378 ‒ Women’s health & performance: how training, nutrition, & hormones interact across life stages

1. 0:00 – 0:11

   Intro

   1. PAPeter Attia0:00

      [upbeat music] Hey, everyone. Welcome to the "Drive Podcast." I'm your host, Peter Attia. [upbeat music]

2. 0:11 – 1:23

   Abbie’s background in distance running & interest in studying women’s health

   1. PAPeter Attia0:11

      Hey, Abbie. Thank you so much for coming out to Austin.

   2. ASAbbie Smith-Ryan0:14

      Really appreciate the invite.

   3. PAPeter Attia0:15

      Tell me a little bit about your background, uh, in terms of, like, what got you interested in this space. Uh, you look pretty fit. I assume, uh, you were an athlete growing up?

   4. ASAbbie Smith-Ryan0:25

      Yeah, I'll take that as a compliment. I, uh, uh, was a collegiate distance runner-

   5. PAPeter Attia0:29

      Okay

   6. ASAbbie Smith-Ryan0:29

      ... but I have always had a love of strength training, which is a little bit impeding, uh, for endurance goals, and I really fell in love with science, the ability to ask a question and answer it. And so I started early with research and then kind of fumbled my way in that space, really understanding the more you know, the more you don't know, and here I am.

   7. PAPeter Attia0:51

      As my friend Bob Kaplan used to say, "The further you get from shore, the deeper the water gets." Um, okay, so you were a distance runner. Uh, so in college, that's what? 5K, 10K?

   8. ASAbbie Smith-Ryan1:02

      Yeah, 3K, 5K, 1500. 800 if my coach was mad. I'm not that fast. [laughs]

   9. PAPeter Attia1:08

      Uh, yeah, my daughter runs track, and I, I feel like the 800 is the worst, most painful event in the, in, in the lot.

   10. ASAbbie Smith-Ryan1:16

       Yeah, I th- I would add the 1500. You have to do two more laps at a similar pace, so [laughs] it leverages that, too.

   11. PAPeter Attia1:22

       Yeah.

3. 1:23 – 5:00

   The role of early-life exercise in building lifelong bone, muscle, & cardiovascular health

   1. PAPeter Attia1:23

      Um, but there is something about that approximately two-minute all-out effort that is really brutal. Um, so all right. There's a lot I wanna talk about, um, and I'm trying to think of the best way to help orient it. But, but clearly, um, there are certain things that just seem o- obvious and true across the board. Uh, for example, we know that exercise is a remarkable tool to delay the onset of chronic disease. We also know that it's a remarkable tool to, um, improve healthspan or quality of life. But particularly, I wanna just focus with you and your expertise around what we can understand in, in terms of exercise across the life cycle of a woman. Um, and I wanna almost start basically at the beginning, right? So I, I'm pretty sure there are no teenage girls-

   2. ASAbbie Smith-Ryan2:15

      [laughs]

   3. PAPeter Attia2:15

      ... listening to this podcast. I would be comfortable saying there are exactly zero of them, but there are probably parents of those. And, um, a, a previous guest, um, made a point that I thought was, uh, amazing and has never left me, which is osteoporosis is a childhood disease. Uh, and what she meant by that, of course, was that particularly for women, they are reaching their genetic ceiling at about the age of 19-

   4. ASAbbie Smith-Ryan2:42

      Mm-hmm

   5. PAPeter Attia2:42

      ... in terms of bone density. And then from 19 until the end of life, they're sort of hanging on to what they've got, and then they've got all of these things that get in the way, such as menopause. So let's just start with that. So if you're even not a teenager, you're a 10-year-old girl, um, how do you think about the role of exercise, um, a- across several dimensions, but not the least of which being bone health, but muscle health and reaching sort of, you know, their cardiorespiratory, uh, potential?

   6. ASAbbie Smith-Ryan3:13

      It's a big question, but I, I would sum it up of exercise is the best medicine. Uh, starting young, I, I would consider it more play, and then transitioning into lots of different types of exercise. But really, and there's lots of literature sh- to, to suggest this, the earlier s- you start and the better base that you have, the easier it is over time to maintain that fitness. Um, so when we think about young girls, uh, the biggest conversation and, and even some of the research we do is the addition of menstruation often is a, a turning point when women and girls leave sport based on a number of things, of how their body changes, how their performance i- differs. And so part of what my lab looks at is understanding how that menstrual cycle might impact performance, recovery, bloating, mental health. And so part of why I'm here is the ability to have that conversation. When I was growing up, no one talked about it.

   7. PAPeter Attia4:12

      Were you a runner growing up as well?

   8. ASAbbie Smith-Ryan4:14

      Uh, yeah, I played all sports.

   9. PAPeter Attia4:15

      Uh-huh.

   10. ASAbbie Smith-Ryan4:15

       Um, I loved every sport you could imagine. It was my ability to, um, like, live life, and, and I'm very thankful for that. But I did-- uh, I mean, I grew up in a space where it was exercise more and eat less. And when you add running, it's this, uh, ability to really, um, see how your fitness changes. Same thing with resistance training. You can see how strong you get. It's a very empowering tool. Uh, but I think we don't talk about it enough with young girls of what is menstruation, what-- why is it healthy? As when you go into sports, a lot of times it's like, oh, it's a badge of honor when you don't have your menstrual cycle, uh, or there's a lack of knowledge of it, it is very much related to nutrition.

4. 5:00 – 9:03

   Training principles for premenstrual girls, & the risks of early specialization & delayed puberty from intense training

   1. PAPeter Attia5:00

      So let's talk first about, uh, pre-menstrual cycle.

   2. ASAbbie Smith-Ryan5:05

      Okay.

   3. PAPeter Attia5:05

      So are there any kind of do's and don'ts that you think of for young girls who are playing sports in terms of what they can be doing to augment their training? So for example, if you're talking about a young girl who plays field hockey or volleyball or basketball, do you have any thoughts on what they should or should not be doing in the weight room, for example?

   4. ASAbbie Smith-Ryan5:27

      Yeah, a- and I don't work a lot with young kids, and I actually have two little boys, but I think the-- I, I would tell you the same thing of-- and there's a lot of really interesting data that we haven't done, but s- not specializing, being, uh, in lots of different sports to, uh, you know, accelerate lots of different types of muscles and movement. And I'll, I'll speak to my personal experience of my favorite lift when I was about 11 or 12 was the Romanian deadlift of, like, there is-- resistance training is the best prevention of injury, and oftentimes coaches don't include that. There's a lot of time on the soccer field or the softball field. And so, um, you know, total body exercises, whether we start with resistance bands or light weights or plyometrics or med balls, those are all really great things.

   5. PAPeter Attia6:14

      Let's talk now about this transition as, um, as a girl enters her reproductive years. It seems that intense exercise can delay that. The two athletes I tend to hear this most about are gymnasts and runners.

   6. ASAbbie Smith-Ryan6:27

      Mm-hmm.

   7. PAPeter Attia6:28

      Um, I don't-- Does that also happen with swimmers? I mean, they seem to have some of the highest volume as well, so I would guess that's the case.

   8. ASAbbie Smith-Ryan6:34

      Yeah, it depends on, I think, the, the events. But yeah, absolutely, cyclists.

   9. PAPeter Attia6:38

      Is there a downside to that?

   10. ASAbbie Smith-Ryan6:40

       I mean, there is. And, and we've done a little bit of work more capturing once the, the female is in college-

   11. PAPeter Attia6:47

       Mm-hmm

   12. ASAbbie Smith-Ryan6:47

       ... so kind of the aftermath of that, and there is data that it, it, it very much negatively impacts bone.

   13. PAPeter Attia6:53

       Because of the delay of estrogen onset.

   14. ASAbbie Smith-Ryan6:55

       Absolutely. And, uh, I mean, there's a, a number of things oftentimes related to caloric restriction or indirectly over-exercise. I am a big believer that it's not always intentional. Um, the other thing we see often with things like track and field and gymnastics is every athlete we scan, they have, um, not full-on scoliosis but a spinal curve-

   15. PAPeter Attia7:19

       Hmm

   16. ASAbbie Smith-Ryan7:19

       ... which really demonstrates the point you mentioned, that, uh, you know, osteoporosis is a childhood disease of setting bone and what we do with those young girls has a lifelong impact, whether that's a straight spine or a curved spine.

   17. PAPeter Attia7:33

       Say more about that. I, I wasn't really aware that the, that the scoliosis component could be partially acquired.

   18. ASAbbie Smith-Ryan7:39

       Yeah. Uh, so h- now I've been at UNC for about 15 years, but when we first started doing DEXA scans, we do a lot of whole body for body composition. Um, every high jumper and every gymnast has a very distinct curve. Some of them are aware. Obviously, it's a very thick scoliosis they know, but many of them were unaware, and it's really important then to say, "Okay, well, how do we stabilize this as you age? You've already got that. You can't necessarily change that at 18, 19, 20, but you can very much work on the musculoskeletal system."

   19. PAPeter Attia8:12

       And I would guess pole vaulters as well, right?

   20. ASAbbie Smith-Ryan8:14

       Yep, pole vaulters. Mm-hmm.

   21. PAPeter Attia8:14

       Anybody who's got an asymmetric-

   22. ASAbbie Smith-Ryan8:16

       Exactly.

   23. PAPeter Attia8:17

       Yeah.

   24. ASAbbie Smith-Ryan8:17

       Mm-hmm.

   25. PAPeter Attia8:17

       Okay, interesting. Um, do we see something different in male equivalent of those sports?

   26. ASAbbie Smith-Ryan8:24

       That's a good question. I, I-- We do not have a male gymnastics team. Um, don't see it as much, uh, but I, I, I would probably love to get your thoughts. What do you think?

   27. PAPeter Attia8:35

       Oh, uh, to be, to be honest, I've never thought about it, uh, until you brought it up. Um, I don't know. I mean, it, it-- you could make an argument that if it were less prevalent in males, that maybe males have more, uh, more musculature around the spine-

   28. ASAbbie Smith-Ryan8:52

       Hmm

   29. PAPeter Attia8:52

       ... and therefore they're more able to offset, uh, what's happening.

   30. ASAbbie Smith-Ryan8:55

       Mm-hmm.
5. 9:03 – 14:51

   Nutrition as fuel in young female athletes

   1. PAPeter Attia9:03

      Um, all right. So as, as girls get into high school and college and they're training, um, let's talk a little bit about this idea of kind of reaching your potential early. Um, and, and let's, let's start with something like VO2 max.

   2. ASAbbie Smith-Ryan9:19

      Mm-hmm.

   3. PAPeter Attia9:19

      So, um, you know, we talk a lot about it in, in adults-

   4. ASAbbie Smith-Ryan9:25

      Mm-hmm

   5. PAPeter Attia9:26

      ... and how important it is and how much you're trying to maintain it. Um, but what do we know about the, uh, the ceiling that a person has when they're, when they're that young? Uh, again, it's-- we don't deal with people so young, but I remember being that young-

   6. ASAbbie Smith-Ryan9:41

      Mm-hmm

   7. PAPeter Attia9:41

      ... and having basically an unlimited capacity to train. Uh, and I'm pretty grateful I took advantage of it, but I know that that's not necessarily something everyone's gonna do.

   8. ASAbbie Smith-Ryan9:51

      Yeah. Maybe I'll reframe it. I don't know, a- and I don't do this work with young, young people, uh, um, but there really isn't a ceiling per se, meaning when you're young, I think the best part is, is to see those training adaptations. Uh, and I think the body is more responsive. So for example, I always joked of like, I went out for cross country to get in shape for basketball. Obviously, very different physiological systems, and I, I did not feel fit when I then transitioned to basketball because it's a different-

   9. PAPeter Attia10:22

      Different, yeah

   10. ASAbbie Smith-Ryan10:22

       ... energy system. Um, but that fitness then by the time the end of basketball, I was more fit. And so that adaptability is there when you're young and setting the stage. Um, is it a ceiling effect that you can never add? I, I always view it as, um, exercise is one of those things you can do regardless how old you are, and you can always see improvements if that's the goal. So I wouldn't say a ceiling, but I think definitely on the skeleton and definitely, uh, on our habits of understanding that you are in control, and you can see these really cool physiological adaptations by changing your training.

