Psychiatry & Psychotherapy Podcast - Exercise & Mental Health 2023 Update

Episode Date: May 12, 2023

In a previous episode of the podcast, we discussed exercise for the brain, reviewing the pathophysiology between exercise and dementia, the pathophysiological mechanisms associated between low skeletal muscle mass and cognitive function, exercise as a treatment, and cardiorespiratory fitness and its relationship to all-cause mortality. In today's episode, we look at the extensive research available on these subjects. By listening to this episode, you can earn 2 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome back to the podcast. I am joined today with soon to be Dr. Rachel Lockard. She is a fourth year medical student who has been working with a couple other medical students on digging into this episode, which is exercise and mental health. This is an update. So I wanted to look at articles that came out in 2022 and now 2023. Because we've done a couple episodes on exercise. And so welcome to the podcast. Thank you. Thank you so much for having me. Yeah. So we connected on social media because you were, you had listened to the podcast on strength training. And you were, I don't know, we just casually connected. And I was like,

hey, do you want to do a project like I always do when people will reach out to me? And they show an interest in a specific thing. And you said you were re-listening to the last episode I did today on exercise in the brain with a group of residents earlier this year. Yeah, yeah. I think that might have been when I reached out to you or just generally seeing you talk about your experiences with power lifting and mental health. And that just really resonated with me. But all the recent articles around the benefits on the brain are just really exciting. and it's a great time to be in this field.

Yeah. We are the people coming to your ear proclaiming the goodness of exercise because there are no drug reps to do that, right? There's no money in this. There's no big companies who have figured out how to, you know, target people with mental health issues and express the benefits of exercise. So today we're going to be going through

a lot of different topics on exercise. We have a 24-page handout that will go with this episode. And you have a background in physical fitness, powerlifting, and you went to nationals for power lifting. So, yeah, what was that like? Yeah, I've always enjoyed exercise, just moving my body intentionally and was involved with, like yoga and running and didn't really find something I was incredibly passionate about until I joined

a powerlifting gym that happened to be by my house. And the community there was just incredible. And I started volunteering just to kind of help out at meets and then fell into hiring a coach and, you know, it kind of snowballed into starting to compete in, you know, having that outlet during medical training was one of the best things I did for myself in the past few years. And somehow during my fourth year of medical school, went to Nationals in St. Louis. And that was an incredible experience, trying to navigate that with residency applications. was definitely a lot, but it was worth it. Awesome. And how did you do?

I got fourth out of five in my weight class, but it was my second meet ever. So I was just honestly happy to be there. And I got... You said some PRs? Yeah, I did. And I'm in a class one total, which there's a lot of different levels, but that is just a nationally ranked total. Awesome.

And so when you were in medical school, you're doing this, did you notice a difference in cognitive function or stress release or just like... Yeah. How did that impact your studies, do you think? I think definitely stress release. It's something that on the days, if it's been a couple days since I've worked out and gone to the gym, you know, you just have that like internal stress and having that release was, you know, super helpful. helpful and trying to find time to either go really, really early in the morning or after shifts, even though it would be a lot easier to go home and lay down. It just really, the days that I went to the gym and just made the hard rotations even easier, even though they were time intensive.

And one of the things that I think from a medical trainee perspective that was really helpful for me was, I think a lot of us suffer from having like the fear of, like, negative evaluation. And that's something that medical trainees have to experience a lot is getting, like, negative feedback and handling that well. Right. And at least when you have a coach, you are getting negative feedback to improve your future performance. And sometimes it can be frustrating when you don't really know what you're doing wrong. And yeah, and I think for me, one of the biggest benefits was being able to, like, change what you're doing to improve future outcomes and handle that kind of emotional

stress as well. Yeah. It's like a fear deconditioning for feedback. Yeah. Which, like, is so important for continued growth, right? In any domain. Yeah. And that's something I think we talked about briefly is the use of putting yourself in kind of fear-inducing situations and being able to handle that, just like the idea of fear extinction.

