strength Training Participation Rates, Preferences, Motivations, Injuries, and Neuromuscular Adaptations.” Journal of strength and conditioning research vol. 37,2 (2023): 494-536. doi:10.1519/JSC.0000000000004329 Verdell, J. Tyler MD; Acker, Matthew MD. Does the LNG-IUD decrease BMD in adolescent females?. Evidence-Based Practice 23(4):p 10-11, April 2020. | DOI: 10.1097/EBP.0000000000000601 Jäger, Ralf et al. “International Society of Sports Nutrition Position Stand: protein and exercise.” Journal of the International Society of Sports Nutrition vol. 14 20. 20 Jun. 2017, doi:10.1186/s12970-017-0177-8 Tan, Yimei et al. “Effect of GLP-1 receptor agonists on bone mineral density, bone metabolism markers, and fracture risk in type 2 diabetes: a systematic review and meta-analysis.” Acta diabetologica vol. 62,5 (2025): 589-606. doi:10.1007/s00592-025-02468-5 Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Bulletproof or Broken- Why 'Perfect Form' Is a Lie Episode Summary In this comprehensive episode, we dismantle the pervasive myth that the human body is a fragile machine susceptible to catastrophic injury from minor technique flaws. This narrative, often perpetuated by social media influencers screaming "Snap City," creates widespread fear avoidance behavior (kinesiophobia) that does more harm than good. By reviewing extensive epidemiological data, we demonstrate that obsessing over "perfect" technique has virtually zero correlation with injury risk. Instead, we explore the true drivers of pain and injury: improper load management (doing too much, too fast) and hyper-specialization (lack of movement variability). We also introduce the REP Model (Repeatable, Efficient, Points of Performance) as a practical compass for movement and provide a new framework for staying healthy: focus on robustness and managing your training dose, not fear-based mechanics. Timestamps 00:00:00 - The Fragility Myth: The Body-as-a-Car Metaphor and the Nocebo Effect. 00:11:31 - Defining Injury: Why the scientific data is a methodological mess. 00:21:46 - Injury Rates Compared: The Gym vs. Running vs. Contact Sports. 00:33:32 - MRI is a Liar: Understanding asymptomatic abnormalities ("wrinkles on the inside"). 00:39:10 - The Body-as-a-Bank-Account: A better analogy for capacity and load. 00:41:59 - Suspect 1: Heavy Weight. (Verdict: Innocent). 00:45:44 - Suspect 2: Orthopedic Cost & Exercise Selection. (Verdict: Innocent). 00:49:53 - Suspect 3: Hyper-Specialization. (Verdict: Guilty). 00:54:23 - Suspect 4: Movement Speed. (Verdict: Innocent). 00:57:21 - Suspect 5: Age. (Verdict: Innocent - The "Old Man Strength" phenomenon). 01:02:17 - Suspect 6: Anabolic Steroids. (Verdict: Guilty-ish). 01:04:38 - Suspect 7: Accidents & Gravity Events. (Verdict: Guilty). 01:08:22 - The Myth of the "Robotic" Elite Lifter: Why variability is a feature, not a bug. 01:15:48 - The REP Model: A new framework for technique (Repeatable, Efficient, Points of Performance). 01:20:01 - Conclusion: Your marching orders. ⭐ Get More Value: Exclusive Content and Resources Want to support the show and get early, ad-free access to all episodes plus exclusive bonus content? Subscribe to Barbell Medicine Plus and get ad-free listening, product discounts, and more. Try it free for 30-days. Unsure which training plan is right for you? Take the free Barbell Medicine Template Quiz to be matched with the ideal program for your goals and experience level. For media, support, or general questions, please contact us at support@barbellmedicine.com Action plan : https://www.barbellmedicine.com/injury-risk-action-plan/ I. The Fragility Myth: Why You Are Not a Car The fitness industry has long relied on the "body-as-a-machine" metaphor to explain pain. The logic suggests that if your alignment is off—much like a car with bad wheel alignment—your parts will wear out and fail. This has led to a culture of fear where athletes spend 30 minutes warming up rotator cuffs or obsessing over a single degree of spinal flexion during a deadlift. However, this mechanical model is fundamentally flawed. Unlike a car, human tissues are adaptable. The Brake Pad vs. The Callus: If you drive a car daily, the brake pads get thinner until they break. If you expose your skin to a barbell daily, it doesn't wear away; it builds a callus. Wolf’s Law & Davis’ Law: Bones get denser, and tendons/ligaments thicken when exposed to appropriate stress. The Nocebo Effect The greatest risk in the gym isn’t a rounded back; it’s the nocebo effect. This is the phenomenon where negative expectations or beliefs lead to negative outcomes. When influencers draw red lines on videos and catastrophize movement, they are socially transmitting pain and fear. This "socially transmitted kinesiophobia" convinces you that you are fragile, leading to hyper-vigilance and, ironically, a higher sensation of pain. Key Takeaway: You do not need to be fixed. You are robust and adaptable. The industry profits from your fragility, but the science supports your resilience. II. The Data Hierarchy of Risk To understand the true risk of the gym, we must look at the epidemiology of injury. Unfortunately, the scientific community struggles to agree on a definition of "injury." Some studies count a stubbed toe, while others only count surgery. Despite this methodological mess, the trends in the data are clear: The gym is one of the safest places to be. Injury Rates by Activity (Per 1,000 Hours) Bodybuilding: 0.2 – 1.0 Powerlifting / Weightlifting: 1.0 – 4.0 Running: ~10 (Novices up to ~18) Field Sports (Soccer, Rugby): 15 – 80+ Motocross: >90 The perception that lifting heavy weights