   11. PAPeter Attia11:00

       So let's talk a little bit about nutrition as well. Um, what do you think are sort of the, the most important things for a young woman to be thinking about? And I guess we can talk about this under different circumstances. We can talk about this under kind of eucaloric conditions, where we're just trying to maybe do recomposition versus weight loss versus weight gain. Take, take it however you, you would like to talk about it.

   12. ASAbbie Smith-Ryan11:26

       Ooh, that's a big question. I think if we talk about young women, my conversation would be all about nutrition as fuel. It, it's really getting adequate nutrition, and that is, um, really where I landed with some of our nutrient timing work of often when you're young or let's say midlife and busy, um, you wanna prioritize getting enough calories, but sometimes you can offset that or take advantage of your training by, uh, what you eat before, during, and after. Not that that is necessarily any better. And so when I think about a young female athlete, uh, and this idea that, you know, that there's increased GI distress, um, there might be, you know, it's hard to exercise when your stomach is full, but really teaching them it's about providing nutrients so that they can p- perform better, recover better, um, that education around what it is versus, you know, necessarily what foods to eat and not to eat.

   13. PAPeter Attia12:21

       So how do we, um... I, I think about this again just through the lens of my own selfish interest around my daughter.

   14. ASAbbie Smith-Ryan12:27

       Mm-hmm.

   15. PAPeter Attia12:27

       So when she's running cross-country, I'm always concerned she's not eating enough.

   16. ASAbbie Smith-Ryan12:31

       Mm-hmm.

   17. PAPeter Attia12:32

       Because practice is first thing in the morning, understandably nobody's really hungry in the morning.

   18. ASAbbie Smith-Ryan12:37

       Mm-hmm.

   19. PAPeter Attia12:38

       So there, you know, she's not really eating. She sort of has a bagel and takes a bite out of it.

   20. ASAbbie Smith-Ryan12:42

       Mm-hmm.

   21. PAPeter Attia12:42

       Then they run, and then they're in class, and then they're not really eating, and then, you know, I just worry that they're- they're sort of not getting enough calories.

   22. ASAbbie Smith-Ryan12:52

       Mm-hmm.

   23. PAPeter Attia12:52

       So what are, what are the strategies you think about for, um, you know, young athletes to hit their caloric requirements when training and school are impediments?

   24. ASAbbie Smith-Ryan13:03

       Yeah, I mean, one of the things is to think about the, what- what types of food. So in that scenario, especially into puberty, is higher quality fat foods, essential fats, and often it's less food and still gets that caloric density.

   25. PAPeter Attia13:16

       What are some things you recommend?

   26. ASAbbie Smith-Ryan13:18

       Yeah, I mean, uh, higher fat milk, higher fat yogurt, um, you know, your nuts, your seeds. Being really intentional about not necessarily changing the foods you're eating, but just small swaps. Instead of a skim milk, a whole milk, um, and things that you can pack with you. Uh, you know, even, um, those would be the- the key first things. The other things would be, uh, there's, you know, a lot of people that talk about intuitive eating, eating when you're hungry, but when you're exercising, you're often blunting that response. Or, uh, most girls and women deal with GI distress, so I say that of planning more of that consumption.

   27. PAPeter Attia13:57

       And why- why is that? Are you saying that, um, the- the- the carbohydrate density or concentration, they- they tend to have more dumping issues or things like that?

   28. ASAbbie Smith-Ryan14:07

       It's not just dumping, it's just the whole GI tract. Uh, I think some of it is stress induced, uh, and, uh, I mean, honestly, it's a really good question. I'm not a gut researcher, but most, um, you know, even some data suggests that it aligns with the menstrual cycle. There's a lot of GI distress before, right before menstruation, and it's not just cramping. So there's a number of elements that- that go into that. It's not just carbohydrate driven, which is an important component because I do think now the conversation with young female athletes is to, you know, not eat as many carbohydrates, be very protein centric, when in reality carb- carbohydrates are so important for any active individual, but especially

6. 14:51 – 27:31

   Training & recovery across the menstrual cycle

   1. ASAbbie Smith-Ryan14:51

      our young females.

   2. PAPeter Attia14:52

      What strategies do you recommend for any woman of any age who's still, uh, who's- who's training and trying to manage her cycle? So whether she's 18 or 38, how do you, how do you think about training around the cycle?

   3. ASAbbie Smith-Ryan15:06

      We've done a lot of work in this space, and, uh, I'll tell you this based on our data and others, is- is we can train at any given time in our cycle. Uh, but what we do see is it's very clear that women, uh, and girls feel worse during different phases of the cycle, and I think that's a really important point. Um, particularly in the luteal phase, right before menstruation, often women feel more fatigued.

   4. PAPeter Attia15:32

      Yeah.

   5. ASAbbie Smith-Ryan15:32

      They have more bloating. It can impact recovery and soreness. And- and I say that of a woman can still compete at, and they will, um, but often it's this, uh, ability to say, like for me, like maybe I didn't meet my max or I'm, you know, my performance is not as good, then it's a little bit of, "Oh, you're fine." Um, that's a physiological response.

   6. PAPeter Attia15:55

      But I- I've always wo- wondered, like, when you watch the Olympics-

   7. ASAbbie Smith-Ryan15:59

      Mm-hmm

   8. PAPeter Attia15:59

      ... or something where you've got this one shot-

   9. ASAbbie Smith-Ryan16:02

      Mm-hmm

   10. PAPeter Attia16:02

       ... in four years, and, you know, it's easy to sort of look at people like Michael Phelps who have been so successful over so many Olympics or Simone Biles, but that's not the norm.

   11. ASAbbie Smith-Ryan16:13

       Mm-hmm.

   12. PAPeter Attia16:13

       Right? The- the- the- the norm, which of course there's nothing about the Olympics that's the norm.

   13. ASAbbie Smith-Ryan16:17

       Yeah. Uh-huh.

   14. PAPeter Attia16:17

       But the norm might be you get one shot at this in your life, and it's always struck me as the greatest injustice that for women, for female athletes, if- if their event falls at the time of the wrong time in their cycle, that- that has to be impeding performance, right?

   15. ASAbbie Smith-Ryan16:38

       I- I mean, I would argue no. It is a question that I've thought about too, of like how great would it be if we could ask, uh, our Olympians whether they're on their menstrual cycle or they're not, or having their period.

   16. PAPeter Attia16:48

       Yeah.

   17. ASAbbie Smith-Ryan16:48

       Um, but what all of the data shows is that a woman is going to compete regardless. I do think it's more about the recovery. So if we take an event where they, often the Olympics is not just a single event, it's repeated. And so really bringing science in to help with recovery and inflammation and protein breakdown, where we might do it differently in the luteal phase versus the follicular phase. So really using more tools to help with the recovery, not necessarily that peak performance. That seems to still be there.

   18. PAPeter Attia17:20

       So let's, let's go through the entire phase. So, uh, day- day zero or day one when the period starts, in some sense I would guess that from that point to the next week, from a hormone perspective, the hormones are very low. But tell me what's happening from a performance perspective and what the-- We'll do it in quarters.

   19. ASAbbie Smith-Ryan17:42

       Okay.

   20. PAPeter Attia17:42

       Let's do this. We'll go, we'll go, you know, sort of, so this, we'll call that the first quarter of the cycle, and w- which is when her period's actually happening-

   21. ASAbbie Smith-Ryan17:48

       Mm-hmm

   22. PAPeter Attia17:48

       ... probably the first four or five days of that, right? Um, both of, you know, F- FSH, LH, estradiol, they're all pretty low.

   23. ASAbbie Smith-Ryan17:55

       Mm-hmm.

   24. PAPeter Attia17:56

       Yeah, so walk through the strategies of, and we don't have to do this through the lens of the Olympics.

   25. ASAbbie Smith-Ryan18:00

       Okay.

   26. PAPeter Attia18:00

       But let's do it through the lens of, like, you are training really, really hard.

   27. ASAbbie Smith-Ryan18:05

       Mm-hmm.

   28. PAPeter Attia18:05

       And you don't wanna, you know, you want to maximize your performance and recovery throughout the entirety of your cycle. So what are you doing this week?

   29. ASAbbie Smith-Ryan18:12

       Well, and let me just qualify, I think it's really important that, uh, we're gonna talk about this traditional cycle, but it's very clear that every cycle is so, so very different. And, um, I say that of we in the lab have used some really cool at-home monitoring tools. Technology has changed.

   30. PAPeter Attia18:29

       Mm.
7. 27:31 – 33:57

   The benefits of creatine supplementation & importance of protein intake

   1. PAPeter Attia27:31

      b- by the way, how are you guys dosing creatine in women?

   2. ASAbbie Smith-Ryan27:33

      It's a good question, and I, I think I know your views on this, but in ri- in reality in a lab-based setting, so we have a pretty cool study right now in, um, the first with creatine in perimenopause.

   3. PAPeter Attia27:44

      Hmm.

   4. ASAbbie Smith-Ryan27:44

      Um, and so because we have a lab restriction, we often will load first just to accelerate that creatine-

   5. PAPeter Attia27:52

      Yep

   6. ASAbbie Smith-Ryan27:52

      ... saturation, um, and then follow it up with, with five grams a day. I'm a big believer that five grams, but even now the, the data in, in our midlife women or the brain health is up to 10 grams.

   7. PAPeter Attia28:03

      10. Yeah. We've, we've changed our thinking on this-

   8. ASAbbie Smith-Ryan28:06

      Yeah. Yeah

   9. PAPeter Attia28:06

      ... is, um... And by the way, I completely hear you on loading because if you just go steady state, it takes weeks to get there.

   10. ASAbbie Smith-Ryan28:12

       It takes way too long. Yeah.

   11. PAPeter Attia28:12

       Yeah, yeah, so totally get that. But yeah, it's actually funny, I had Rhonda Patrick on the podcast recently.

   12. ASAbbie Smith-Ryan28:17

       Mm-hmm.

   13. PAPeter Attia28:17

       We were talking about that, and I came out of that podcast thinking, "You know what? I think we should move our maintenance dose-

   14. ASAbbie Smith-Ryan28:21

       Hmm

   15. PAPeter Attia28:21

       ... from five to 10."

   16. ASAbbie Smith-Ryan28:22

       Mm-hmm.

   17. PAPeter Attia28:23

       And so we've kinda just done that.

   18. ASAbbie Smith-Ryan28:24

       That's great.

   19. PAPeter Attia28:25

       Yeah.

   20. ASAbbie Smith-Ryan28:25

       Yeah. And so we typically will do five grams following that loading.

   21. PAPeter Attia28:29

       Uh-huh.

   22. ASAbbie Smith-Ryan28:29

       And that's what we're doing now.

   23. PAPeter Attia28:30

       And your load is how long, and what-

   24. ASAbbie Smith-Ryan28:32

       It's usually five days.

   25. PAPeter Attia28:33

       Five days at 20?

   26. ASAbbie Smith-Ryan28:33

       So 20 grams-

   27. PAPeter Attia28:34

       Yep

   28. ASAbbie Smith-Ryan28:34

       ... mm-hmm, at five days split in, in four five gram doses.

   29. PAPeter Attia28:38

       Yep. Okay. But for the average person who's not trying to enter a study, just go to 10 a day, and we feel pretty good about it. And, uh, so, so again, really interesting point, and I'd love to hear what women are experiencing-

   30. ASAbbie Smith-Ryan28:50

       Hmm
8. 33:57 – 38:31

   How women should approach training intensity & volume across the menstrual cycle

   1. PAPeter Attia33:57

      So are you... Now let's not talk about a team athlete, let's just talk about an individual.

   2. ASAbbie Smith-Ryan34:03

      Okay.

   3. PAPeter Attia34:03

      So we're, we're long done with college, we're not on a team anymore. We as the individual are in charge of our own training.

   4. ASAbbie Smith-Ryan34:08

      Mm-hmm.

