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

1. https://pubmed.ncbi.nlm.nih.gov/16352683/
2. https://pubmed.ncbi.nlm.nih.gov/18347346/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC2657499/
4. https://pubmed.ncbi.nlm.nih.gov/9849822/
5. https://pubmed.ncbi.nlm.nih.gov/10496658/
6. https://pubmed.ncbi.nlm.nih.gov/21298258/
7. https://pubmed.ncbi.nlm.nih.gov/18981485/
8. https://pubmed.ncbi.nlm.nih.gov/9467542/
9. https://pubmed.ncbi.nlm.nih.gov/18981485/
10. https://pubmed.ncbi.nlm.nih.gov/20554713/
11. https://pubmed.ncbi.nlm.nih.gov/39813152/
12. Duzel 2007
13. Strinic 2017
14. Sikiric 1993
15. He 2022
16. https://pmc.ncbi.nlm.nih.gov/articles/PMC2289708/
17. https://pubmed.ncbi.nlm.nih.gov/10469335/
18. https://pubmed.ncbi.nlm.nih.gov/23050815/
19. https://pubmed.ncbi.nlm.nih.gov/20536454/
20. https://pubmed.ncbi.nlm.nih.gov/29986520/
21. https://pmc.ncbi.nlm.nih.gov/articles/PMC4508379/
22. https://pubmed.ncbi.nlm.nih.gov/41090431/
23. https://pubmed.ncbi.nlm.nih.gov/38858523/
24. https://pubmed.ncbi.nlm.nih.gov/20445536/
25. https://pmc.ncbi.nlm.nih.gov/articles/PMC3136748/#R41
26. https://pubmed.ncbi.nlm.nih.gov/25738459/
27. https://pubmed.ncbi.nlm.nih.gov/33473109/
28. https://pmc.ncbi.nlm.nih.gov/articles/PMC5826726/
29. https://pubmed.ncbi.nlm.nih.gov/31599840/
30. https://pubmed.ncbi.nlm.nih.gov/18206919/
31. https://pmc.ncbi.nlm.nih.gov/articles/PMC5820696/

Our Sponsors:
* Check out Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy

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 Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy

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 Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy

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 [email protected]

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 Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy

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 [email protected]

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 Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy

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:

1. Duration: Moving from twice-daily injections (Exenatide) to weekly injections (Ozempic) and future monthly options.
2. Potency: Increasing efficacy through molecular engineering and multi-agonist targeting (e.g., Tirzepatide hitting GLP-1 and GIP receptors).7
3. 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 Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy

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 [email protected]

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:

1. Used incorrect zone definitions ("Zone 1 is sitting around").
2. Failed to integrate high-load resistance training into the cardio recommendation.
3. 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.

1. 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.
2. Lift Weights: If your goal is to get stronger and improve bone mineral density, you must lift weights.
3. 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 Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy

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 [email protected]

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. Data does not support excessive muscle loss, and the benefit of reducing obesity-related risks far outweighs the low risk of muscle loss when coupled with resistance training.