is dangerous while recreational sports are "safe fun" is backward. The gym is a controlled environment where you dictate the load, tempo, and rest. In contrast, field sports are chaotic, "dirty" environments with high impact forces and unpredictable variables. MRI is a Liar: The "Wrinkles on the Inside" Modern medicine often over-relies on imaging. Studies on asymptomatic populations (people with no pain) show: High rates of disc bulges and degeneration in healthy adults. "Abnormalities" in 100% of elite baseball pitchers' shoulders. These findings are often adaptations, not pathologies. Just as you get wrinkles on your skin as you age, you get "wrinkles" on your spine. Treating an MRI finding rather than the person leads to unnecessary fear and medical interventions. III. The True Culprit: Load Management If technique isn't the primary driver of injury, what is? The answer lies in the balance between Load and Capacity. Think of your body as a Bank Account: Capacity: The funds you have in the bank ($1,000). Load: The withdrawal you are trying to make ($1,200). Injury/Pain: The overdraft fee. Pain occurs when the training load exceeds your current tissue capacity. The form police believe the overdraft happened because you swiped the debit card with your left hand (technique). In reality, the overdraft happened because you spent too much money. The Lineup of Suspects: Who is Guilty? We analyzed the common scapegoats for gym injuries to determine their actual guilt based on the evidence. Suspect: Heavy Weight Verdict: Innocent. Powerlifters (high load) have similar or lower injury rates than runners (low load). Suspect: Orthopedic Cost / Exercise Selection Verdict: Innocent. Squats and deadlifts are not "expensive" to joints; they are investments that build bone density and tissue strength. Suspect: Hyper-Specialization Verdict: Guilty. Doing the exact same movement pattern (same stance, same tempo, same shoe) for years creates overuse issues. Variation "rotates the tires" and spreads stress across tissues. Suspect: Movement Speed Verdict: Innocent. Olympic weightlifting (high velocity) is as safe as powerlifting. It comes down to preparation, not speed. Suspect: Age Verdict: Innocent (Inverse Trend). Older lifters tend to have lower injury rates than younger lifters, likely due to "old man strength" (accumulated capacity), better autoregulation, and less ego-lifting. Suspect: Anabolic Steroids Verdict: Guilty-ish. Steroids allow muscles to adapt faster than tendons and ligaments, creating a "Ferrari engine in a Honda Civic" mismatch. Suspect: Accidents (Gravity Events) Verdict: Guilty. A significant portion of gym injuries are simply dropping weights on toes or tripping. IV. Technique: The Compass, Not the Rulebook We have been taught that elite lifters move like robots—that every rep is identical. However, motion capture data reveals that elite athletes exhibit significant movement variability (motor noise) from rep to rep. This variability is a feature, not a bug; it allows the biological system to solve the problem of "lifting the weight" in real-time. Instead of forcing your body into a rigid, robotic ideal, we utilize the REP Model as a compass for technique. The REP Model R - Repeatable: Can you perform the movement with relatively consistent range of motion and patterns? (Your squat should look like a squat, not a Good Morning). E - Efficient: Does the movement solve the problem with the least wasted energy? (e.g., keeping the bar close in a deadlift). P - Points of Performance: Does it meet the specific constraints of your goal? (e.g., squatting below parallel for powerlifting standards). If your lift meets these criteria, your technique is likely safe and effective. You do not need a "neutral spine" to be safe—in fact, keeping a truly neutral spine during a heavy deadlift is anatomically impossible. V. Actionable Takeaways It is time to stop playing defense with your training and start playing offense. Stop optimizing for "safety" by avoiding exercises. You are safer in the squat rack than almost anywhere else. Use a wide variety of exercises to build a broad base of capacity. Abandon the Robotic Mindset. Use the REP Model. If the lift is repeatable, efficient, and meets your goals, stop obsessing over millimeter deviations. Manage the Dose. This is the single most important variable for health. Most injuries are "too much, too soon." Keep the majority of your training in the RPE 6–8 range. Build the callus; don't rub until you get a blister. References Aagaard, P., et al. (1996). Neural adaptation to resistance training: changes in evoked V-wave and H-reflex responses. Journal of Applied Physiology. Aasa, U., et al. (2017). Injuries among weightlifters and powerlifters: a systematic review. British Journal of Sports Medicine. Aasa, U. (2019). (Likely referring to a follow-up study or commentary on powerlifting injuries, e.g., Preventing injuries in weightlifting and powerlifting). Bahr, R. (2009). No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. British Journal of Sports Medicine. Bahr, R., et al. (2011). International Olympic Committee consensus statement: Methods for recording and reporting of epidemiological data on injury and illness in sport. British Journal of Sports Medicine. (PMID: 21719329) Bartlett, R. M., et al. (2007). Fast bowling laws of cricket and their impact on the lumbar spine. Journal of Sports Sciences. (PMID: 17449180) Behm, D. G., & Sale, D. G. (1993). Velocity specificity of resistance training. Sports Medicine. Berger-Roscher, N., et al. (2017). Complex loading of the lumbar spine changes the failure mode of the intervertebral disc. Clinical Biomechanics. Bible, J. E., et al. (2010). Normal functional range of motion of the lumbar spine during 15 activities of daily living. Journal of Spinal Disorders & Techniques. Callaghan, J. P., & McGill, S. M. (2001). Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clinical Biomechanics. Campbell, B., et al. (2014). International Society of Sports Nutrition position stand: energy drinks. Journal of the International Society of Sports Nutrition. (Note: "Campbell 2014" often refers to this, though a specific biomechanics paper is possible given the context). Claudino, J. G., et al. (2018). CrossFit Overview: Systematic review and meta-analysis. Sports Medicine - Open. Clausen, M. B., et al. (2014). High injury incidence in adolescent female soccer. American Journal of Sports Medicine. Colado, J. C., et al. (2009). Technique and safety aspects of resistance exercises: a systematic review of the literature. Physician and Sportsmedicine. Dhawale, A. A., et al. (2017). The prevalence of scoliosis in children with spinal cord injury. Journal of Pediatric Orthopaedics. Dominski, F. H., et al. (2018). Profile of injuries in CrossFit training. Physical Therapy in Sport. Faigenbaum, A. D., et al. (2010). Youth resistance training: updated position statement paper from the National Strength and Conditioning Association. Journal of Strength and Conditioning Research. George, P. E., et al. (1989). Acute back injuries in weight lifters. The Physician and Sportsmedicine. Gooyers, C. E., et al. (2015). The flexion–relaxation phenomenon: A review of the literature and update on the underlying biomechanics. Journal of Biomechanics. (PMID: 26162399 / PMC4505796) Hak, P. T., et al. (2013). The nature and prevalence of injury during CrossFit training. Journal of Strength and Conditioning Research. (PMID: 24022651) Hay, D. C., et al. (2015). Spinal injuries in golf. Asian Journal of Sports Medicine. (PMID: 25646361) Hill, A. V. (1922). The maximum work and mechanical efficiency of human muscles, and their most economical speed. The Journal of Physiology. Jacobsson, J., et al. (2013). Injury patterns in Swedish elite athletics: annual incidence, injury types and risk factors. British Journal of Sports Medicine. Keogh, J. W., & Winwood, P. W. (2017). The Epidemiology of Injuries Across the Weight-Training Sports. Sports Medicine. (PMID: 28597618) Kim, M. H., et al. (2014). Effects of different trunk exercises on trunk muscle activation. Journal of Physical Therapy Science. Klimek, C., et al. (2018). Are injuries more common in CrossFit training than other forms of exercise? Journal of Sports Rehabilitation. Kristiansen, E., et al. (2019). A comparison of muscle activation during the bench press and dumbbell fly. Journal of Sports Sciences. Kwon, Y. J., et al. (2011). The effect of core stability training on performance. Journal of Strength and Conditioning Research. Latash, M. L. (2012). The bliss of motor abundance. Experimental Brain Research. (PMC3445213) Martimo, K. P., et al. (2008). Effect of training on the perception of back pain and disability: a meta-analysis of randomized controlled trials. Spine. (PMID: 18244957) McGill, S. M. (2012). Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Human Kinetics. (See also PMID: 22773066) Montalvo, A. M., et al. (2017). Retrospective injury epidemiology and risk factors for injury in CrossFit. Journal of Sports Science & Medicine. Morin, J. B., et al. (2016). Technical ability of force application as a determinant factor of sprint performance. Medicine & Science in Sports & Exercise. Mueller-Wohlfahrt, H. W., et al. (2013). Terminology and classification of muscle injuries in sport: the Munich consensus statement. British Journal of Sports Medicine. (PMC3607100) Mundt, D. J., et al. (1993). An epidemiologic study of low back pain. Spine. Myer, G. D., et al. (2009). The effects of plyometric vs. dynamic stabilization and balance training on lower extremity biomechanics. American Journal of Sports Medicine. Nordin, M., & Frankel, V. H. (2019). Basic Biomechanics of the Musculoskeletal System. (Textbook). Panjabi, M. M. (1992a). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. Journal of Spinal Disorders. Panjabi, M. M. (1992b). The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of Spinal Disorders. Potvin, J. R., et al. (1991). Trunk muscle and lumbar ligament contributions to dynamic lifts with varying degrees of trunk flexion. Spine. Raske, A., & Norlin, R. (2002). Injury incidence and prevalence among elite weight and power lifters. American Journal of Sports Medicine. Ribeiro, A. L., et al. (2012). Exercise selection and resistance training. Journal of Strength and Conditioning Research. Rodriguez, M. A., et al. (2020). Injury in CrossFit: A systematic review of epidemiology and risk factors. The Physician and Sportsmedicine. (PMC7318830) Schollum, M. L., et al. (2018). Sense of effort and force production in the spine. Journal of Biomechanics. Setchell, J., et al. (2017). Individuals' explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskeletal Disorders. Shaw, G., et al. (2020). (Likely Shaw et al. regarding concussion or injury epidemiology). Siewe, J., et al. (2014). Injuries and overuse syndromes in competitive and elite bodybuilding. International Journal of Sports Medicine. (PMID: 24886919 / PMC3960980) Sjöberg, H. (2018). (Associated with the Aasa/Strömbäck powerlifting injury studies, likely a thesis or co-authored paper). Strömbäck, E., et al. (2018). Prevalence and Consequences of Injuries in Powerlifting: A Cross-sectional Study. Orthopaedic Journal of Sports Medicine. Veres, S. P., et al. (2010). Sub-failure pressurization of the intervertebral disc causes herniation. Spine. Vialle, R., et al. (2005). Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects. Journal of Bone and Joint Surgery. (PMID: 15972618) Vigotsky, A. D., et al. (2015). Biomechanical effects of good morning, spinal flexion, and spinal extension exercises. Journal of Strength and Conditioning Research. (PMID: 25951917) Wade, S. M., et al. (2017). Injury risk of CrossFit participants. Orthopaedic Journal of Sports Medicine. Weisenthal, B. M., et al. (2014). Injury rate and patterns among CrossFit athletes. Orthopaedic Journal of Sports Medicine. Williams, S., et al. (2013). Kinesio taping in treatment and prevention of sports injuries: a meta-analysis. Sports Medicine. Winwood, P. W., et al. (2014). Retrospective injury epidemiology of strongman athletes. Journal of Strength and Conditioning Research. (PMID: 25031367) Wu, X., et al. (2014). Effects of core strength training on core stability. Journal of Physical Therapy Science. Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Episode Summary: The Cardiometabolic Revolution of Semaglutide, Tirzepatide, and Beyond This episode provides a comprehensive, evidence-based update on GLP-1 receptor agonists (anti-obesity medications), featuring Dr. Jordan Feigenbaum, Dr. Austin Baraki, and Dr. Spencer Nadolsky. The hosts review the rapid evolution of these drugs—from short-acting injectables to potent multi-agonists like Tirzepatide (Mounjaro/Zepbound) and Retatrutide—which now achieve weight loss efficacy rivaling bariatric surgery. The discussion clarifies the broad, weight-independent benefits these drugs offer for cardiovascular, renal, and liver health (CKM Syndrome). The experts address common concerns, including the high incidence of gastrointestinal side effects and the heavily debated risk of muscle mass loss, concluding the risk is often overblown and easily mitigated by resistance training and adequate protein intake. Finally, they discuss the biggest hurdle to access: cost, and the role of newer oral and compounded options in the evolving landscape. ⏱️ Episode Timestamps 00:00 Welcome and Introductions 00:05:48 Defining GLP-1 and the Incretin Effect 00:08:06 Debunking "Nature's Ozempic" (DPP-4 resistance) 00:11:17 Evolution of GLP-1 Drugs (Longer duration, higher potency) 00:14:35 Defining and Discussing "Food Noise" 00:19:43 Semaglutide Efficacy (STEP & SUSTAIN Trials) 00:22:36 Tirzepatide Efficacy (SURMOUNT Trials) 00:24:50 Triple Agonist Pipeline (Retatrutide) 00:28:04 Oral Options and Future Accessibility (Orforglipron) 00:33:10 Weight-Independent Cardio Benefits (SELECT Trial) 00:38:12 Benefits for Kidney and Liver Health (CKM Syndrome) 00:41:47 Emerging Benefits (Sleep Apnea, Addiction, Cancer) 00:48:20 Common Side Effects (Nausea, Constipation, Fatigue) 00:52:59 Rare/Serious Risks (Pancreatitis, NAION) 00:58:36 Muscle Mass Loss Concern (Hype vs. Data) 01:13:44 Biggest Hurdle: Cost and Prior Authorization 01:16:50 Compounded Versions vs. Research Chemicals 01:19:57 Role of Older Anti-Obesity Medications and Microdosing 01:24:41 Final Summary 🔗 Resources and Next Steps Work with Experts on Cardiometabolic Health: Connect with Dr. Austin Baraki and Dr. Spencer Nadolsky: https://joinvineyard.com/ For evidence-based resistance training programs: barbellmedicine.com/training-programs For individualized medical and training consultation: barbellmedicine.com/coaching Explore our full library of articles on health and performance: barbellmedicine.com/resources To join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/ I. Basic Science and The Evolution of Anti-Obesity Medication Defining GLP-1 and the Incretin Effect GLP-1 (Glucagon-like peptide 1) is a naturally occurring peptide hormone released by the intestines after food ingestion.1 It plays a role in the incretin effect, which enhances insulin secretion from the pancreas.2 However, natural GLP-1 is quickly broken down by the DPP-4 enzyme, limiting its efficacy.3 Modern GLP-1 receptor agonists (like Semaglutide and Tirzepatide) are synthetic analogs engineered to be resistant to DPP-4 breakdown, allowing them to stick around longer and reach receptors in the brain to modulate appetite. The concept of food noise describes the persistent, relentless, non-hunger-related thoughts about food that many individuals with obesity experience.5 Patients often report that the cessation of this food noise is one of the most profound effects of the medication, freeing up cognitive energy previously dedicated to ruminating over food. The Rapidly Advancing Pipeline The evolution of this drug class has been defined by three trends: Duration: Moving from twice-daily injections (Exenatide) to weekly injections (Ozempic) and future monthly options. Potency: Increasing efficacy through molecular engineering and multi-agonist targeting (e.g., Tirzepatide hitting GLP-1 and GIP receptors).7 Tolerability: Improving the side effect profile, making newer agents easier to tolerate. Upcoming agents include oral options like Orforglipron and high-dose oral Semaglutide, which promise easier administration and potentially lower costs.8 Triple agonists like Retatrutide are showing efficacy in the mid-20% total weight loss range, rivaling metabolic surgery outcomes. II. Efficacy and Broad Health Benefits Weight Loss Efficacy The clinical data demonstrates significant efficacy, classifying these drugs as game-changers: Semaglutide (Ozempic/Wegovy): Averages around 15% total body weight loss.10 Tirzepatide (Mounjaro/Zepbound): Averages 20-21% total body