   5. PAPeter Attia34:08

      So a woman who's listening to this, who is herself, you know, uh, active-

   6. ASAbbie Smith-Ryan34:14

      Mm-hmm

   7. PAPeter Attia34:14

      ... she's, you know, whether it's my wife, she's training for marathons, or whether it's, you know, a woman who's just training to stay in shape.

   8. ASAbbie Smith-Ryan34:20

      Mm-hmm.

   9. PAPeter Attia34:20

      Um, what guidance are you giving around, if anything, how you would change intensity and volume throughout the cycle?

   10. ASAbbie Smith-Ryan34:29

       It's a good question. I mean, if we're talking about, uh, let's just say someone in their 40s-

   11. PAPeter Attia34:34

       Yeah

   12. ASAbbie Smith-Ryan34:34

       ... uh, I mean, I would say we're just trying to exercise and, and that intensity and volume would be periodized based on something else.

   13. PAPeter Attia34:42

       Got it. So in other words, you're gonna change intensity and volume based on longer mesocycles-

   14. ASAbbie Smith-Ryan34:47

       Yes

   15. PAPeter Attia34:47

       ... that are around peaking and tapering for whatever the events are. But not, we're not gonna do a monthly up and down based on the cycle, which means you are accepting the fact that you will sometimes train not feeling as good as you do during other times in the cycle.

   16. ASAbbie Smith-Ryan35:04

       Well, right, I have, uh, two, two thoughts on that, of should we, or does your periodized, you know, four-week program, could we align it with our period and our menstrual cycle? That might be something that we need to look into, of like you're out, you're just shifting-

   17. PAPeter Attia35:18

       Mm-hmm

   18. ASAbbie Smith-Ryan35:18

       ... your four-week mesocycle. Um, but yes, 100%, we are gonna train whenever and, and do those long-term effects, but then also giving ourselves some grace of like, oh, if you didn't hit your, your goals or your, your minute per mile or whatever it may be, um, to take a step back and say, "Oh, wh- where do my hormones play a role?" Or I also maybe needed a little bit longer recovery. Um, and there's some interesting data, too, with work-to-rest ratio. We might just, uh, need to, um, I think empower women to say, first of all, when is your menstrual cycle? Or what does that look like? How long? Which helps us understand when it changes. How long are you bleeding? And are you more tired based on those hormonal things, or is it something else?

   19. PAPeter Attia36:02

       So this might be a relief to some women to hear that because it makes them maybe accept the fact that, hey, I don't need to, like, over-science this thing.

   20. ASAbbie Smith-Ryan36:12

       Mm-hmm.

   21. PAPeter Attia36:12

       Like, it is what it is, and I, I, I can't imagine what it would be like as a guy where, you know, my hormones are pretty much always the same.

   22. ASAbbie Smith-Ryan36:21

       Mm-hmm.

   23. PAPeter Attia36:21

       And yet if, if, you know, these very powerful androgens are moving up and down throughout a cycle, the lack of predictability in how you're going to, to perform can be pretty frustrating. But it seems like grace with yourself is, uh, is a high virtue.

   24. ASAbbie Smith-Ryan36:37

       Yeah, I, I guess I would, I would say that's one of the reasons I came as a scientist of like, I have a lot of data and evidence, but how I do it in real life, I mean, some days I'm lucky. I'm training at 5:00 in the morning, 'cause then I'm, you know, all day, like we're lucky just to get it in. And so consistency matters, and I would say empowering women, we were not taught about our, like, uh, our bleeding patterns, our changes in hormones, what's normal, even down to the changes in, in brain and mental health. And so I, I kick that back and say, if there's a way that we can measure that, and a woman can track that, it's really empowering versus, "Wow, I just feel terrible," or, "What am I doing?" It allows us to tease out when there is something we need to change, whether it's our nutrition, our meds, or whatever it may be. Um, but first and foremost, asking, okay, well, where do my hormones play a role, and how does that change as I do get older?

   25. PAPeter Attia37:32

       Now, if a, if a woman is on an oral contraceptive with- without the placebo week

   26. ASAbbie Smith-Ryan37:37

       Mm-hmm

   27. PAPeter Attia37:37

       ... so if a woman is just taking the hormone throughout the cycle, obviously completely suppressing ovulation and therefore completely suppressing a menstrual cycle, is there a performance advantage to that? Uh, in other words, if you were trying to make that Olympics, [laughs] would that potentially be the strategy?

   28. ASAbbie Smith-Ryan37:53

       It's more indirect, I would say, based on the literature of, a- and even working with female athletes, is that that consistency, uh, potentially over time there's less variability, so there is more consistency with the training. And indirectly, a lot of times women are taking a hormonal contraception for the, to help with symptoms of their cycle, whether that be mood or cramps, and so a lot of times females feel better. Uh, and then l- just in general, not having to bleed. Some, um, women I know skip the placebo week so that they don't have to deal with that, and that in itself is a, is a, is a nice thing not have to worry about.

   29. PAPeter Attia38:30

       Got

9. 38:31 – 43:51

   How to identify & monitor the perimenopausal transition—a critical window for exercise & nutrition interventions

   1. PAPeter Attia38:31

      it. All right, so let's talk about now as women enter the perimenopausal stage of life, which, you know, obviously for some women can be relatively short and brief, and for others can, can sort of drag on for a while. But if we, if we, um, if we identify it based on some sort of irregularity, you know, a slowly upward drifting FSH, um, what, what are the ways you would, would, you would advise a woman to start thinking about how she exercises and eats during that phase of her life, which again, could, could last for years?

   2. ASAbbie Smith-Ryan39:07

      Yeah, I, I mean, well, this is where a lot of the data has led me, luckily, um, as I roll into it. It, it's not how I planned it, but I am, am happy to have more data. [laughs]

   3. PAPeter Attia39:17

      You're becoming an expert into the, the period, the period of life you're going into at some point, yeah.

   4. ASAbbie Smith-Ryan39:20

      Yeah, I mean, not really intentionally, but, um, I, I would say that, uh, it very much symptom driven.

   5. PAPeter Attia39:26

      Mm.

   6. ASAbbie Smith-Ryan39:26

      And so often we don't know when our FSH is rising or we're not getting our measures. So first and foremost, getting blood work done is really h- valuable into our, you know, even starting in our 30s so that we know individually when that changes. Um, we have leveraged at home hormone urine analyses, like where you measure daily urine, which really starts to say, "Okay, well, maybe my hormones are changing in a different day."

   7. PAPeter Attia39:50

      And what are you measuring in the urine?

   8. ASAbbie Smith-Ryan39:52

      So, um, there's a couple different devices that we've used, and, and this is just in the science perspective. Um, most of them are measuring some form of estrogen, some form of, of progesterone, FSH, LH, all in like a pee stick, a urine stick.

   9. PAPeter Attia40:08

      And how accurate are they relative to blood?

   10. ASAbbie Smith-Ryan40:11

       Great question. Um, not, they're not, I always say they're, th- they're not telling us the exact same thing, um, but we're trying to work on some of that validation so that instead of-

   11. PAPeter Attia40:21

       So you can correlate what you're seeing in the urine?

   12. ASAbbie Smith-Ryan40:22

       Absolutely.

   13. PAPeter Attia40:23

       Yeah.

   14. ASAbbie Smith-Ryan40:23

       Yeah, but more importantly, we're then now able to see that daily variation.

   15. PAPeter Attia40:27

       Yeah.

   16. ASAbbie Smith-Ryan40:28

       And so, like if I have a spike or one of our participants does, or it's a drop and I feel terrible or I feel better, you can start to identify that. Or if there's no peak at all and, uh, it's impacting sleep or hot flashes, it really allows us to have those tools to say, "Okay, no, this is what's happening," versus that single point in time we're getting our blood work done.

   17. PAPeter Attia40:50

       And the estrogen that's being measured, is it just estradiol or is it estriol or estrone and everything?

   18. ASAbbie Smith-Ryan40:56

       Yeah, I mean, usually it's one marker. Uh, it, it depends on the device.

   19. PAPeter Attia41:01

       The, the thing I would advise women who are listening is to be really consistent. We think that day five FSH in the blood is probably your best test.

   20. ASAbbie Smith-Ryan41:10

       Hmm.

   21. PAPeter Attia41:10

       Um, because again, you really consistency, consistently know what it should be. So, um, when you're fertile, day five, so if day one is the day your period starts, if you have an FSH level on day five, it really should be low.

   22. ASAbbie Smith-Ryan41:25

       Hmm.

   23. PAPeter Attia41:25

       Um, and that's, that's the thing that we're watching to climb-

   24. ASAbbie Smith-Ryan41:29

       Interesting

   25. PAPeter Attia41:29

       ... as she's entering perimenopause. So once that number is even hitting 10-

   26. ASAbbie Smith-Ryan41:33

       Mm-hmm

   27. PAPeter Attia41:33

       ... we sort of know that she's, she's now entering that, that zone. And, um, obviously, if you look at a woman in menopause, that number's gonna very quickly rise to 25, 30, 50, et cetera. Um-

   28. ASAbbie Smith-Ryan41:45

       Can I ask you a follow-up?

   29. PAPeter Attia41:46

       Yeah, yeah.

   30. ASAbbie Smith-Ryan41:47

       Uh, what do you do if they have an IUD, and do you ever use like AMH numbers?
10. 43:51 – 56:50

    Case study: time-efficient exercise program for a perimenopausal woman

    1. PAPeter Attia43:51

       So what is a potentially cha-- what is a specific change you might make, um, for a woman? So maybe let's take the first example, which is a woman who's actually not exercising that much because she's got three kids under six, and she's, [laughs] she, she has her hands full.

    2. ASAbbie Smith-Ryan44:11

       Yeah.

    3. PAPeter Attia44:11

       Like, the going to the gym every day is not on the list when you're trying to manage, uh, that. But as she's becoming perimenopausal, how do you make the case to her that exercise should be prioritized for her health beyond the usual things that you would hear? Like, of course exercise is good for you, but, but how do you make the case, if you can, that actually despite how busy you are, this is a great time to start this, uh, or reengage in this habit?

    4. ASAbbie Smith-Ryan44:39

       I mean, I would follow it up of not just say reengage or start this habit. You're never too late, old to start, and it will literally impact your health forever. Um, and I would say based on the data, it doesn't have to be 150 minutes a week of exercise. It's really consistency, so, um, and there's data, uh, I, I would love to get your opinion on this, but, uh, that intensity is more important than volume and, uh, consistency is more important than volume. And so really telling her that, um, I, I know I struggle with mom guilt, and often these women are, are worried about taking care of everyone else with this desire to care for them, but the best way-

    5. PAPeter Attia45:20

       It's amazing how little dad guilt occurs in the-

    6. ASAbbie Smith-Ryan45:22

       [laughs] I mean, I was gonna ask you. Surely there's dad guilt, no? [laughs]

    7. PAPeter Attia45:25

       It's not the same. I think the truth of the matter is, um, yeah, I, I'm, I'm way less selfish than I used to be, but the truth of the matter is my wife is infinitely more selfless.

    8. ASAbbie Smith-Ryan45:37

       Mm-hmm.

    9. PAPeter Attia45:37

       And-

    10. ASAbbie Smith-Ryan45:38

        We're wired that way, aren't we? [laughs]

    11. PAPeter Attia45:41

        Y- yeah. She, y- you know, I f- and I feel bad sometimes. It depends. Like, look, if my wife is in the middle of training for a marathon-

    12. ASAbbie Smith-Ryan45:48

        Mm-hmm

    13. PAPeter Attia45:48

        ... and only one of us can do our workout, uh, it will be her.

    14. ASAbbie Smith-Ryan45:51

        Mm-hmm.

    15. PAPeter Attia45:51

        Um, but ordinarily she'll always be the one to say, "Look, if only one of us, if we only have time for one of us to do something today-"

    16. ASAbbie Smith-Ryan45:58

        Mm-hmm.

    17. PAPeter Attia45:58

        She- she'll-

    18. ASAbbie Smith-Ryan45:59

        She'll take it

    19. PAPeter Attia45:59

        ... she'll, she'll take the hit and let me do it.