References

• Adulkasem, Nath et al. “Evaluation of the Diagnosis Accuracy of the AWGS 2019 Criteria for "Possible Sarcopenia" in Thai Community-Dwelling Older Adults.” Clinical interventions in aging vol. 20 425-433. 9 Apr. 2025, doi:10.2147/CIA.S513657
• Ahtianen 2016 (Implied: Ahtianen, Juha P et al. “Effects of high-load vs. moderate-load resistance training on muscle hypertrophy and strength gain in younger and older men.” Journal of applied physiology 120.3 (2016): 481-487)
• Alan A Aragon, Kevin D Tipton, Brad J Schoenfeld, Age-related muscle anabolic resistance: inevitable or preventable?, Nutrition Reviews, Volume 81, Issue 4, April 2023, Pages 441–454, https://doi.org/10.1093/nutrit/nuac062
• Allen, M.D., Power, G.A., Filion, M.E., Doherty, T.J., Rice, C.L., Taivassalo, T. and Hepple, R.T. (2013), Motor unit number estimates in world-class masters athletes: is 80 the new 60?. The FASEB Journal, 27: 1150.1-1150.1. https://doi.org/10.1096/fasebj.27.1_supplement.1150.1
• Andreo-López, María Carmen et al. “Prevalence of Sarcopenia and Dynapenia and Related Clinical Outcomes in Patients with Type 1 Diabetes Mellitus.” Nutrients vol. 15,23 4914. 24 Nov. 2023, doi:10.3390/nu1523491
• Anoohya Gandham, Giulia Gregori, Lisa Johansson, Helena Johansson, Nicholas C Harvey, Liesbeth Vandenput, Eugene McCloskey, John A Kanis, Henrik Litsne, Kristian Axelsson, Mattias Lorentzon, Sarcopenia definitions and their association with fracture risk in older Swedish women, Journal of Bone and Mineral Research, Volume 39, Issue 4, April 2024, Pages 453–461, https://doi.org/10.1093/jbmr/zjae026
• Bahat, G et al. “Performance of SARC-F in Regard to Sarcopenia Definitions, Muscle Mass and Functional Measures.” The journal of nutrition, health & aging vol. 22,8 (2018): 898-903. doi:10.1007/s12603-018-1067-8
• Bhasin, Shalender et al. “Sarcopenia Definition: The Position Statements of the Sarcopenia Definition and Outcomes Consortium.” Journal of the American Geriatrics Society vol. 68,7 (2020): 1410-1418. doi:10.1111/jgs.16372
• Brook 2016 (Implied: Brook, Mitchell S et al. “Novel approaches to assess muscle protein turnover.” The American journal of clinical nutrition 103.3 (2016): 658-69)
• Canal de Velasco, Luis M et al. “Testosterone Replacement Therapy in Men Aged 50 and Above: A Narrative Review of Evidence-Based Benefits, Safety Considerations, and Clinical Recommendations.” Cureus vol. 17,9 e92538. 17 Sep. 2025, doi:10.7759/cureus.92538
• Candow, Darren G et al. “Effectiveness of Creatine Supplementation on Aging Muscle and Bone: Focus on Falls Prevention and Inflammation.” Journal of clinical medicine vol. 8,4 488. 11 Apr. 2019, doi:10.3390/jcm8040488
• Clark, Brian C, and Todd M Manini. “Sarcopenia =/= dynapenia.” The journals of gerontology. Series A, Biological sciences and medical sciences vol. 63,8 (2008): 829-34. doi:10.1093/gerona/63.8.829 (Appears twice)
• Clark, Brian C. “Neural Mechanisms of Age-Related Loss of Muscle Performance and Physical Function.” The journals of gerontology. Series A, Biological sciences and medical sciences vol. 78,Suppl 1 (2023): 8-13. doi:10.1093/gerona/glad029
• Clark and Taylor 2011 (Implied: Clark, Brian C, and Jessica L Taylor. “The potential for neuromuscular adaptations to prevent age-related muscle weakness.” Exercise and sport sciences reviews vol. 39.3 (2011): 120-7)
• Cruz-Jentoft, Alfonso J et al. “Sarcopenia: revised European consensus on definition and diagnosis.” Age and ageing vol. 48,4 (2019): 601. doi:10.1093/ageing/afz046
• Currier BS, Mcleod JC, Banfield L, et alResistance training prescription for muscle strength and hypertrophy in healthy adults: a systematic review and Bayesian network meta-analysisBritish Journal of Sports Medicine 2023;57:1211-1220.
• Cuthbertson et al., 2005 (Implied: Cuthbertson, Don et al. “An oral dose of leucine, but not an isonitrogenous mixture of essential amino acids, stimulates muscle protein synthesis in older women.” The American journal of clinical nutrition 83.3 (2006): 621-8)
• de Vos, Nathan J et al. “Optimal load for increasing muscle power during explosive resistance training in older adults.” The journals of gerontology. Series A, Biological sciences and medical sciences vol. 60,5 (2005): 638-47. doi:10.1093/gerona/60.5.638 (Appears twice)
• Delbono 2011 (Implied: Delbono, Osvaldo. “Neural control of muscle aging.” Aging clinical and experimental research 23.4 (2011): 278-83)
• Delmonico 2009 (Implied: Delmonico, Matthew J et al. “Longitudinal changes in muscle strength and mass in older adults.” The American journal of clinical nutrition 90.6 (2009): 1579-85)
• Dent, E et al. “International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management.” The journal of nutrition, health & aging vol. 22,10 (2018): 1148-1161. doi:10.1007/s12603-018-1139-9
• Deutz, Nicolaas E P et al. “Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group.” Clinical nutrition (Edinburgh, Scotland) vol. 33,6 (2014): 929-36. doi:10.1016/j.clnu.2014.04.007
• Dungan, Cory M. “Less is more: the role of mTORC1 activation in the progression of ageing-mediated anabolic resistance.” The Journal of physiology vol. 595,9 (2017): 2781-2782. doi:10.1113/JP274154
• Francaux, Marc et al. “Aging Reduces the Activation of the mTORC1 Pathway after Resistance Exercise and Protein Intake in Human Skeletal Muscle: Potential Role of REDD1 and Impaired Anabolic Sensitivity.” Nutrients vol. 8,1 47. 15 Jan. 2016, doi:10.3390/nu8010047