weight loss, generally showing superiority and improved tolerability compared to Semaglutide.11 Pipeline Agents (Retatrutide): Showing potential for 24-25% total weight loss, pushing pharmacological intervention into the same league as bariatric surgery. Weight-Independent Organ Protection (CKM Syndrome) A significant portion of the benefit derived from these medications is weight-independent, meaning it's separate from the mass lost.12 The drugs exert pleiotropic (multiple) effects across organ systems, leading to the coining of CKM Syndrome (Cardiovascular-Kidney-Metabolic Syndrome). Cardiovascular Health: The SELECT trial demonstrated a radical reduction in Major Adverse Cardiovascular Events (MACE), with evidence suggesting at least two-thirds of this benefit is independent of the weight lost. Renal and Liver Health: Trials like FLOW are demonstrating benefits for Chronic Kidney Disease (CKD) progression.14 Furthermore, resolution or significant improvement of Fatty Liver Disease is commonly observed once weight loss exceeds the 7.5-10% threshold. Emerging and Future Benefits Research is exploring the impact of GLP-1 agonists on: Obstructive Sleep Apnea (OSA): Leading to resolution or reduction in severity, confirmed in trials. Addiction: Early anecdotal and some retrospective data show reduced alcohol consumption, with potential benefits being explored for gambling and opioid addiction due to strong effects in the brain's reward center. Neuroprotection and Cancer: The potential for favorable effects on neurodegenerative disease and certain adiposity-associated cancers is under investigation. III. Side Effects and Mitigating Muscle Loss Concerns Common and Rare Side Effects The vast majority of side effects are Gastrointestinal and highest during the initial dose escalation: Nausea: Most common, but typically resolves over time. Management includes smaller, more frequent meals and temporarily lower-fat diets. Constipation: Persistent and requires active management with fiber and potentially laxatives. Rare Risks: Pancreatitis is a common concern but has shown no increased incidence compared to placebo in trials. Gallstone development is linked to rapid weight loss by any mechanism, including bariatric surgery. Muscle Mass Loss: Hype vs. Data The concern that these agents cause a unique, disproportionate amount of skeletal muscle loss is largely overblown hype. Initial Subgroup Analysis: Early analysis of Semaglutide trials suggested a higher proportion of fat-free mass loss (around 38%) than expected (25%). This was often cited as evidence of muscle catabolism. Physiological Reality: Experts suggest that much of the observed fat-free mass loss includes fluid shifts (glycogen, water) rather than pure skeletal muscle. Tirzepatide trials showed fat-free mass loss closer to the expected 25%. Muscle Quality Improves: Studies like SEMI-LEAN have shown that in patients with sarcopenia/obesity, muscle function (quality) actually improves despite some lean mass loss. Mitigation: The solution to minimizing any proportional muscle loss is simple: resistance training (2-3 days per week) and high protein intake (1.0 to 1.2 g/kg of body weight). Exercise is the primary controller here, minimizing the effect of the agents on the muscle compartment. IV. Access, Cost, and Future Outlook The Biggest Hurdle: Cost The primary barrier to access remains cost, with list prices for branded medications often exceeding $1,000 per month, despite lower net costs for manufacturers.18 Insurance approval often requires complex Prior Authorization (PA) processes, which overwhelm standard primary care practices. The Role of Compounding and Older Medications Compounded Versions: Compounded versions are cheaper but lack safety and efficacy data from controlled trials. There are risks associated with the source and purity of the active pharmaceutical ingredient.19 Older Medications: Older anti-obesity medications (e.g., Phentermine/Topiramate) still have a role, offering proven efficacy (though less potent) and significantly lower cost, serving as a bridge until GLP-1 prices decline. Future Trend: Prices are expected to drop significantly in the next 5-10 years, making the FDA-approved versions more accessible and rendering compounded versions largely obsolete. Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Cycle Syncing, Cardio Myths, and Iron Deficiency: A Barbell Medicine Review of Viral Claims Episode Summary: Debunking Women's Health Claims and Setting Optimal Targets In this in-depth episode, Dr. Jordan Feigenbaum, joined by Dr. Lauren Colenso-Semple and Dr. Austin Baraki, breaks down the viral women's health claims made on a popular podcast, separating misleading mechanistic theory from actionable, evidence-based advice. They tackle three major topics: the idea that Cycle Syncing is necessary for performance (spoiler: it's not); the confused messaging surrounding HIIT and Zone 2 cardio (consistency is key); and a critical discussion on Iron Deficiency, clarifying why standard lab cutoffs for ferritin are too low and why treating to an optimal target (greater than or equal to 50 ng/mL) is essential for managing fatigue and optimizing exercise performance in women. ⏱️ Episode Timestamps 1:29 I. Cycle Syncing: The Claim and the Mechanistic Logic 18:54 II. Conditioning Confusion: High Intensity, Zone 2, and Zone Definitions 21:10 Polarized vs. Pyramidal Training (Context) 47:08 III. Iron Deficiency: Normalizing Low Ferritin 51:52 Evidence Review: Setting Accurate Ferritin Cutoffs ⭐ Get More Value: Exclusive Content and Resources Connect with Dr. Lauren Colenso-Semple: @drlaurencs1 Want to support the show and get early, ad-free access to all episodes plus exclusive bonus content? Subscribe to Barbell Medicine Plus and get ad-free listening, product discounts, and more. Try it free for 30-days. Unsure which training plan is right for you? Take the free Barbell Medicine Template Quiz to be matched with the ideal program for your goals and experience level. For media, support, or general questions, please contact us at support@barbellmedicine.com I. Cycle Syncing: Why Consistency Trumps Hormone Status The Problem with Mechanistic Reductionism The viral claim that women must systematically adjust their training volume and intensity based on fluctuating hormones (estrogen and progesterone) to optimize performance or avoid harm is based on a reductionist and largely unproven hypothesis. While hormone changes are real, relying solely on mechanistic data (what happens in isolated cells or textbook diagrams) is insufficient, as the complex, interactive nature of human physiology often overrides these single-factor effects. Dr. Feigenbaum and Dr. Colenso-Semple clarify that no reliable human evidence supports the idea that cycle syncing leads to superior athletic performance or adaptation. The fundamental flaw in the advice is that it confuses a plausible mechanism with a meaningful outcome. Harm Assessment: The Cost of Inconsistency The primary harm in cycle syncing is that it leads to missed training opportunities. Adaptation is driven by consistent training load (mechanotransduction), not a temporary hormone profile. Planning to proactively reduce training intensity or volume based on an unproven hormone schedule is detrimental to long-term strength and endurance gains. Training modifications should be reactive—if a person genuinely feels symptoms of fatigue, pain, or discomfort on a given day (regardless of their cycle status), they should adjust or skip the workout. The advice to only exercise or train hard when you "feel awesome" is inconsistent with the reality of progressive training and often sets unrealistic expectations. II. Conditioning Confusion: Context is Everything Debunking Zone 2 and HIIT Extremism The hosts address the confusing and contradictory advice regarding high-intensity interval training (HIIT) and Zone 2 cardio, particularly the claim that Zone 2 is "bro science" and should be avoided. The issue lies in a lack of context. The discussion on polarized (80/20) versus pyramidal training only becomes relevant for high-volume endurance athletes (those training for 10+ hours per week) where managing fatigue via intensity distribution is critical. For the general population—the vast majority of people consuming the viral content—the goal is simple: consistency. Adhering to the minimum physical activity guidelines (150 minutes of moderate or 75 minutes of vigorous activity per week) is the priority. For this audience, almost any combination of volume and intensity works, as long as it is challenging enough and sustainable. The complex debate over intensity distribution is entirely non-actionable for people simply trying to start or maintain an exercise habit. The advice was non-actionable because it: Used incorrect zone definitions ("Zone 1 is sitting around"). Failed to integrate high-load resistance training into the cardio recommendation. Ignored the relationship between training frequency, volume, and total training load. III. Iron Deficiency: Treating to Optimal Physiology Normalizing Deficiency: The Problem with Lab Cutoffs Dr. Baraki addresses the critical issue of Iron Deficiency, emphasizing that many standard laboratory cutoffs for ferritin are misleadingly low. Labs often set the lower limit of "normal" (e.g., 12–15 ng/mL) based on population averages, not optimal physiology. This is problematic because upwards of 50% of young women in these samples may have completely depleted iron stores (non-anemic iron deficiency) due to menstrual blood loss and insufficient dietary intake. By accepting these low limits, the medical system is effectively normalizing deficiency. Optimal Ferritin Targets and Clinical Management The consequences of non-anemic iron deficiency include significant symptoms like fatigue, impaired exercise performance, and restless leg syndrome. The body strips iron from other tissues, including muscle, to prioritize red blood cell production, masking the deficiency until it reaches the end stage of anemia. Clinical guidelines are evolving, recognizing that higher ferritin levels are necessary for optimal health: General Target: A ferritin target of greater than or equal to 50 ng/mL is reasonable for most patients, especially those experiencing fatigue. Restless Leg Syndrome (RLS): A higher target of greater than or equal to 75 ng/mL may be necessary to address RLS, which is strongly linked to low iron stores in the brain. Treatment: Management often involves oral or IV iron supplementation to treat to this optimal target, while also investigating and treating the underlying causes of blood loss or malabsorption. The idea that we are accepting lower levels due to a "sicker population" is a misconception; in reality, cutoffs are being increased (e.g., American Gastroenterology Association: 45 ng/mL; American Society of Hematology: 50 ng/mL) as clinicians learn more about optimal physiology and the necessity of managing non-anemic iron deficiency. IV. Conclusion: Core Takeaways The goal of reviewing this viral content is to provide a vital filter for the public, differentiating between a simple mechanism and an outcome that truly matters to long-term health and training. Consistency