    20. ASAbbie Smith-Ryan46:01

        Mm-hmm. Well, and I, I think, um, I mean, you throw in the kids. I have two little boys, and they say, "Don't go." Like, "Why are you going to run?" Of like... And so it's bringing them into it too. I think women, the other reason I'm passionate about it is that we have the ability to not only change our healthspan but also generations behind us of, hey, this is really important so that I can... I always joke with my kids of like, "Do you see any other mom killing you on the flag football or the baseball?" Of like it allows me to be out there and to keep up with them as well. So I, I tie it back into health and longevity and quality of life of if you want to, to live healthier longer, you need to put the time in now, and it will ultimately help you be a better mom, wife, et cetera, um, in, um-

    21. PAPeter Attia46:46

        Grandmother.

    22. ASAbbie Smith-Ryan46:46

        Exactly.

    23. PAPeter Attia46:47

        Yeah.

    24. ASAbbie Smith-Ryan46:47

        Yeah.

    25. PAPeter Attia46:48

        Um, I wanna touch on your point about, uh, volume and intensity. Um, you know, we've been looking at this a lot, and I'll tell you what our reading is of the literature is actually that, um, with unlimited time, volume matters the most. As volume goes down, intensity becomes more important.

    26. ASAbbie Smith-Ryan47:14

        Okay.

    27. PAPeter Attia47:14

        In other words, if a person only has 150 minutes a week to exercise, you have to prioritize intensity because you're not really getting enough volume to maximize, uh, conditioning. If a person is willing to train 12 hours per week, you know, which is obviously [laughs] a lot-

    28. ASAbbie Smith-Ryan47:38

        Mm-hmm

    29. PAPeter Attia47:38

        ... um, then you have the luxury of, you know, relying on the volume for the benefits, and y- the, the, the ratio of high intensity to low intensity is gonna be a lot shorter. And so this is a slightly more nuanced view than, than I, than I think often gets communicated, and it's the difference between the professional runner or the professional cyclist who's out there 25 hours a week training. And yes, 80% of their volume is going to be really, really low intensity, but that's none of us.

    30. ASAbbie Smith-Ryan48:09

        Mm-hmm.
11. 56:50 – 1:02:12

    Why improving body composition is a better goal than weight loss

    1. PAPeter Attia56:50

       Let's talk a little bit about some of the goals that women might be coming into this with. So, um, let's start with, I mean, do you ever differentiate between weight loss and body composition? I mean, they're basically the same thing, aren't they?

    2. ASAbbie Smith-Ryan57:03

       Well, I- it's, it's one of the things I'm passionate about because most women say, "I want to weigh less." Um, or we were taught like, "Oh, I don't want to know my body fat," when in reality, like we should know, and you want to measure so that a lot of times the weight doesn't change or goes up. Um, and so it is all about body composition, but a lot of women don't understand that.

    3. PAPeter Attia57:26

       Yeah. So how do you, how would you counsel a woman that, um, that, that came to you and said, "I, I want to lose weight," which would be the common statement for anyone. This is not, this is men-

    4. ASAbbie Smith-Ryan57:35

       Yeah

    5. PAPeter Attia57:35

       ... this is women.

    6. ASAbbie Smith-Ryan57:35

       Mm-hmm.

    7. PAPeter Attia57:35

       Everybody says, "I want to lose weight."

    8. ASAbbie Smith-Ryan57:37

       Yes.

    9. PAPeter Attia57:37

       What they really mean is, "I want to lose fat."

    10. ASAbbie Smith-Ryan57:39

        Lose fat.

    11. PAPeter Attia57:39

        Yeah.

    12. ASAbbie Smith-Ryan57:39

        Yes. Um, so we would do some sort of measurement and, and we do a pretty comprehensive, whether it be a, a DEXA scan or a multi-frequency bioelectrical impedance or an at-home scale. Um, they're all different, but most of them do a pretty good job with tracking changes. And what I would do is based on that number, calculate ideal weight, and from that it tells us, okay, here's our percent fat and our muscle, um, but here's my goal percent fat and muscle based on my health goals or my, you know, weight goals. To-- A lot of times people think, "Oh, I want to weigh what I did in high school," but in reality, they'd have to lose muscle for that, and so giving them more of a target percent fat with that weight or to inform our weight goal.

    13. PAPeter Attia58:23

        And how do you make a, um, determination of what the ideal body fat percent is?

    14. ASAbbie Smith-Ryan58:29

        I mean, depending on the device, a lot of times you can use NHANES. Uh, what, uh, really at around the 50th percentile we see a lot of cardiometabolic changes. So I mean, it, it, it-- using a lower percentage, there's normative data that I would use based on the individual.

    15. PAPeter Attia58:45

        But to what percentile do you bank? Down to the 50th percentile?

    16. ASAbbie Smith-Ryan58:49

        Oh, no, no. Usually, we want it down to like the 25th percentile-

    17. PAPeter Attia58:53

        Okay

    18. ASAbbie Smith-Ryan58:53

        ... and lower. Yeah, 50th is, is what you want to stay away from.

    19. PAPeter Attia58:56

        Yeah. Got it. Okay.

    20. ASAbbie Smith-Ryan58:57

        Yeah.

    21. PAPeter Attia58:57

        So I, again, I'm-- if a woman came in and she was, I don't know, five foot six-

    22. ASAbbie Smith-Ryan59:05

        Mm-hmm

    23. PAPeter Attia59:06

        ... sort of probably the average height, and 150 pounds-

    24. ASAbbie Smith-Ryan59:09

        Mm-hmm

    25. PAPeter Attia59:09

        ... um, which tells us nothing yet 'cause-

    26. ASAbbie Smith-Ryan59:12

        Yep

    27. PAPeter Attia59:12

        ... right. But now you do a DEXA scan, and she is 30% body fat. My guess is that's probably about the 50th percentile of NHANES?

    28. ASAbbie Smith-Ryan59:22

        How old is she?

    29. PAPeter Attia59:23

        Uh, 40.

    30. ASAbbie Smith-Ryan59:24

        Yeah. I would say that, that's still not, that, that's a little bit lower.
12. 1:02:12 – 1:08:02

    How to preserve muscle & bone while using GLP-1 medications

    1. PAPeter Attia1:02:12

       lot of women, or anyone for that matter, but l- we're talking about this p- hypothetical case.

    2. ASAbbie Smith-Ryan1:02:16

       Mm-hmm.

    3. PAPeter Attia1:02:16

       A, a lot of women in this situation of being 150 could easily get to 130 with a GLP-1 agonist.

    4. ASAbbie Smith-Ryan1:02:22

       Yeah.

    5. PAPeter Attia1:02:22

       Okay.

    6. ASAbbie Smith-Ryan1:02:23

       Mm-hmm.

    7. PAPeter Attia1:02:25

       Are you, are you gon-- And so let's just say a woman says, "Look, I'm going to take this GLP-1 agonist because I'm going to weigh 130 pounds."

    8. ASAbbie Smith-Ryan1:02:31

       Mm-hmm.

    9. PAPeter Attia1:02:32

       What are the strategies you're going to employ to figure out a way to say, "Look, I want-- Of the 20 pounds that you're going to net lose-

    10. ASAbbie Smith-Ryan1:02:40

        Mm-hmm

    11. PAPeter Attia1:02:41

        ... I'd like to make sure that no more than five of them are muscle, and therefore, 15 of them are fat," which by the way would be an enormous improvement in body composition, right?

    12. ASAbbie Smith-Ryan1:02:51

        Absolutely.

    13. PAPeter Attia1:02:51

        She, she would go from being 35% body fat to 20% body fat or 22% body fat or something like that. So what kind of strategies would you employ there, both in terms of nutrition and in terms of her training?

    14. ASAbbie Smith-Ryan1:03:07

        Yeah, so I mean, the, in those cases, uh, in general, in that life space, we know that our muscle quality is also changing. And so i- it just emphasizes the need for resistance training. Um, and, and there's a lot of different ways to do that. But I would absolutely prioritize resistance training to help to maintain that lean mass and improve the muscle quality. And then protein has to be a conversation, particularly, um, thinking about maintaining amino acids over the day, so kind of consistently feeding. You know, usually the goal is around 30 grams of protein evenly spaced throughout the day. We've also done some work with essential amino acids around exercise, which really helps optimize that, that maintenance of lean mass.

    15. PAPeter Attia1:03:55

        And what would you target per day? So if she's at 150, would you target 150 grams of protein a day?

    16. ASAbbie Smith-Ryan1:04:01

        Yeah, I mean, usually you use the goal weight to identify-

    17. PAPeter Attia1:04:04

        Yeah

    18. ASAbbie Smith-Ryan1:04:04

        ... um, but yes, I would say 130 to 150 grams of protein. It, it has a higher thermic effect. Um-

    19. PAPeter Attia1:04:11

        Yeah

    20. ASAbbie Smith-Ryan1:04:11

        ... and if, if we're-- that's a pretty, uh, aggressive fat loss-

    21. PAPeter Attia1:04:15

        Yeah

    22. ASAbbie Smith-Ryan1:04:15

        ... weight loss. So yes, um, if we could get to 150, that would be a good goal.

    23. PAPeter Attia1:04:21

        Yeah. B- And, and, and the reason I bring this up is I, I think that y- you know, we just have to accept that many people are going to use these drugs.

    24. ASAbbie Smith-Ryan1:04:31

        Yeah.

    25. PAPeter Attia1:04:31

        They're becoming-

    26. ASAbbie Smith-Ryan1:04:32

        Mm-hmm

    27. PAPeter Attia1:04:32

        ... uh, more and more tolerable. Um, again, you know, M- Mounjaro or tirzepatide is significantly easier to tolerate than semaglutide. Um, and what I just wanna make sure is that all the people that are out there, you know, wasting away have the insight into, hey, it doesn't have to be this way. I can still take this drug. I can still lose weight, but I also have to do something kind of deliberate-

    28. ASAbbie Smith-Ryan1:04:58

        Mm-hmm

    29. PAPeter Attia1:04:59

        ... to make sure I don't have a negative impact on my skeletal muscle.

    30. ASAbbie Smith-Ryan1:05:03

        Well, which I think is such an important point that, um, I mean, most men and women, but most women really wanna weigh less.
13. 1:08:02 – 1:12:18

    Designing a three-hour-per-week training plan for sustainable body recomposition

    1. PAPeter Attia1:08:02

       Yeah. So let's assume in this case of this hypothetical woman, she, she's showing up and she's not really got much of a huge exercise routine.

    2. ASAbbie Smith-Ryan1:08:11

       Mm-hmm.

    3. PAPeter Attia1:08:12

       So now you're kind of introducing her for the first time, and let's assume she's also in the Look, I've, I've got three hours a week I'm willing to put into this. How are you gonna divide her three hours per week where now her goal is recomposition?

    4. ASAbbie Smith-Ryan1:08:25

       You know what? It-- I don't think I would change much. I mean, I would definitely-

    5. PAPeter Attia1:08:28

       Only two 30-minute strength training sessions-

    6. ASAbbie Smith-Ryan1:08:31

       I mean, if we have more

    7. PAPeter Attia1:08:31

       ... or would you, would you flip it?

    8. ASAbbie Smith-Ryan1:08:33

       Yeah, I think i- if you're doing high intensity resistance training, like optimally you, you might do one additional. Um, it does depend on the soreness and what we're doing. Uh, uh, I think the other thing that we need to consider is the lack of energy. So if she's-- we're undereating, we might not have the ability to do as high of, of volume and intensity on those two resistance training days. Um, the, the other thing we wanna consider though is those cardiovascular changes, and that, that's why I like HIIT, is that it can stimulate an increase in muscle at the same time and still improve those kind of vascular changes we would see. So maybe one day maybe I would flop it, um, but I would still-

    9. PAPeter Attia1:09:14

       Meaning give a third day of resistance training?

    10. ASAbbie Smith-Ryan1:09:16

        I mean, if we had it, um, or encourage her to add-

    11. PAPeter Attia1:09:19

        Yeah, she's giving you the time.