• Frontera et al. 2000 (Implied: Frontera, Walter R et al. “Strength training and determinants of strength development in older adults.” Medicine and science in sports and exercise 32.1 (2000): 64-9)
• Gallagher 1997 (Implied: Gallagher, Dympna et al. “Visceral fat is associated with increased $\beta$-adrenergic-stimulated lipolysis in elderly humans.” The American journal of physiology. Endocrinology and metabolism 272.2 (1997): E359-64)
• Geng, Qian et al. “The efficacy of different interventions in the treatment of sarcopenia in middle-aged and elderly people: A network meta-analysis.” Medicine vol. 102,27 (2023): e34254. doi:10.1097/MD.0000000000034254
• Grosicki et al. 2016 (Implied: Grosicki, Gregory J et al. “Resistance training increases skeletal muscle fiber force in nonagenarians.” Applied physiology, nutrition, and metabolism 41.11 (2016): 1182-1188)
• Guillet et al., 2004 (Implied: Guillet, Christophe et al. “Impaired postprandial muscle protein synthesis in old adults is not due to a failure to increase blood flow.” The American journal of physiology. Endocrinology and metabolism 287.4 (2004): E697-701)
• Hendrickse, P W et al. “A 10-Year Longitudinal Study of Muscle Morphology and Performance in Masters Sprinters.” Journal of cachexia, sarcopenia and muscle vol. 16,3 (2025): e13822. doi:10.1002/jcsm.13822
• Hua-Rui, Li et al. “Optimal dose of resistance training to improve handgrip strength in older adults with sarcopenia: a systematic review and Bayesian model-based network meta-analysis.” Frontiers in physiology vol. 16 1564988. 2 Jul. 2025, doi:10.3389/fphys.2025.1564988
• Hunter, Sandra K et al. “The aging neuromuscular system and motor performance.” Journal of applied physiology (Bethesda, Md. : 1985) vol. 121,4 (2016): 982-995. doi:10.1152/japplphysiol.00475.2016
• Janssen 2000 (Implied: Janssen, I et al. “Skeletal muscle mass and distribution in 468 men and women aged 18–88 yr.” Journal of applied physiology 89.1 (2000): 81-88)
• Keller, Karsten, and Martin Engelhardt. “Strength and muscle mass loss with aging process. Age and strength loss.” Muscles, ligaments and tendons journal vol. 3,4 346-50. 24 Feb. 2014 (Appears twice)
• Kittilsen 2021 (Implied: Kittilsen, H. E. et al. “Maximal strength training is superior to other forms of resistance training in improving muscle strength in older adults.” Scandinavian Journal of Medicine & Science in Sports 31.5 (2021): 1121-1130)
• Koopman et al., 2009 (Implied: Koopman, René et al. “In older men, postprandial muscle protein synthesis is higher after a meal containing highly digestible protein compared with a meal containing more slowly digestible protein.” The Journal of nutrition 139.12 (2009): 2452-2458)
• Larsson, Lars et al. “Sarcopenia: Aging-Related Loss of Muscle Mass and Function.” Physiological reviews vol. 99,1 (2019): 427-511. doi:10.1152/physrev.00061.2017
• Latella, Christopher et al. “Using Powerlifting Athletes to Determine Strength Adaptations Across Ages in Males and Females: A Longitudinal Growth Modelling Approach.” Sports medicine (Auckland, N.Z.) vol. 54,3 (2024): 753-774. doi:10.1007/s40279-023-01962-6
• Li, Chun-Wei et al. “Pathogenesis of sarcopenia and the relationship with fat mass: descriptive review.” Journal of cachexia, sarcopenia and muscle vol. 13,2 (2022): 781-794. doi:10.1002/jcsm.12901
• Lima, Sara Souza et al. “How does the cut-off point for grip strength affect the prevalence of sarcopenia and associated factors? Findings from the ELSI-Brazil Study.” Cadernos de saude publica vol. 41,5 e00155624. 27 Jun. 2025, doi:10.1590/0102-311XEN155624
• Marcell 2014 (Implied: Marcell, Timothy J et al. “Physical activity prevents age-related loss of muscle mass and strength in healthy older adults.” The American journal of physiology. Endocrinology and metabolism 307.3 (2014): E356-62)
• Matthew D. L. O'Connell, Stephen A. Roberts, Upendram Srinivas-Shankar, Abdelouahid Tajar, Martin J. Connolly, Judith E. Adams, Jackie A. Oldham, Frederick C. W. Wu, Do the Effects of Testosterone on Muscle Strength, Physical Function, Body Composition, And Quality of Life Persist Six Months after Treatment in Intermediate-Frail and Frail Elderly Men?, The Journal of Clinical Endocrinology & Metabolism, Volume 96, Issue 2, 1 February 2011, Pages 454–458, https://doi.org/10.1210/jc.2010-1167
• Mitchell, W Kyle et al. “Sarcopenia, dynapenia, and the impact of advancing age on human skeletal muscle size and strength; a quantitative review.” Frontiers in physiology vol. 3 260. 11 Jul. 2012, doi:10.3389/fphys.2012.00260 (Appears twice)
• Mitchell et al., 2015a, 2015b (Implied: Mitchell, W Kyle et al. “The Impact of Protein Digestion on Muscle Protein Synthesis Rates in Young and Older Adults.” PloS one 10.9 (2015): e0134751)
• Mitchell et al., 2017 (Implied: Mitchell, W Kyle et al. “Modulation of whole body protein turnover rates by resistance exercise and protein ingestion in older men.” Physiology & behavior 179 (2017): 32-8)
• Moro, Tatiana et al. “Resistance exercise training promotes fiber type-specific myonuclear adaptations in older adults.” Journal of applied physiology (Bethesda, Md. : 1985) vol. 128,4 (2020): 795-804. doi:10.1152/japplphysiol.00723.2019
• Murray et al. 1980 (Implied: Murray, Michael P et al. “Gait patterns in men and women aged 61 to 81 years.” The American journal of physical medicine 59.5 (1980): 245-58)