is King: For health, find a training program you can adhere to consistently. Do not let fear of cortisol or unproven hormone matching keep you from moving your body. Lift Weights: If your goal is to get stronger and improve bone mineral density, you must lift weights. Address Fatigue: Do not overlook iron deficiency; address fatigue by targeting optimal ferritin levels. V. Citations https://pmc.ncbi.nlm.nih.gov/articles/PMC6120973/ https://pubmed.ncbi.nlm.nih.gov/30559681/ https://pubmed.ncbi.nlm.nih.gov/30559681/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6120973/ https://pubmed.ncbi.nlm.nih.gov/30559681/ https://www.nature.com/articles/s41467-025-63475-2 https://journals.lww.com/acsm-msse/pages/articleviewer.aspx?year=2025&issue=11000&article=00025&type=Fulltext https://onlinelibrary.wiley.com/doi/10.1155/tsm2/2008291 https://pubmed.ncbi.nlm.nih.gov/40010355/ https://pubmed.ncbi.nlm.nih.gov/33955140/ https://pubmed.ncbi.nlm.nih.gov/37084486/ https://pubmed.ncbi.nlm.nih.gov/39576887/ https://pmc.ncbi.nlm.nih.gov/articles/PMC7497427/ https://pmc.ncbi.nlm.nih.gov/articles/PMC10300696/ https://pubmed.ncbi.nlm.nih.gov/38066931/ Our Sponsors: * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out Cometeer and use my code BBM for a great deal: https://www.cometeer.com * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com * Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com * Check out Quince and use my code BBM for a great deal: https://www.quince.com Advertising Inquiries: https://redcircle.com/brands

Episode Summary: Dynapenia, Motor Neurons, and the Firewall In this episode, Dr. Jordan Feigenbaum and Dr. Austin Baraki redefine sarcopenia, shifting the focus from simple age-related muscle size loss (atrophy) to the more critical loss of muscle strength and power (dynapenia), a process that starts in the 40s. They explain the profound pathophysiology: sarcopenia is primarily a neurological event caused by the death of high-threshold motor neurons, leading to the selective loss of fast-twitch (Type II) muscle fibers. This explains why strength declines 3x faster than size. The hosts detail the modern diagnostic framework—prioritizing functional tests like the sit-to-stand test over late-stage mass measurements. They provide the definitive, evidence-based management plan: lifelong heavy resistance training is non-negotiable as it acts as a firewall against motor neuron death. The episode concludes with a debunking of common myths (e.g., "walking is enough," "muscle turns to fat," "lifting heavy is unsafe for the elderly") and practical advice on optimizing protein and creatine use to combat anabolic resistance. ⭐ Get More Value: Exclusive Content and Resources Want to support the show and get early, ad-free access to all episodes plus exclusive bonus content? Subscribe to Barbell Medicine Plus and get ad-free listening, product discounts, and more. Try it free for 30-days. Unsure which training plan is right for you? Take the free Barbell Medicine Template Quiz to be matched with the ideal program for your goals and experience level. For media, support, or general questions, please contact us at support@barbellmedicine.com Key Takeaways Sarcopenia is a Neurological Problem: The primary cause is the death of high-threshold alpha motor neurons, leading to the selective loss of fast-twitch (Type II) muscle fibers—the fibers responsible for power, speed, and fall prevention. This explains why strength (dynapenia) declines 3x faster than muscle size. Diagnosis Must Be Functional: Waiting for a doctor to diagnose sarcopenia via a muscle mass measurement (like a DEXA scan) is too late. Modern guidelines prioritize functional tests like grip strength and the sit-to-stand test as early warning signs, as muscle can be normal-sized but still dysfunctional. Resistance Training is the Firewall: Lifelong heavy resistance training slows motor neuron loss by 300% compared to the general population. Walking is not enough; only challenging resistance work sends the necessary signals (mechanotransduction) to preserve these critical motor neurons and Type II fibers. Nutrition for Treatment: For individuals diagnosed with sarcopenia, managing anabolic resistance is key. This requires attention to protein timing: consume a good dose of high-quality protein (rich in essential amino acids) at each meal. Supplementing with a third-party tested whey protein and 3-5g of creatine daily may be beneficial. Safety & Risk: The risk of injury from lifting weights, even heavy weights, in the elderly population is relatively low (2-4 injuries per 1,000 participation hours) and is greatly outweighed by the risk of immobility, falls, and subsequent complications. Episode Timestamps 0:00 Introduction: The Silent Epidemic and Dynapenia 8:50 Defining Sarcopenia: Why Size Alone is Misleading (The Green Banana Analogy) 17:37 Epidemiology and Sarcopenic Obesity 23:39 Screening Tools: SARC-F, Sit-to-Stand Test, and When to Screen 40:53 Pathophysiology: Why Sarcopenia is a Neurological Event 42:28 Motor Neuron Death and Selective Type II Fiber Loss 52:33 The Problem of Anabolic Resistance 53:16 Management and Prevention Strategies 57:20 Exercise Prescription (The "Why" and "How" of Resistance Training) 1:10:44 Nutritional Strategy (Protein Boluses and Supplements) 1:16:21 Sarcopenia Myths: Walking, Muscle Turning to Fat, and SafetySection I: Sarcopenia Redefined—A Failure of the Nervous System Dynapenia and the Shift in Diagnostic Focus The episode establishes that sarcopenia must be understood as a problem of dynapenia (loss of strength and power) first, not just muscle