    12. ASAbbie Smith-Ryan1:09:20

        Okay.

    13. PAPeter Attia1:09:20

        She's saying, "Look, I'm gonna give you three hours. You tell me how to do it."

    14. ASAbbie Smith-Ryan1:09:23

        Yeah, h- honestly, I would maybe, um, do the three resistance training and, and take one of those 30 minutes low intensity, uh, cardiovascular days, um, to add the resistance training.

    15. PAPeter Attia1:09:36

        All right, so she's gonna do one low intensity cardio day, two high intensity cardio days, three strength days. All of those are 30 minutes a pop.

    16. ASAbbie Smith-Ryan1:09:45

        Yeah. Um, I would say if she's unfit, that might, uh-

    17. PAPeter Attia1:09:50

        That's gonna be a lot

    18. ASAbbie Smith-Ryan1:09:50

        ... be a lot for her. Yeah. So, um, probably pl- change one of those HIIT days for a low intensity day.

    19. PAPeter Attia1:09:56

        Okay, so two low intensity, one HIIT, three days in the gym.

    20. ASAbbie Smith-Ryan1:10:00

        Mm-hmm.

    21. PAPeter Attia1:10:00

        And those three days in the gym are all whole body, or at that point do you start to go body type once a week?

    22. ASAbbie Smith-Ryan1:10:07

        Yeah, I mean, I still like body type or the, our major muscle groups twice a week, so a push/pull.

    23. PAPeter Attia1:10:15

        Mm-hmm.

    24. ASAbbie Smith-Ryan1:10:16

        Um, I really think it depends on the individual. Is she tolerating it well? Is she feeling good or is she run down? If, if we, you know, like if she doesn't have energy, then I would split it up.

    25. PAPeter Attia1:10:25

        Would you suggest a timeframe over which that degree of body recomposition is gonna be more sustainable and therefore less dramatic in the, uh, in the getting there phase?

    26. ASAbbie Smith-Ryan1:10:40

        Yeah, and I think it's a really important point, especially when we think about, um, like a lot of our lab-based work where we're, we're looking for accelerated time, uh, or accelerated changes in a short period of time. So yeah, for more sustainable, um, y- I think the body part over a, a specific... So if we're looking at 24 weeks-

    27. PAPeter Attia1:10:57

        Yeah

    28. ASAbbie Smith-Ryan1:10:58

        ... is often what we're, we're looking at, would be, um, yeah, a l- a, more of a concentrated push/pull, whether it be leg day, upper body, leg, upper body.

    29. PAPeter Attia1:11:07

        And you would say 24 weeks. If she came to you and said, "Look, how long would you like this to take?"

    30. ASAbbie Smith-Ryan1:11:13

        Mm.
14. 1:12:18 – 1:19:13

    Abbie’s insights from her 20+ years of self-tracking

    1. PAPeter Attia1:12:18

       now you've done a lot of tracking in yourself, right?

    2. ASAbbie Smith-Ryan1:12:21

       Mm-hmm.

    3. PAPeter Attia1:12:21

       And you've... How, how many years have you been at this yourself, your, your sort of self-quantification?

    4. ASAbbie Smith-Ryan1:12:26

       Hmm. Gosh, at least, like, uh, more than 20 years. That was, uh... We measured it in, in college all the way through grad school and, and now, um, I, I do mine every, like, six to nine months.

    5. PAPeter Attia1:12:38

       Okay, so what have been your observations in yourself based on this, and how generalizable do you think they might be?

    6. ASAbbie Smith-Ryan1:12:44

       Uh, I mean, I think initially, it, it's really important to understand kind of low, like what... Uh, so just for instance, um, when I was a distance runner, I had nine stress fractures, and it was every time my body fat got below about 15%, which is really not ridiculously lean, um, so that injury indicator. Uh, and then what I've noticed-

    7. PAPeter Attia1:13:05

       And just to...

    8. ASAbbie Smith-Ryan1:13:06

       Mm-hmm.

    9. PAPeter Attia1:13:06

       You're, you're how tall?

    10. ASAbbie Smith-Ryan1:13:07

        I'm about 5'6".

    11. PAPeter Attia1:13:09

        And when you were at 15% body fat, that was what weight?

    12. ASAbbie Smith-Ryan1:13:12

        Hmm. That's a long time ago. Uh, 120.

    13. PAPeter Attia1:13:16

        Okay.

    14. ASAbbie Smith-Ryan1:13:16

        115.

    15. PAPeter Attia1:13:17

        So that looks pretty normal.

    16. ASAbbie Smith-Ryan1:13:18

        Yeah.

    17. PAPeter Attia1:13:18

        Like you're a lean-looking person-

    18. ASAbbie Smith-Ryan1:13:19

        Yeah

    19. PAPeter Attia1:13:19

        ... but that's not, you're not a bean pole.

    20. ASAbbie Smith-Ryan1:13:22

        No, um, but it was my, like, set point.

    21. PAPeter Attia1:13:24

        Yep.

    22. ASAbbie Smith-Ryan1:13:25

        And so it's really important to use these numbers of not, like, "Hey, how do I compare to someone else?"

    23. PAPeter Attia1:13:30

        Yep.

    24. ASAbbie Smith-Ryan1:13:31

        But "Oh, about this is, is too much for my body."

    25. PAPeter Attia1:13:34

        So when, at that point-

    26. ASAbbie Smith-Ryan1:13:35

        Mm

    27. PAPeter Attia1:13:35

        ... you, you did, you were amenorrheic, I'm assuming?

    28. ASAbbie Smith-Ryan1:13:38

        Um, I wa- honestly, like no one talked about it, but yes, I, I, uh, for most of my competitive career probably.

    29. PAPeter Attia1:13:44

        Is that, is that a sign to a young girl that she's either not eating enough or she's exercising too much?

    30. ASAbbie Smith-Ryan1:13:51

        Oh, I, I mean, I think, um, the... Well, absolutely.
15. 1:19:13 – 1:28:40

    How pregnancy & the postpartum period affect body composition

    1. ASAbbie Smith-Ryan1:19:13

       maybe a little bit different than, than then, um, but omega-3, vitamin D, uh, magnesium, creatine, uh, multivitamin, those are the, the key ones. I, I do, like, a probiotic, which is debatable, but multi-strain based on my GI system.

    2. PAPeter Attia1:19:33

       How did your body comp then change over pregnancies, and have you-- So if you go back to prior to your first pregnancy-

    3. ASAbbie Smith-Ryan1:19:41

       Mm-hmm

    4. PAPeter Attia1:19:42

       ... what was your body composition, and how did that change at your second and then obviously following that? I mean, this is probably something most women are very interested in, which is what, what should I expect-

    5. ASAbbie Smith-Ryan1:19:54

       Mm-hmm

    6. PAPeter Attia1:19:54

       ... uh, is gonna happen? Do I have a new set point after pregnancy?

    7. ASAbbie Smith-Ryan1:19:57

       Yeah, and I think this is, I don't really need to talk about my personal, like, numbers, but I think this is really important where science plays a role of where now and even through pregnancy, like, I, I think through, with my, both my children, I, um, it was maybe about an 8% increase in body fat, and depending on measurement, sometimes that lean, you can't really tell the lean mass components. Um- But I definitely didn't lose muscle, and I gained some fat. And then as a follow-up, usually I would measure about three months postpartum, uh, and it took about six months to get back to normal, but I was not... I think it's important to say you don't have to exercise crazy, and you don't have to, um, you know, it's, it's finding time when to train, and, uh, I've been the same percent body fat and, and changed muscle depending on my training for the last 15, 20 years, um, a- after I learned a little bit in grad school how to optimize. Uh, a lot of my students always say, "It's not fair you have science on your side," but we all can have that, meaning consistency, some high intensity, and appropriate nutrition can really... Y- you don't necessarily have to have a new set point, um, and if you have that consistency, it can really help.

    8. PAPeter Attia1:21:15

       So is your body comp- So your, your, your youngest child is how old today?

    9. ASAbbie Smith-Ryan1:21:20

       Uh, eight.

    10. PAPeter Attia1:21:20

        Okay, so you're eight years post your second pregnancy, and is your body composition today approximately the same as it was prior to the birth of your first child?

    11. ASAbbie Smith-Ryan1:21:30

        Mm-hmm.

    12. PAPeter Attia1:21:31

        Interesting. Not just your weight, but your actually, your actual body composition.

    13. ASAbbie Smith-Ryan1:21:34

        Yeah, and I would say the biggest change, um, I like, I like to periodize. Like, I, you know, sometimes I'm leaner or sometimes I'm not, like, as part of my training. But it's not very m- different, and I, uh, also like to play around, especially now when the message is, "Oh, as a midlife woman, you can't gain mass," or you're losing muscle mass. That's, it doesn't have to be true. And, um, I have gained lean muscle, or if I'm training for something that's more aerobic, I've maybe lost a little muscle. Um, but it all... Or, I mean, you can appreciate this with your traveling of sometimes your diet is more locked in and sometimes it's not. Uh, but it's all about kind of prioritizing that. And one thing I often tell women is the times that I want to be leaner is I'm act- actually eating more. I'm prioritizing whole foods, eating consistently throughout the day, versus the times when I'm not, uh, paying as much attention is where I might gain some fat mass.

    14. PAPeter Attia1:22:31

        So yeah, explain that. That seems a little counterintuitive. When you say you're eating more during the periods in which you're leaner, you mean more volume of food but lower caloric density, or what do you mean?

    15. ASAbbie Smith-Ryan1:22:42

        Uh, and more frequency. So, and I, and I'd love to, to talk through some of the, the fasting literature, but in reality as a woman, a- and this is not, this is not just me personally, this is based on science as well, of many women, um, might go for a long wake up, not eat breakfast, you know, might have something at 11:00 and then continue on, um, or grab a snack, and those foods are typically not necessarily nutrient dense. Um, whereas if you shoot for about 30 grams of protein and some fiber, some vegetables kind of evenly throughout the day, it stimulates metabolism. You're getting more macro and micronutrients.

    16. PAPeter Attia1:23:20

        Yeah, so in other words, um, the, the mistake that you think people are making is, is time restriction on their, on their feeding?

    17. ASAbbie Smith-Ryan1:23:29

        Well, I, and s- I, I think there's a time and place for time restriction. Uh, what we've seen right now, and, and we're looking at this, is many women chronically time restricting, it can lower metabolism. And then there's the, the aftermath on our hunger hormones that whether that when they start eating, they can't stop, or it does impact, uh, protein synthesis and, and metabolic rate and muscle loss. So especially in this midlife window, I think we need to pay a little bit more attention to, uh, food consumption.

    18. PAPeter Attia1:23:59

        By the way, going back to what you said about within six months of your pregnancy you had returned to your pre-pregnancy body composition, were you breastfeeding during that period of time?

    19. ASAbbie Smith-Ryan1:24:11

        I was breastfeeding, and I will tell you, I, I do not do pregnant research, but I did take this approach during pregnancy of I still, I, I believe birth is one of the most athletic events you'll do, and you should train for it. So, like, I, I exercised consistently, and I slowly increased my calories in a way that was almost, um, like a refeed period so that I was, had a bit of a caloric surplus. And then postpartum, I, obviously it's hard to nurse and feed yourself and all the things, but I was able to go back to normal kind of calorie balance. And so yes, nursing does help, but I also was exercising consistently. And so there's a bit of, um, calorie play you can do, uh, to help with those metabolic changes.

    20. PAPeter Attia1:24:59

        What was your exercise in the third trimester? What were you prioritizing?

    21. ASAbbie Smith-Ryan1:25:03

        Um, with my first child, I could do some running, but it was resistance training. I, I squatted, I, I did lots of lats, like, really thinking about what are the muscles that are gonna help you deliver. Those are the ones that I worked, um, up until the day I delivered. And so, uh, I wasn't doing as much necessarily high intensity work, but changes optimizing blood flow and muscle fatigue to help with birth.

    22. PAPeter Attia1:25:28

        And w- once... How, how long after delivery were you back to exercising?