• O’Bryan 2022 (Implied: O’Bryan, Stephen J et al. “Resistance training intensity and volume as determinants of muscle strength and hypertrophy in healthy adults: a systematic review and meta-analysis.” Sports Medicine 52.8 (2022): 1845-1863)
• Paddon-Jones, Douglas, and Blake B Rasmussen. “Dietary protein recommendations and the prevention of sarcopenia.” Current opinion in clinical nutrition and metabolic care vol. 12,1 (2009): 86-90. doi:10.1097/MCO.0b013e32831cef8b
• Payne and Delbono 2004 (Implied: Payne, A H, and O Delbono. “Age-related changes in sarcoplasmic reticulum $\mathrm{Ca}^{2+}$ release in rat skeletal muscle fibers.” The Journal of physiology 557.3 (2004): 813-23)
• Phillips et al., 2015 (Implied: Phillips, Stuart M. “Nutritional and pharmacological manipulation of resistance exercise-induced muscle protein synthesis.” Nutrition Reviews 73.suppl 3 (2015): 238-245)
• Phillips et al., 2016 (Implied: Phillips, Stuart M. “The science of muscle hypertrophy: making sense of the molecular pathways for muscle growth.” Comprehensive physiology 6.2 (2016): 655-681)
• Propst, David & Biscardi, Lauren & Dornemann, Tim. (2023). Clinical sarcopenia identification: Justification for increased sensitivity in SARC-F scores for probable sarcopenia. 10.1101/2023.10.31.23297840.
• Ran, Jianxin et al. “Dose-response effects of resistance training in sarcopenic older adults: systematic review and meta-analysis.” BMC geriatrics vol. 25,1 849. 5 Nov. 2025, doi:10.1186/s12877-025-06559-4 (Appears twice)
• Rieu et al., 2009 (Implied: Rieu, Isabelle et al. “Leucine-enriched essential amino acid supplementation enhances muscle protein synthesis and amino acid availability in the elderly.” Clinical nutrition 28.1 (2009): 74-78)
• Rogeri, Patricia S et al. “Strategies to Prevent Sarcopenia in the Aging Process: Role of Protein Intake and Exercise.” Nutrients vol. 14,1 52. 23 Dec. 2021, doi:10.3390/nu14010052
• Rosenberg, I H. “Sarcopenia: origins and clinical relevance.” The Journal of nutrition vol. 127,5 Suppl (1997): 990S-991S. doi:10.1093/jn/127.5.990S
• Sanchez-Tocino, Maria Luz et al. “Definition and evolution of the concept of sarcopenia.” Nefrologia vol. 44,3 (2024): 323-330. doi:10.1016/j.nefroe.2023.08.007
• Shin, Hyung Eun et al. “Sex-Specific Differences in the Effect of Free Testosterone on Sarcopenia Components in Older Adults.” Frontiers in endocrinology vol. 12 695614. 22 Sep. 2021, doi:10.3389/fendo.2021.695614
• Sklivas, Alexander B et al. “Efficacy of power training to improve physical function in individuals diagnosed with frailty and chronic disease: A meta-analysis.” Physiological reports vol. 10,11 (2022): e15339. doi:10.14814/phy2.15339
• Souza Rocha 2024 (Implied: Souza Rocha, I. R. et al. “Effects of Resistance Training Volume and Frequency on Muscle Strength Gains in Older Adults: A Systematic Review and Meta-analysis.” Sports Medicine 54.2 (2024): 379-397)
• Steps et al., 2015 (Implied: Stephens, Jacalyn M. et al. “The obesity-induced inflammatory state and skeletal muscle anabolic resistance.” The Journal of clinical endocrinology and metabolism 100.2 (2015): 655-666)
• Talbot, Jared, and Lisa Maves. “Skeletal muscle fiber type: using insights from muscle developmental biology to dissect targets for susceptibility and resistance to muscle disease.” Wiley interdisciplinary reviews. Developmental biology vol. 5,4 (2016): 518-34. doi:10.1002/wdev.230 (Appears three times)
• Tezze, Caterina et al. “Anabolic Resistance in the Pathogenesis of Sarcopenia in the Elderly: Role of Nutrition and Exercise in Young and Old People.” Nutrients vol. 15,18 4073. 20 Sep. 2023, doi:10.3390/nu15184073 (Appears twice)
• Titova, Angelina et al. “Muscle Aging Heterogeneity: Genetic and Structural Basis of Sarcopenia Resistance.” Genes vol. 16,8 948. 11 Aug. 2025, doi:10.3390/genes16080948
• Trombetti, A et al. “Age-associated declines in muscle mass, strength, power, and physical performance: impact on fear of falling and quality of life.” Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA vol. 27,2 (2016): 463-71. doi:10.1007/s00198-015-3236-5
• Verdijk et al., 2014 (Implied: Verdijk, Lex B et al. “The role of muscle mass in the reduced muscle protein synthesis rate in older men.” The American journal of clinical nutrition 100.2 (2014): 584-93)
• von Haehling, Stephan et al. “An overview of sarcopenia: facts and numbers on prevalence and clinical impact.” Journal of cachexia, sarcopenia and muscle vol. 1,2 (2010): 129-133. doi:10.1007/s13539-010-0014-2 (Appears three times)
• Wang, Yichen, and Jeffrey E Pessin. “Mechanisms for fiber-type specificity of skeletal muscle atrophy.” Current opinion in clinical nutrition and metabolic care vol. 16,3 (2013): 243-50. doi:10.1097/MCO.0b013e328360272d (Appears three times)
• Zaromskyte, Gabriele et al. “Evaluating the Leucine Trigger Hypothesis to Explain the Post-prandial Regulation of Muscle Protein Synthesis in Young and Older Adults: A Systematic Review.” Frontiers in nutrition vol. 8 685165. 8 Jul. 2021, doi:10.3389/fnut.2021.685165
• Zhu, Yang et al. “Advances in exercise to alleviate sarcopenia in older adults by improving mitochondrial dysfunction.” Frontiers in physiology vol. 14 1196426. 5 Jul. 2023, doi:10.3389/fphys.2023.1196426
• https://stacks.cdc.gov/view/cdc/103492
• https://www.mdpi.com/1660-4601/20/3/2033
• https://pubmed.ncbi.nlm.nih.gov/29792107/