size. Historically, the term, coined in 1989, focused on flesh poverty (Sarc-o-penia), but data quickly revealed that strength declines 3x faster than muscle mass. Old guidelines prioritized size, leading to a paradox: people with normal-sized muscles were still experiencing falls and fractures. The modern framework, driven by groups like the European Working Group, prioritizes functional outcomes. Waiting for a diagnosis via muscle size (like a DEXA scan measurement) means intervention is often too late. Muscle quality—the force produced per unit mass—declines dramatically due to neurological and cellular changes, even if the muscle maintains its volume through fat or water infiltration. The Pathophysiology: Alpha Motor Neuron Death The root cause of dynapenia is primarily neurogenic atrophy. Motor Neuron Loss: As individuals age, the high-threshold alpha motor neurons that innervate fast-twitch (Type II) muscle fibers begin to die (a process that can start in the 40s). Fiber Type Conversion: When a high-threshold neuron dies, a neighboring low-threshold (slow-twitch) neuron attempts to rescue the abandoned Type II muscle fiber. The fiber survives but is converted into a slow-twitch (Type I) fiber. Loss of Power: Since Type II fibers are responsible for rapid force production, the selective loss and conversion of these fibers means the individual loses speed and power, severely compromising the ability to perform activities like quickly rising from a chair or catching oneself during a trip (the righting reflex). This is why falls and subsequent hip fractures become common. Sarcopenic Obesity A particularly dangerous presentation is sarcopenic obesity, where a person carries both a significant amount of fat mass and poor muscle function. While individuals with obesity generally carry more lean mass, the fat infiltration (lipotoxicity) into the muscle tissue exacerbates anabolic resistance and insulin resistance, making the muscle dysfunctional and resistant to training and nutritional signals. This combination significantly compounds the risks of immobility and mortality. Section II: Management, Prevention, and Training Prescription Resistance Training is the Firewall The primary goal of intervention is prevention, as lost motor neurons cannot be regrown. Resistance training acts as a firewall against further motor neuron death. Mechanotransduction: Challenging resistance work sends necessary signals back to the motor neurons, signaling that the muscle fibers are still needed, slowing the rate of death. Evidence: Lifelong lifters show a neurogenic decline of only 0.35% per year, compared to the general population's decline of 1% per year—a 300% slower rate of loss. Walking is not enough to achieve this protective effect, as endurance athletes still show evidence of Type II fiber loss. Exercise Prescription: The Physical 401K For prevention, the goal is to fully fund the "physical 401K." This means exceeding the minimum physical activity guidelines: Resistance Training: At least twice a week, training all major muscle groups. Cardio: Aim for double the minimum (e.g., 300 minutes of moderate-to-vigorous activity per week). Progression: Individuals should build a big base of fitness, allowing them to be more aggressive with training load and resilient against co-morbidities later in life. For individuals with a diagnosis of sarcopenia (secondary prevention/treatment), the training emphasis shifts: Intensity is Non-Negotiable: Lifts must be challenging and performed with the intent of moving the load quickly to stimulate remaining Type II fibers. Start Lower, Progress Gradually: The population is more vulnerable to over-dosing due to chronic disuse. Start with a lower total volume but ensure progression is gradual and consistent. Type: While barbells are fine, machine-based training (e.g., leg press) may be a less intimidating entry point and can allow for higher training loads by mitigating the balance/fall risk of free weights. Section III: Nutrition, Supplements, and Myths Combating Anabolic Resistance with Protein Anabolic resistance—the reduced responsiveness of muscle to nutritional signals—is prevalent in sarcopenia. To overcome this, the focus should be on protein timing and quality: Total Intake: Aim for 1.2 to 1.6 grams of protein per kilogram of body weight per day (0.6 to 0.8g per pound). Protein Bolus: Ensure each meal contains a significant bolus of high-quality protein, rich in essential amino acids, to maximize the anabolic signal. This is critical for individuals whose appetite is often low. Supplements: A third-party tested whey protein supplement can be a useful tool for those who struggle to meet targets. Creatine (3-5g/day) is also strongly advised due to data supporting its benefit in improving lean mass and functional outcomes like the sit-to-stand test. Sarcopenia Myths Debunked (The Safety of Lifting) Myth: Walking is enough. Fact: No. Walking does not provide the challenging stimulus required to save high-threshold motor neurons and Type II fibers. Myth: Muscle turns to fat. Fact: No. Muscle and fat are distinct tissues. However, chronic disuse leads to fat infiltration into the muscle (lipotoxicity), which impairs function. Myth: It's unsafe to lift heavy after 60. Fact: The risk of injury from lifting weights in the elderly is relatively low (2-4 injuries per 1,000 participation hours) and is greatly outweighed by the high risk of immobility, falls, and subsequent complications caused by inactivity. Myth: GLP-1 agonists (Ozempic/Wegovy) cause sarcopenia. Fact: This is hysteria. 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