    23. ASAbbie Smith-Ryan1:25:33

        I had two natural deliveries, so I, um, I definitely started walking within a couple days, and then I was doing resistance training, uh, within a couple weeks, but lightweight. Like, I mean, that's the benefit of being active, of I could go back and then I would run within a few weeks. Nothing crazy.

    24. PAPeter Attia1:25:53

        When you were pregnant, what, um, how much did you need to sort of fight cravings? Did you fight cravings? Did you give in to cravings? Did you have the typical cravings that, that women often talk about during pregnancy?

    25. ASAbbie Smith-Ryan1:26:08

        Yeah. Oddly, I didn't want to eat animal proteins, which was really hard, and I didn't, um, want, like, a protein shake. None of that sounded good. And so I definitely had to prioritize plant-based proteins. That's just what tasted better. Uh, and then interestingly, like, I craved, um, like donuts. I'm not a, a person that eats a lot of refined carbohydrates, but I, I, I ate those. Like, I, I included those. And I didn't track my macros necessarily, but I, I was intentional about eating consistently to fuel so that I was a bit on a caloric surplus.

    26. PAPeter Attia1:26:43

        And then once you had your children, what changed in your nutrition? Did you very quickly get back to your baseline eating, or was there a period in which you still had cravings?

    27. ASAbbie Smith-Ryan1:26:55

        Yeah, no, I mean, I think GI distress so often, you know, there was probably some lactose intolerance, uh, immediately post. And, um, I do remember eating a lot of liquid foods because you're carrying a child, so I was prioritizing, then I kind of integrated protein shakes back and, um, big omega-3 and creatine to help maintain when you're, you're not sitting down to eat full meals.

    28. PAPeter Attia1:27:19

        So what do you think are the biggest mistakes women are making in the pregnancy and the post-pregnancy phase with respect to training and nutrition?

    29. ASAbbie Smith-Ryan1:27:28

        For nutrition, I think it's some-- we either go one way or the other. We use it as an excuse to eat whatever we want, or the opposite of, of not paying attention. Um, it, it should be a key priority, and I, I always still think about, um, kind of the development of the baby, of the neural development. There's a lot of nutrition that can play a role there, and even down to the gut health, so, like, fruits and vegetables, variety, so really prioritizing nutrition. Um, first, like, resistance and, and aerobic exercise is, is it-- it is an athletic event to deliver a baby. Uh, like, we should exercise. If you've never exercised, you should include something, and if you've always exercised, then, then you can, uh, continue that. Um, I think there's better guidance now than there was eight to ten years ago. Um, and then into postpartum, it goes back to not the mom guilt, but how do-- now how do I incorporate this, um, especially, uh, with nursing and hydration?

    30. PAPeter Attia1:28:26

        And sleep deprivation.
16. 1:28:40 – 1:40:26

    Changes in muscle quality & metabolic flexibility during menopause

    1. PAPeter Attia1:28:40

       Let's now talk about sort of this, this, this, again, going back to kind of this perimenopausal state and even into menopause now. So, um, women disproportionately suffer from sarcopenia relative to men. Um, presumably that's-- there's two things that are feeding into that, right? Genetically, women have less muscle mass to begin with. Um, and then secondly, it seems that women are less likely to engage in resistance training than men. Do we have data on what the differences are?

    2. ASAbbie Smith-Ryan1:29:10

       Yeah, I mean, there's-- uh, and I think it's-- I love that you're asking compared to men, um, and you started this, this conversation of... And what I think is important is let's just look at women too. It's not just the comparator. And there's some really good data, a paper, uh, b-by Bill Kramer, he just wrote and said about one in five women participate in resistance training, so about nineteen percent, and it's only one day a week.

    3. PAPeter Attia1:29:33

       Hmm.

    4. ASAbbie Smith-Ryan1:29:34

       Um, I think the-

    5. PAPeter Attia1:29:34

       That's women of all ages.

    6. ASAbbie Smith-Ryan1:29:36

       All ages.

    7. PAPeter Attia1:29:36

       That's all comers. Okay.

    8. ASAbbie Smith-Ryan1:29:37

       Yep. Um, I also think we're at this really unique time because we have-- So Title IX was about 1972, so now we have this group of women that are aging that do have more experience with exercise, um, and they're aging differently than we knew before. And so when we think about w- you know, women in this timeframe, whether we compare them against men or not, there are key things that happen with our changes in hormones, even that, that impact sarcopenia. Um, things like oxidative stress and inflammation and change in vasodilation, all of that can impact nutrient delivery and blood flow and, and cardiometabolic health.

    9. PAPeter Attia1:30:18

       What are the most important things that a woman should do different in menopause c-compared to premenopause with respect to training? Or is the answer whatever you were doing before, assuming you were doing the right thing, is all you need to continue? In other words, do you need to make adjustments between that, that phase of life?

    10. ASAbbie Smith-Ryan1:30:39

        I would say yes. And there is this-- Everyone throws out menopause, and, and we actually have some good data on people post-menopause in our sixties and our seventies. What we're really missing is what's happening in our forties and fifties, and, and our data and some other labs show that muscle quality very much changes. And so we actually did a two-year longitudinal study and brought women back after kind of initial measurements, and in that initial measurement, we gave them pretty comprehensive information about their body composition, their strength, their nutrition. Um, and what we saw was then two years later, individuals that followed some of those recommendations, there were less changes. It didn't align with a lot of our SWAN data, um, the, the Study of Women's Health Across the Lifespan. They, they were able to maintain some muscle size, but we saw significant changes in muscle quality. And the way I describe that is, is very much like a ribeye versus a filet. Uh-

    11. PAPeter Attia1:31:41

        Did you guys do muscle biopsies? Is that-

    12. ASAbbie Smith-Ryan1:31:42

        We did muscle quality from ultrasound and PQCT, um, and that PQCT is very related to MRI. We have some of that data now that we've looked at with MRI, and it's the same theme. Um, and there's also a group out of Australia, uh, Severine Lemone. They just did this long, uh, longitudinal study looking at, um, perimenopause and postmenopause, and the data continues to show that muscle quality changes most in perimenopause.

    13. PAPeter Attia1:32:12

        And is this, um, it-- like, is the muscle fat-

    14. ASAbbie Smith-Ryan1:32:18

        Mm-hmm

    15. PAPeter Attia1:32:18

        ... is the marbling occurring between cells or within cells?

    16. ASAbbie Smith-Ryan1:32:22

        I don't know if we know. Uh, it depends on measurement. Uh, so yeah, I'm not sure I can answer that.

    17. PAPeter Attia1:32:28

        Got it. So no one's doing a biopsy, 'cause that's obviously how we would figure it out, or are people doing a biopsy?

    18. ASAbbie Smith-Ryan1:32:33

        Um, this is a g-- Yeah, there's a preprint that just came out from, uh, Lemone's group that they did biopsies. I would say the downside is-- So they had pre, peri, and post, but I think there was only about five perimenopause. Um, and, uh, yeah, I have to-- I'd have to go look and see exactly where the marbling was coming from.

    19. PAPeter Attia1:32:52

        Okay.

    20. ASAbbie Smith-Ryan1:32:52

        I mean, there, there is a really good data on neuromuscular changes-

    21. PAPeter Attia1:32:56

        Mm-hmm

    22. ASAbbie Smith-Ryan1:32:56

        ... and the ability of, uh, and muscle fiber type, uh, but I don't know if I'd-- Yeah, I'd have to look sp-- I guess my question back to you would be, what's your thought process on why it would matter?

    23. PAPeter Attia1:33:07

        Well, intra cellular fat accumulation would contribute to insulin resistance.

    24. ASAbbie Smith-Ryan1:33:12

        Yes.

    25. PAPeter Attia1:33:13

        Um, that would be viewed as more pathologic.

    26. ASAbbie Smith-Ryan1:33:16

        Mm.

    27. PAPeter Attia1:33:17

        Um, athletes often have a lot of fat-

    28. ASAbbie Smith-Ryan1:33:21

        Yeah

    29. PAPeter Attia1:33:21

        ... between cells.

    30. ASAbbie Smith-Ryan1:33:22

        Mm-hmm.
17. 1:40:26 – 1:48:27

    The biggest open questions about women’s health

    1. PAPeter Attia1:40:26

       so you haven't studied that, because that was gonna be my next question, which is how does hormone replacement therapy impact this change, all things otherwise being equal?

    2. ASAbbie Smith-Ryan1:40:34

       Yeah, I, I mean, so what we've started, the, the bad thing about research is it has to be somewhat controlled. And so just now, especially based on the number of women taking hormone therapy, is now we're including individuals that are on hormone therapy or are not, and some of my colleagues are, are, are prescribing that to, to understand, but that's really where we're at now. And I think it comes back to why we need more research and dollars in this space to, to dial that in, uh, because it would be great if adding hormones would really help overcome that, but you still have to add lifestyle. So what is that combination? And then like you asked of what component is changing it? Is it oxidative stress? Is it arterial stiffness? Is it, you know, blood flow? What are the things that are really gonna optimize that so that we can really help these women as they age?

    3. PAPeter Attia1:41:25

       Yeah, and again, w- how should the, what should the portfolio of training look like? Uh, to me, I think is-

    4. ASAbbie Smith-Ryan1:41:32

       Mm-hmm

    5. PAPeter Attia1:41:32

       ... maybe the most interesting question because I just can't imagine there is anything that is going to change metabolic flexibility more than training.

    6. ASAbbie Smith-Ryan1:41:41

       Yeah.

    7. PAPeter Attia1:41:42

       And because virtually everybody who is going to be exercising is gonna be constrained on time-

    8. ASAbbie Smith-Ryan1:41:49

       Mm-hmm

    9. PAPeter Attia1:41:49

       ... figuring out what, what is gonna give the most bang for the buck matters.

    10. ASAbbie Smith-Ryan1:41:54

        Agreed, and I, I think that's where a, a really important takeaway, I think especially now, it's a little confusing. A lot of women are getting a lot of information about what they should and shouldn't do, uh, but you're exactly right. First, we just need to exercise, and that's a potent stimulus. Uh, but then it's about optimizing. And so, um, when we go back to metabolic flexibility, a lot of the data when we pull in nutrition is around carbohydrate feeding. Um, but when you th- talk about insulin sensitivity a- and those changes, which is where my group has focused and tried to look at what happens when you provide amino acids to also elevate protein synthesis and breakdown, and it seems that if we are eating our protein around training versus our carbohydrate or changing from high to lower glycemic index, that can also optimize metabolic flexibility.

    11. PAPeter Attia1:42:43

        Yeah, and I guess the question is that would probably be true at any age, right?

    12. ASAbbie Smith-Ryan1:42:50

        Yeah. Yeah, I, I just think it matters more if you-

    13. PAPeter Attia1:42:53

        Yeah

    14. ASAbbie Smith-Ryan1:42:53

        ... um, with such a big change, and I guess, I don't, let's not quantify big, but when there is a significant change in muscle size, quality, cardiometabolic health, arterial stiffness, neuromuscular changes that are happening in our 40s and our 50s, then those little tweaks do make a difference regardless. Like, it's gonna matter-

    15. PAPeter Attia1:43:15

        Yeah

    16. ASAbbie Smith-Ryan1:43:15

        ... then, but it, it, it gives us, um, a bigger bang for our buck when we have less time.

    17. PAPeter Attia1:43:22

        What do you think are the most interesting questions around women's health that we don't yet have a clear answer to, that, that, that could be answerable if we had the resources to study it and, and the, the, the will to do so?

    18. ASAbbie Smith-Ryan1:43:38

        Well, I hope we do. I hope we can, can really, uh, build this out. I think one of them is women ultimately wanna lose weight, um, so how do we com- uh, combine our GLP-1s with the kind of what I would call minimal effective dose of exercise and nutrition in a way that women can still live their lives and feel good? So many women are, are not feeling great on those drugs, or they're not feeling good off the drugs. And so, um, there's also a very big component of mental health in here that I think exercis- I know exercise can have a really important role in. Um, the other big question, uh, that I think is really important is the impact. We've, we've seen a swing, and I would be curious of your take, that there's much more conversation now around menopause hormone therapy. Um, and I think there's a lot of indirect effects on muscle and training volume, but how much? Uh, for instance, adding hormones isn't gonna increase muscle directly, but indirectly, I, maybe I have more energy, or I can do higher volume and intensity.