Our Sponsors:
* Check out Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy

Episode Summary

This is a preview of our subscriber-only Ask Us Anything episode, where Dr. Jordan Feigenbaum and Dr. Austin Baraki tackle the most persistent problems in training and nutrition. Hear the science behind managing pain in the gym—determining the threshold for acceptable discomfort versus a true programming error. They also analyze why short-term study findings often fail in the real world, cover the science of pre-exhaust training, and give practical advice on the psychology of managing dietary cravings when transitioning to a healthier diet.

Takeaways

• Pain Threshold: Learn the 3/10 rule for pain in training: low-level, self-limiting discomfort is common, but anything more should be addressed.
• Programming Fix: Recurrent pain (e.g., every 5-6 weeks) is often a programming issue caused by a lack of training tolerance, not a technique fault. The solution is modifying the total load, not just changing your form.
• Training Philosophy: Stop "pushing" harder every session. The best way to progress is to wait for fitness to show up (the lift feels easier) before increasing the load.
• Pre-Exhaust Science: Find out why techniques like leg extensions before squats are suboptimal for both strength and hypertrophy because they compromise the necessary total training load.
• Cravings Are Transient: The intense difficulty experienced when switching from ultra-processed, hyper-palatable foods to home-cooked meals is normal (hedonic adaptation) and transient. Understanding that this discomfort will fade is key to long-term adherence.