    19. PAPeter Attia1:44:46

        I can recover better.

    20. ASAbbie Smith-Ryan1:44:47

        Exactly.

    21. PAPeter Attia1:44:47

        Yeah.

    22. ASAbbie Smith-Ryan1:44:47

        But then does that also put me at greater risk for injury or, um, like, our tendons still change. Actually, one of the things I think we have in common, my biggest injury fear is an Achilles tendon tear. Um, and so I think about that a lot, of like, how do some of these changes in hormones and really helping women feel better with this new wave of very active women Um, they're, you know, they're, they're women that are training. Like, how do they combine? Um, and then you, that has application to the military, et cetera. But we need to know a lot more as we're changing our, our pharmaceutical agents with our lifestyle components.

    23. PAPeter Attia1:45:27

        Yeah. I mean, on that particular topic, I, my intuition is that the answer comes down to the type of training.

    24. ASAbbie Smith-Ryan1:45:33

        Mm-hmm.

    25. PAPeter Attia1:45:34

        And, um, you're less likely to tear your Achilles sitting on the couch if you never get off the couch.

    26. ASAbbie Smith-Ryan1:45:42

        Yeah.

    27. PAPeter Attia1:45:42

        You're, you're not gonna tear that Achilles. Um, now of course, you're gonna die a thousand deaths.

    28. ASAbbie Smith-Ryan1:45:46

        Yeah.

    29. PAPeter Attia1:45:47

        So if we give a person hormones as a part of a broader-

    30. ASAbbie Smith-Ryan1:45:52

        Mm-hmm
18. 1:48:27 – 1:57:13

    How the training response differs between men & women

    1. PAPeter Attia1:48:27

       Um, what, what are the other maybe misconceptions about women's training that you think, uh, y- you know, what, what do you find yourself at parties having to correct people on?

    2. ASAbbie Smith-Ryan1:48:40

       [laughs] Um, Peter, I don't go to many parties. But no, I think it, it comes back to these absolutes that we're hearing of I have to lift heavy weights or I have to do high intensity training or I have to do plyometrics, and I really wish that we could just tell women of, of exercise and doing something is better than nothing. And then I do think we can leverage a lot of the traditional strength and conditioning research that we have that was founded in male science. We know the female muscle will respond. Um, and so I, it's, it's taking our program design that we know has worked, but then understanding that there might be some differences as far as recovery and rest or, um, uh, you know, joint pain. Like, there's modifications that are needed. And, and so I, I, I guess I just wish we could empower women to, to do the things that give them, um, that they, that they like to do, and the traditional rules that we have of, you know, change it if we want strength, if we want hypertrophy. Do we want fat loss? H- like, leverage what we have now.

    3. PAPeter Attia1:49:51

       Mm-hmm. Meaning take all of the data we have on how do you optimize around hypertrophy versus strength-

    4. ASAbbie Smith-Ryan1:49:57

       Right

    5. PAPeter Attia1:49:57

       ... which again, to your point, a lot of those studies have been done disproportionately in male subjects.

    6. ASAbbie Smith-Ryan1:50:02

       Yeah.

    7. PAPeter Attia1:50:02

       I- are you saying that to the first order approximation, the results should be the same in women?

    8. ASAbbie Smith-Ryan1:50:07

       I mean, when we look at things like strength and hypertrophy, w- we know that ex-- yes, those same methods can apply. Uh, I, we do see differences, I think, in detraining or percentages of, of loss in strength and muscle of absolutes, but yes, I think right now-

    9. PAPeter Attia1:50:24

       Are, are women more susceptible or men?

    10. ASAbbie Smith-Ryan1:50:27

        Um, we see, uh, this is some early data, um, meaning I don't know if we absolutely know because it's so individual. Uh, and I think that's where we need to dive in, too, of the I'm, there are women that will gain more strength than men or have more muscle than men. Um, but when we look at the, the baseline fiber types, because women tend to have, generally speaking, more type one fibers, they might change slightly different. And there's also some new data, I mean, that's not new, but, um, neuromuscular aging and motor unit recruitment could vary between males and females. But it goes back to your question. Strength training works, um, and a woman is gon- going to gain strength and gain muscle, but not, uh, to the same absolute effect as a man.

    11. PAPeter Attia1:51:16

        Are women more susceptible to the loss of Type 2A fibers when they age? Or are men-

    12. ASAbbie Smith-Ryan1:51:22

        That, yeah, that's a debatable topic.

    13. PAPeter Attia1:51:23

        Okay.

    14. ASAbbie Smith-Ryan1:51:23

        Um, men tend to have more Type 2 fibers, so then there's a, a, a, a bigger area to lose per, or a percentage.

    15. PAPeter Attia1:51:32

        Yep.

    16. ASAbbie Smith-Ryan1:51:32

        Um, but with age, there's denervation that happens, where the, uh, properties look more hybrid or Type 1 for males than females. It does seem that it maybe happens a little bit faster for females. Um, but there's a lot, I think, that we're still... H- how do you... How much exercise prevents that?

    17. PAPeter Attia1:51:52

        Does that suggest... Yeah, well, I was gonna ask, so I, I, a couple of years ago, I had Andy Galpin on the podcast, and he said something that always struck with me, which is that hypertrophy of the Type 2A muscle fiber is, I don't think he said it this way, but-

    18. ASAbbie Smith-Ryan1:52:02

        Uh-huh

    19. PAPeter Attia1:52:02

        ... it was, is, is basically the sine qua non of aging.

    20. ASAbbie Smith-Ryan1:52:05

        Mm-hmm.

    21. PAPeter Attia1:52:05

        Right?

    22. ASAbbie Smith-Ryan1:52:05

        Mm-hmm.

    23. PAPeter Attia1:52:06

        And boy, that always stuck with me.

    24. ASAbbie Smith-Ryan1:52:08

        Mm-hmm.

    25. PAPeter Attia1:52:08

        Which is, and, and it really resonates, right? The first thing you're going to lose, you and I are long past our peak on this-

    26. ASAbbie Smith-Ryan1:52:17

        Mm-hmm

    27. PAPeter Attia1:52:17

        ... is explosiveness.

    28. ASAbbie Smith-Ryan1:52:18

        Yep.

    29. PAPeter Attia1:52:18

        We've lost power.

    30. ASAbbie Smith-Ryan1:52:19

        Mm-hmm.
19. 1:57:13 – 2:05:05

    Training advice for a 70-year-old woman who has never exercised

    1. PAPeter Attia1:57:13

       would be some specific advice? So now we're talking to a 70-year-old woman-

    2. ASAbbie Smith-Ryan1:57:17

       Mm-hmm

    3. PAPeter Attia1:57:17

       ... who's never exercised deliberately in her life. She's never had a workout routine. Um- And, you know, she's, she's healthy in the sense that, uh, you know, she's not riddled with injury at the moment. But, um, you know, she's already experiencing a dramatic reduction in stamina and strength. Maybe she's struggling to open a jar. Um, she can walk up a flight of stairs, but it's sure she notices it in a way she didn't notice it 10 years earlier. Um, so now she has one thing on her side, which is time.

    4. ASAbbie Smith-Ryan1:57:53

       Mm-hmm.

    5. PAPeter Attia1:57:54

       Right? So how, how would you advise her to go about starting a routine for the rest of her life? And how would she, how would she titrate up?

    6. ASAbbie Smith-Ryan1:58:02

       Yeah, I'm... I mean, honestly, I would, I would highly recommend hiring a personal trainer as an initial step to, to really teach her, uh-

    7. PAPeter Attia1:58:09

       How should she look for one? 'Cause-

    8. ASAbbie Smith-Ryan1:58:11

       Mm-hmm

    9. PAPeter Attia1:58:11

       ... there, there's such a quality continuum in that spectrum. So what is she, what is she looking for in a personal trainer?

    10. ASAbbie Smith-Ryan1:58:16

        I mean, there's a lot of, uh, recommendations, so I think referral is a really important starting point. Um, I would hope that maybe a physical therapist has a good recommendation or someone locally. There are some, some credentials to look for, but it does depend on where she lives and-

    11. PAPeter Attia1:58:32

        But let's just say you were her trainer.

    12. ASAbbie Smith-Ryan1:58:34

        Okay.

    13. PAPeter Attia1:58:34

        Yeah, she brought you in. [laughs]

    14. ASAbbie Smith-Ryan1:58:35

        Okay, okay. [laughs]

    15. PAPeter Attia1:58:36

        Or it was, you know, she, she, either she was lucky enough to find someone of your, of your, uh, of, of your knowledge. Um, how would you think about creating a program for her?

    16. ASAbbie Smith-Ryan1:58:45

        Uh, I mean, it's all about adding a slightly higher stimulus than what her- she's doing now. So we-

    17. PAPeter Attia1:58:51

        She has no stimulus at the moment.

    18. ASAbbie Smith-Ryan1:58:52

        Right. Yeah, so like, I mean, I think for someone like that, there's consideration. So one thing we haven't talked about is, is people are motivated by different things. Is she motivated by a group? Is she motivated to do it on her own? Um, is she motivated to, to be in a gym? Um, in those scenarios, like, uh, uh, starting with resistance bands at home is, is a, is a starting point, or is she excited to go do Silver Sneakers somewhere? Um, that would be a starting point. Uh, or does she need to be in a gym with... You know, I, I wouldn't start with a ton of free weights, more of our, our machine-based controlled stimulus. So there's so many options.

    19. PAPeter Attia1:59:34

        So yeah, let's say she's, um, she's got a gym nearby. It's, it's got a great range of everything. So, you know, she can, she can do all the machines in the world. There's no machine she doesn't have access to.

    20. ASAbbie Smith-Ryan1:59:46

        Mm-hmm.

    21. PAPeter Attia1:59:46

        How would you think about putting a program together?

    22. ASAbbie Smith-Ryan1:59:49

        I would do a total body program where we're really focused on, um, and this is not just specific to females, but glute activation to help with that lower body. Uh, that will also help with slips, trips, and falls. Um, a push/pull for every muscle group.

    23. PAPeter Attia2:00:04

        So, so a glute activation for her is gonna be a leg press? What do you mean?

    24. ASAbbie Smith-Ryan2:00:07

        A leg press, but also just, um, some neuromuscular activate. Standing up with, uh, like being able to actually con- A lot of times the leg press is not activating the glutes, so some banded work to activate the glutes to get started. Uh, maybe a leg press, leg extension. Um, I, I wouldn't probably start with a lunge for this individual. Um, and then from there, something like definitely hitting the l- uh, hamstring. So every muscle group in the lower body. I'd do something to get the calves to help with the stability. Um, I think we haven't talked about the shoulder joint, upper body. There's a lot of, uh, uh, benefit in, in strengthening all aspects of the, the shoulder joint and the deltoids. So a full body upper body exercise or routine.

    25. PAPeter Attia2:00:53

        Okay, and so how many days a week are you gonna have her, and how many minutes a week would you have her doing resistance training?

    26. ASAbbie Smith-Ryan2:00:59

        Um, that's a tricky question. I wouldn't start her... Like, we'd want her to come back. Um-

    27. PAPeter Attia2:01:04

        Yeah, yeah. We're not tr- Yeah, we-

    28. ASAbbie Smith-Ryan2:01:05

        So soreness is gonna be a-

    29. PAPeter Attia2:01:06

        No, we don't want her to be sore

    30. ASAbbie Smith-Ryan2:01:07

        ... consideration. Um, I mean, I think basic initial, not knowing a lot about her, three days a week of resistance training, most days a week of some sort of movement, aerobic exercise is where I would start, and obviously titrate depending. So kind of an every other day to allow for recovery.
20. 2:05:05 – 2:12:30

    Misinformation about exercise & nutrition for women, injury risk, supplement hype, & more

    1. ASAbbie Smith-Ryan2:05:05

       for.