⏱️ Preview Timestamps

• 00:00 Introduction & Plus Subscriber Offer
• 00:40 How Often Should I Feel Pain in Training? (Pain Threshold & Training Tolerance)
• 09:31 The Science of Pre-Exhaust Training (Why it compromises total load)
• 16:54 Managing Dietary Cravings When Switching Habits (Hedonic Adaptation)
• 27:49 Conclusion: Barbell Medicine Plus Offer

🔓 Unlock the Full Episode & Exclusive Benefits

The topics above are only a fraction of what's covered in the full Ask Us Anything episode, which also includes:

• How to structure high-intensity conditioning intervals and why heart rate is often a poor metric.
• The science behind Powerlifting peaking and tapering for non-elite athletes.
• The latest, large-scale meta-analysis on Vitamin D and respiratory infections and why the real-world benefit is highly modest.
• A full discussion on the discrepancy between short-term studies and real-world results in diet and exercise.

Subscribe Today to Barbell Medicine Plus

When you join Barbell Medicine Plus, you get the full ad-free episode, access to our bonus content library, and major discounts:

• 25% off all courses and seminars
• 15% off consultations
• 10% off all our programs

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 [email protected]

Resources

Pain

It is normal and acceptable for lifters to experience low-level, self-limiting discomfort during training. The threshold for acceptable pain is generally considered to be less than 3/10 on the pain scale, provided the discomfort is not sharp, does not cause fear, and is gone within 24 to 48 hours.

The real warning sign is recurrent pain—when the same tweak flares up every 5 to 6 weeks. This is typically not a technique fault but a programming issue—the lifter is demanding more from their body than their current training tolerance allows. The solution is usually to reduce the overall training load, modify the volume/intensity, and rebuild capacity gradually.

• www.barbellmedicine.com/blog/training-with-pain-a-practical-approach
• www.barbellmedicine.com/blog/the-barbell-medicine-guide-to-tendinopathy 
• Shrier, I. (2004). Does stretching help prevent injuries? Clinical Journal of Sports Medicine. DOI: {10.1097/00042752-200405000-00002} (Review discussing prior injury as a key risk factor).
• Gabbett, T. J. (2016). The training—injury prevention paradox: should athletes be training smarter and harder? British Journal of Sports Medicine. DOI: {10.1136/bjsports-2016-096319} (Discusses role of prior injury and training load).
• Siewe et al. (2014). Injuries in powerlifting: how common are they and what are their causes? Sports Medicine - Open. DOI: {10.1186/s40798-014-0016-x} (Epidemiology and common injury sites in powerlifting).
• Calhoon, N. L., & Fry, A. C. (1999). Injury rates and profiles of elite competitive weightlifters. Journal of Strength and Conditioning Research. DOI: {10.1519/00124278-199902000-00010} (Injury rates in weightlifting).
• Raske, Å., & Norlin, R. (2002). Injury incidence and prevalence among elite weight and powerlifters. Scandinavian Journal of Medicine & Science in Sports. DOI: {10.1034/j.1600-0838.2002.01188.x} (Injury sites in powerlifting).
• Nijs et al. (2014). Treatment of central sensitization in patients with chronic musculoskeletal pain: new insights and practical implications. Physical Therapy. DOI: {10.2522/ptj.20130360} (Discusses non-mechanical factors like stress on pain).

Pre-Exhaustion

The technique of pre-exhastion training (e.g., leg extensions before squats) is generally suboptimal for both strength and hypertrophy.

Compromised Load: Pre-fatiguing the muscle compromises the ability to perform the subsequent compound lift with high intensity and high volume, thereby reducing the total training load. This directly hurts both muscle growth (less mechanical tension) and strength (less high-fidelity force production).

Limited Use Case: This technique is primarily useful in rehab (as a load-limiting or desensitization tool) or for highly specific muscular endurance challenges (e.g., preparing for certain high-rep CrossFit workouts).

• https://www.barbellmedicine.com/blog/how-to-exercise-when-you-have-no-time/ (training load preservation)
• Schoenfeld, B. J., et al. (2018). Differential effects of attentional focus strategies during long-term resistance training. European Journal of Sport Science. DOI:10.1080/17461391.2018.1500632 (Discusses mind-muscle connection effectiveness).
• Schoenfeld, B. J. (2010). The mechanisms of muscle hypertrophy and their application to resistance training. Journal of Strength and Conditioning Research. DOI: 10.1519/JSC.0b013e3181e840f3(Reviews mechanical tension as the primary driver).
• Fisher, J. P., et al. (2013). The effects of pre-exhaustion, exercise order, and rest intervals in resistance training. Journal of Applied Sports Science Reports. DOI: 10.1016/j.jassr.2013.06.002 (Discusses pre-exhaustion's impact on load).
• Gentil, P., et al. (2007). Effect of exercise order on upper-body strength and muscle thickness in untrained men. Journal of Strength and Conditioning Research. DOI: 10.1519/R-20415.1 (Found pre-exhaustion did not enhance hypertrophy over traditional training).