    2. PAPeter Attia2:05:05

       Do you think there are any trends that are out there today, um, that, that you think are at, at best, uh, incorrect, at worst, potentially harmful as it comes to, as it pertains to sort of things women are being told about exercise or nutrition as it pertains to, you know, conditioning?

    3. ASAbbie Smith-Ryan2:05:23

       Yeah, I, I, I think it's harmful to say you need to only do this or not do that. Our very black and white pragmatic thinking is, is harmful because in reality every woman is individual. And, uh, that's the best part about research is it's little tools in our toolbox, and that changes as we get an injury or, um, you know, maybe I have lifted heavy my whole life, but I still wanna gain strength. Well, I need to modify and adapt. And so exercise does not have to be overwhelming, neither does nutrition. And I think so much of it now is, is, "Oh, you have to do it this way," or, "This is the only way that'll work now that you're in midlife," or, "You have to change your training," when in reality, most of us are just trying to get something in and do it consistently. So less rules and really understanding that e- exercise is powerful no matter really how you do it. Um, and then thinking about the injury piece. I think injury and recovery from injury we're not giving enough conversation to. Um, that can be really impactful, especially with injury rates taking longer as we age.

    4. PAPeter Attia2:06:30

       One of the injuries we seem to see more in women than in men, and my wife has a theory about this, is, uh, high hamstring injuries.

    5. ASAbbie Smith-Ryan2:06:39

       Mm.

    6. PAPeter Attia2:06:40

       Um, and so y- you know-

    7. ASAbbie Smith-Ryan2:06:42

       What's her theory?

    8. PAPeter Attia2:06:43

       Uh, that after pregnancy when the pelvis-

    9. ASAbbie Smith-Ryan2:06:45

       Mm

    10. PAPeter Attia2:06:45

        ... sort of moves a little bit-

    11. ASAbbie Smith-Ryan2:06:47

        Mm-hmm

    12. PAPeter Attia2:06:47

        ... it, it cha... So my wife was a runner before-

    13. ASAbbie Smith-Ryan2:06:50

        Mm-hmm

    14. PAPeter Attia2:06:50

        ... and a, is a runner after, but she, you know, she said, "Look, I've never run the same post-pregnancy."

    15. ASAbbie Smith-Ryan2:06:56

        Mm-hmm. Mm-hmm.

    16. PAPeter Attia2:06:56

        So she actually runs the same times. She ran the Boston Marathon this year, and she ran it 19 years ago.

    17. ASAbbie Smith-Ryan2:07:02

        Yeah.

    18. PAPeter Attia2:07:02

        And her time this year was only 45 seconds slower than her time 20, you know, almost 20 years ago. Now she trains a lot smarter today.

    19. ASAbbie Smith-Ryan2:07:13

        Mm-hmm. Mm-hmm.

    20. PAPeter Attia2:07:13

        So I think that's why her running times are still really good, but she says, "I don't feel the same."

    21. ASAbbie Smith-Ryan2:07:19

        Yeah.

    22. PAPeter Attia2:07:19

        Like, "I used to float, and now I don't feel like I float." And she's had a couple of these really high hamstring tendinopathies. Um, and we see this a lot in women.

    23. ASAbbie Smith-Ryan2:07:30

        Mm-hmm.

    24. PAPeter Attia2:07:30

        And, and I, I, again, more so than men, but I don't-- It could be just a small N.

    25. ASAbbie Smith-Ryan2:07:34

        Hmm.

    26. PAPeter Attia2:07:34

        Um, but are there any other injuries that you're, that you're seeing that, that you think, um, women need to be aware of?

    27. ASAbbie Smith-Ryan2:07:41

        Yeah, I mean, this is probably because most of my colleagues at UNC are studying knee injury.

    28. PAPeter Attia2:07:47

        Mm-hmm.

    29. ASAbbie Smith-Ryan2:07:47

        But it does seem to, um, uh, kind of ACL injury in midlife, w- we're, I, we're seeing-

    30. PAPeter Attia2:07:53

        You're seeing more in women?
21. 2:12:30 – 2:15:50

    Benefits of hormone therapy in midlife women & its interaction with exercise & lifestyle interventions

    1. PAPeter Attia2:12:30

       A, there's a generation of women now that have sort of, um, have fallen outside of the window in which doctors who are even starting to come around on hormones feel comfortable prescribing hormones. Although, um, you know, Rachel Rubin was a guest on this podcast, and she made a very compelling argument for the fact that that's a little bit of a BS argument, and that really there-- you know, if a woman is sixty and she's been in menopause for ten years, that's not disqualifying. And, and, and there's no evidence that we can point to that, that we're driving, you know, rates of breast cancer by giving that woman hormones. And so if she's gonna benefit from it, then she should be on it. A-as far as women that are going through this process now, I think, again, the good news is I think there are enough doctors out there who, um... It's still a, a very small number in absolute terms who are, who are, who are, um, simultaneously willing to do this and competent to do it. The competence is a hard piece, um, because there are more tools than ever before. You know, the, the old-- in the olden days, it was MPA and CEE, and that was it. And, and of course, today, we would never use either of those hormones. Um, so you have to know more. But look, we also-- [chuckles] That's why this podcast exists, right?

    2. ASAbbie Smith-Ryan2:13:39

       Mm-hmm.

    3. PAPeter Attia2:13:39

       I mean, anybody who wants to understand how to, how to safely and intelligently, uh, provide hormones and think through the nuances, right? When do, when does, when do we want to start with this topical? When do we want to use this variation, that variation? I mean, that, like we- we've got more content on that than I can, than I can point to. So, so it's out there. Um, and I would just say, look, don't be satisfied with no. You know? If, if a person says no, then it's time to find another person. Um, and, uh, again, fortunately, it looks a lot better today than it did five years ago. Five years ago, it was pretty bleak.

    4. ASAbbie Smith-Ryan2:14:13

       Mm-hmm.

    5. PAPeter Attia2:14:14

       Um, and I think in, in five years, it's gonna be even less bleak than it is today.

    6. ASAbbie Smith-Ryan2:14:19

       And what do you think about the exercise piece? So, you know, we were talking about GLP-1s with exercise. Often, when we're talking about hormones and hormone therapy, we're, we're not talking about lifestyle behaviors of, of the co-com- combination of the two to help relieve symptoms. Do you ever see that coming in play or being a, an, a important component?

    7. PAPeter Attia2:14:39

       Well, again, I think, uh, my-- where I sit, I, i-it's not really a concern because we're always talking about all of these things all the time.

    8. ASAbbie Smith-Ryan2:14:49

       Mm-hmm.

    9. PAPeter Attia2:14:50

       So I'm probably not the right person to answer that question because I'm not, um, I'm not seeing the other side of that. But I can appreciate the fact that any time you can take a drug, it's easier than making a change, and a lot of times, those changes end up being more powerful. The, the, the sort of quote unquote lifestyle change-

    10. ASAbbie Smith-Ryan2:15:11

        Hmm

    11. PAPeter Attia2:15:11

        ... ends up being a bigger issue. In both the cases that you've mentioned, a lot of times the drug makes it easier to make the change. And in the case of hormone, I think there's just an independent benefit that also comes from it-

    12. ASAbbie Smith-Ryan2:15:23

        Yeah

    13. PAPeter Attia2:15:23

        ... that's unmistakable. I mean, I think independent of whether you exercise or not, you're going to benefit from taking hormones. The point is, can you have an accretive benefit-

    14. ASAbbie Smith-Ryan2:15:32

        Mm-hmm

    15. PAPeter Attia2:15:32

        ... if you do both of these things? And I, I think the, the answer is almost assuredly yes.

    16. ASAbbie Smith-Ryan2:15:37

        Mm-hmm.

    17. PAPeter Attia2:15:37

        Again, it's we're not gonna prove that in a study, but, um... It's really hard to imagine a scenario where by combining both of those things doesn't lead to an even better outcome than-

    18. ASAbbie Smith-Ryan2:15:47

        Sure

    19. PAPeter Attia2:15:47

        ... doing one by the, by itself.

    20. ASAbbie Smith-Ryan2:15:49

        And do

22. 2:15:50 – 2:24:20

    Peter’s takeaways

    1. ASAbbie Smith-Ryan2:15:50

       you see, is there any, like, key research in this area that would inform your, um, clinical practice, or do you see a gap that would be beneficial?

    2. PAPeter Attia2:15:59

       Um, with respect to hormones and exercise?

    3. ASAbbie Smith-Ryan2:16:01

       Yeah, or, uh, midlife women, like even thinking, uh, obviously hormones are often a part of the conversation, but not always.

    4. PAPeter Attia2:16:08

       You know, I think there's the, there's the sort of really interesting questions scientifically that often don't matter that much in the real world. So for example, there are lots of questions I could imagine asking if we were talking about unconstrained or unlimited amounts of time. Um, and that applies to some people. I do know some people who have eight to 10 hours a week to exercise, and I think in those situations, we could, we could have a very different discussion about how to optimize training. Um, I'm obviously pretty interested in, you know, how you would optimize it in a resource constraint world, and, and that would be, you know, are, are four by fours better than, you know, one by ones? Um, I don't know the answer, but I al- I suspect that in the real world, the answer comes down to whichever you can do more diligently. And, um, I think the application of this stuff is, is, is what matters the most, but I also think that, you know, the le- it, so this is the unfortunate reality of training, which is if you're not providing enough training stimulus, you're getting a suboptimal result. And so what I really want is for people to understand how potent this tool is if you can provide the right stimulus. And the shorter your volume of training, the more important the intensity of that is.

    5. ASAbbie Smith-Ryan2:17:34

       Mm-hmm.

    6. PAPeter Attia2:17:34

       And therefore, if you're only going to lift twice a week for 30 minutes, you can't phone those in.

    7. ASAbbie Smith-Ryan2:17:41

       Yeah.

    8. PAPeter Attia2:17:42

       Like, you gotta actually do the work.

    9. ASAbbie Smith-Ryan2:17:43

       Mm-hmm.

    10. PAPeter Attia2:17:43

        In fact, it's easier for me, 'cause I'm in the gym six hours a week.

    11. ASAbbie Smith-Ryan2:17:46

        Mm-hmm.

    12. PAPeter Attia2:17:47

        So it's like I, I'm making up for it in volume.

    13. ASAbbie Smith-Ryan2:17:51

        Sure. Mm-hmm.

    14. PAPeter Attia2:17:51

        Like, my volume is more than covering it. I'm, I'm going to one or two reps in reserve, um, but I have so much volume that it's, that it's okay.

    15. ASAbbie Smith-Ryan2:17:59

        Yeah.

    16. PAPeter Attia2:17:59

        But if you told me, "Peter, you get, you get two 30-minute shots," I mean, I'm probably gonna go to failure on every set.

    17. ASAbbie Smith-Ryan2:18:06

        Mm-hmm.

    18. PAPeter Attia2:18:06

        And that's harder. That is, that is, that is neurologically way more taxing.

    19. ASAbbie Smith-Ryan2:18:11

        Mm-hmm.

    20. PAPeter Attia2:18:12

        Um, if you told me I only have these, you know, two short cardio workouts per week, again, can't phone those in.

    21. ASAbbie Smith-Ryan2:18:20

        Yep.

    22. PAPeter Attia2:18:21

        Like, you're showing up to push. Now, does that matter if you're starting out from a low base? No.

    23. ASAbbie Smith-Ryan2:18:26

        No. Yeah.

    24. PAPeter Attia2:18:27

        'Cause any training stimulus matters.

    25. ASAbbie Smith-Ryan2:18:29

        Right.

    26. PAPeter Attia2:18:29

        But if, if it's you or I-

    27. ASAbbie Smith-Ryan2:18:30

        Yeah

    28. PAPeter Attia2:18:30

        ... who have a training history that is, you know, this thick-

    29. ASAbbie Smith-Ryan2:18:35

        Mm-hmm

    30. PAPeter Attia2:18:35

        ... then no, we actually have to show up and crush those workouts if we're going to get the benefit.

Episode duration: 2:24:20