Cravings

Switching from ultra-processed, hyper-palatable foods (e.g., pizza, fast food) to a whole-food, home-cooked diet involves temporary challenges due to hedonic adaptation (the brain is adapting away from high food reward).

The difficulty of managing cravings is complex. Switching is often easier when the body is in an energy surplus (biologically supported).

The tension and cravings intensify when the lifter moves into a calorie deficit, activating biological defense mechanisms (hormonal signaling increases hunger). Recognizing that the acute cravings are transient is crucial for maintaining self-efficacy and adherence, as it reinforces the belief that the new, healthier habit will eventually become easier.

• https://www.barbellmedicine.com/blog/how-to-eat-a-healthy-diet/ 
• https://www.barbellmedicine.com/blog/how-to-train-while-losing-weight/ 
• https://www.youtube.com/watch?v=oYeh1xTnlxU&themeRefresh=1 
• https://www.barbellmedicine.com/blog/does-your-metabolism-change-with-weight-loss/ 
•  Rosenbaum, M., & Leibel, R. L. (2010). Adaptive thermogenesis in humans. International Journal of Obesity. DOI: {10.1038/ijo.2010.184}
• Considine, R. V. (2012). Leptin and the regulation of body weight. The Journal of Clinical Investigation. DOI: {10.1172/JCI65051}
• Sumithran, P., et al. (2011). Long-term persistence of hormonal adaptations to weight loss. New England Journal of Medicine. DOI: {10.1056/NEJMoa1005813}
• Finlayson, G., et al. (2011). The role of palatability in appetite regulation. Journal of Physiology and Behavior. DOI: {10.1016/j.physbeh.2011.08.016}
•  Lally, P., et al. (2010). How are habits formed: modelling habit formation in the real world. European Journal of Social Psychology. DOI: {10.1002/ejsp.674}
• Baumeister, R. F., et al. (1998). Ego depletion: Is the active self a limited resource? Journal of Personality and Social Psychology. DOI: {10.1037/0022-3514.74.5.1252}
• Spiegel, K., et al. (2004). Brief sleep restriction alters the neuroendocrine profile of ghrelin and leptin. Annals of Internal Medicine. DOI: {10.7326/0003-4811-141-11-200412070-00008}

Our Sponsors:
* Check out Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy

Barbell Medicine Q&A: Cholesterol, Hypertrophy Volume, and Training Efficiency

Episode Summary

In this Q&A session, Dr. Jordan Feigenbaum addresses listener questions on optimizing training, managing health metrics, and navigating supplement use. Key topics include the latest evidence on cholesterol management (statins vs. PCSK9 inhibitors), why routine Vitamin D supplementation is usually unnecessary, and the mechanics of hypertrophy, emphasizing that volume is superior to intensity once a functional threshold is met. Dr. Feigenbaum also offers practical coaching advice on dynamic volume regulation, the importance of efficiency in the deadlift, and why training models like Pilates do not offer the same benefits as traditional strength work.

⏱️ Episode Timestamps

• 00:00 Introduction
• 00:43 Cholesterol Lowering Medication (Statins vs. PCSK9 Inhibitors)
• 03:27 Volume vs. Intensity for Hypertrophy
• 06:48 Regulating Training Volume and the 5% Rule
• 11:43 Barbell Medicine Supplement Philosophy and Safety
• 14:14 Pilates as a Training Modality
• 16:31 Is Zone 2 Cardio Really That Amazing?
• 
  

⭐ 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 [email protected]

⚕️ Section I: Clinical and Healthspan OptimizationCholesterol Management: The Lower is Better Philosophy

The core principle of managing atherogenic risk is that the risk of heart disease is proportional to the overall lifetime exposure (level $\times$ duration) to atherogenic lipoproteins, specifically LDL, triglycerides, and particles tagged with Apolipoprotein B (ApoB). These particles constitute the "atherogenic load."

Lowering this load is beneficial, and the data suggests that lower is better for cardiovascular health. While powerful medications like PCSK9 inhibitors offer an immense magnitude of cholesterol lowering and are proven for both primary and secondary prevention of major adverse cardiac events, the general population will often achieve substantial risk reduction with statins or statin/ezetimibe combinations, which are more accessible and cost-effective.

This approach is validated by observing individuals with genetic mutations who maintain low cholesterol levels throughout their lives—they demonstrate the lowest risk of heart disease, period. Therefore, for active lifters seeking to optimize healthspan and longevity, the goal should be active management and mitigation of this exposure. This requires understanding how to interpret blood work for active lifters and working with a physician to find the most appropriate and sustainable treatment plan, which may include setting targets to lower LDL cholesterol to near-neonatal levels.

Vitamin D Supplementation: Questioning the Routine Recommendation

Routine, widespread Vitamin D supplementation for the general, otherwise healthy population is generally not recommended due to a lack of strong evidence showing that replacing low levels improves actual health outcomes. While low Vitamin D levels frequently coexist with various medical conditions, simply replacing the vitamin doesn't mitigate the primary disease trajectory.

The potential risks of routine supplementation, though low, include supplement contamination and the risk of overdosing (leading to unwanted calcium deposits). Unless an individual has a specific medical condition (like chronic kidney disease, severe malabsorption issues, or high risk of fall and fracture due to osteoporosis), the benefits of routine supplementation are questionable. Barbell Medicine favors interventions where the clinical benefit is clearly demonstrated to improve meaningful health outcomes, not just laboratory values.

🏋️ Section II: Hypertrophy and Training Load OptimizationVolume is the Dose: The Hypertrophy Principle

The relationship between resistance training and hypertrophy (muscle growth) is a dose-dependent relationship on volume, provided a functional threshold is met. This threshold means training must involve a load greater than approximately 30% of a lifter's one-rep maximum (1RM) and be taken relatively close to failure (around 4-5 repetitions left in reserve, RIR).

Advising low volume training to failure, as some influencers do, is sub-optimal for muscle growth because it generates insufficient total training load. Once a lifter has achieved this functional threshold, volume is superior to intensity. High training volume is optimal for muscle growth, and only when volume has been maximized does pulling the intensity lever (training even closer to failure) provide an additional, albeit smaller, benefit.

Optimal hypertrophy and how to structure a strength program for longevity relies on maximizing training load—the total volume of effective work—within the constraints of a person's time and physiological tolerance.

Dynamic Volume Regulation and The 5% Rule

Coaching requires dynamic volume regulation—adjusting the training plan based on a person's current performance and recovery status. One method is to use RPE (Rate of Perceived Exertion) caps to autoregulate volume within a session. For example, prescribing back-off sets that terminate once the prescribed RPE is reached means a lifter performs more work on a good day and less work on a slow day, ensuring sufficient training stimulus without causing excessive fatigue or burnout.

For long-term progression, true strength gain must exceed day-to-day performance fluctuations. A strength gain greater than $\pm 5\%$ over a multi-week period is considered a "real" or minimal clinically important difference in strength. Tracking this trend, rather than session-to-session RPE, is how a coach determines whether to increase the overall training load, which is necessary to continue achieving fitness adaptations.

🧘 Section III: Training Modalities and ApplicationsDeadlift Technique: Efficiency Over Absolute Neutrality

The belief that any slight movement in the thoracic or lumbar spine during a heavy deadlift is uniquely injurious is not supported by evidence. The human body is highly adaptable, provided the training load is progressed gradually.

The primary coaching concern is not achieving an absolute "neutral spine" (which is difficult to define and rarely achieved in heavy lifting) but maintaining efficiency. Excessive spinal movement can compromise the lockout, making the lift harder than necessary. Coaching should focus on improving the efficiency of the lift to maximize the load that can be lifted strongly, not reducing an overstated injury risk.

Pilates: Recreation, Not Resistance Training

Pilates is generally not a valuable addition to an individual's training if the goal is to drive the primary adaptations of resistance training: increases in strength, hypertrophy, muscle function, or bone mineral density.

Pilates is simply not designed to apply the necessary loading stress to the musculoskeletal system to achieve these benefits. It is best viewed as an enjoyable recreational activity or accouterment, not a replacement for "real exercise." For individuals seeking true physical adaptations, the focus should remain on evidence-based resistance training for older adults and other populations that meet or exceed the established physical activity guidelines.

Zone 2 Cardio: Efficiency and Application

While Zone 2 cardio is popular, it is not a panacea. Evidence shows that vigorous physical activity (higher intensity work, Zone 3/Zone 4) is actually more efficient for disease risk reduction than moderate intensity (Zone 2).

Zone 2 work is most useful for individuals performing high volumes of conditioning (three or more hours per week), as it allows them to accumulate volume without causing undue systemic fatigue. For most people performing less than 150 minutes of moderate-to-vigorous activity per week, incorporating more vigorous work is the most time-efficient way to achieve health benefits.

Our Sponsors:
* Check out Factor: https://factormeals.com/bbm50off
* Check out Quince: https://quince.com/BBM


Support this podcast at — https://redcircle.com/barbell-medicine-podcast/donations

Advertising Inquiries: https://redcircle.com/brands

Privacy & Opt-Out: https://redcircle.com/privacy