Because for me personally, one of the three lists, so there's the three-lifts, bench, squat and deadlift. For me, squat causes the most fear. Absolutely. Getting under a bar with more weight. then I weigh and having that not crush you metaphorously and like truly causes fear. Yeah, there's a reason why people avoid leg day. Yeah. Yeah. I think there's something about the squat when you're like, because of how the weight is

compressing you, it does elicit a lot of fear and avoidance. I remember when I started lifting, it was like all I could think about some days was the upcoming lift and dreading it. Yeah. Yeah. Yeah, I can definitely relate to that. And then also if you have high expectations for yourself, which I think a lot of people in medical training often carry high expectations for themselves and trying to manage that without getting too in your head. Yeah. It's like what is a way of overcoming perfectionism?

going through medical school. Yes, yes. Because you can't. You just can't learn everything. You can't know everything. And then you go rotation to rotation for a month or a month and a half. And you're literally with someone who's in it for 20 years sometimes. They're going to know stuff that you don't.

So you're just always going to be in a place of not knowing. And it's like building intolerance for that. But in the same way, like lifting, it's like you're always at, at a weight that is pushing you right at the edge of your ability. Yeah. Yeah. Cool. Well, I think, yeah, I was thinking about, like, what we've talked about in the past

and kind of how exercise has the ability to improve memory and decrease the risk of dementia, weight, like muscle acting like a neuroendocrine organ? What do you think about that idea? Yeah. It's actually really interesting. Prior to medical school, I used to work in a lab that was studying maternal high fat diet and offspring neurodevelopment in both primates and human moms. Okay.

Wow. And that lab studied a lot more on the side of. of, you know, lipid tissue being a neuroendocrine organ. And so with exercise, we're thinking of it as, like, the skeletal tissue being leading a lot of that. And from the last podcast, it was really interesting hearing about the brain-derived neurotropic hormone or BDNF effects on cognition and dementia. And what we know about some antidepressants or antidepressant therapy, how that all. also modulates BDNF, same as exercise. And so there's a lot of really interesting correlations between those.

Yeah, or ketamine. Or ketamine, yeah. ECT increases BDF. Yeah, so there seems to be a theme of like things that work influencing BDNF, right? Yeah. Yeah, just the inflammatory cytokines and yeah, just the reduced inflammation that can help. Right. Yeah, there's this, like, how does exercise help that we talked about last time?

But I think, you know, we know that it helps. It's probably many mechanisms, right? And it's, like, very complex. And it does improve survival outcomes. Yeah, like you guys were talking about last time, just all-cause mortality more than statins is one of the comparisons that you made in the last episode. which is truly incredible, being one of the most prescribed medications that we have and being more effective than that. Right. I mean, I've never seen a study that shows all-cause mortality decreasing more than exercise. Or I've never seen this, like there's no drug that decreases dementia more than exercise.

Yeah. So those are very, very important. That's not the problem I have. The problem that I have is getting people to exercise. And kind of like slowly, you know, encouraging. Encouraging in a way that's not shaming, you know, because people come in who are depressed with, like, high amounts of shame. And just general impacts on motivation, which is part of the disease.

process and trying to overcome that is incredibly challenging. Yeah, so there's these studies on like hand grip strength and it seems to be really clear that the more hand grip strength you have, the lower your risk of future anxiety episode or depression episode. Anything jump out at you as we looked at those articles? Yeah, I think that those studies are so interesting and they've been replicated in multiple countries and huge sample sizes. But what we're seeing is that just having baseline strength with yet, which yeah, they measure through hand grip strength, the stronger you are, the lesser the incidence of depression in a lot of these studies. And it's such a simple measure for how impactful it is on the patient population. And yeah, I just,

I've always thought those studies were really, really fascinating. Yeah, so I think when someone gets out of depression enough to be able to start exercising, it's like something I start to talk to them about. It's like, okay, if we can get you stronger, your risk of relapse will go down. Like, I think there's pretty strong data to support that at this point. And I think a lot of people buy into it when they look at the data or they're just like, yeah, this was the most miserable thing I've ever been through. I never want that to happen again. How do I decrease my chance of that happening? There's one physician that I know who's like a

mostly psychopharmacologist. And he'll say to patients, if you exercise, if you sleep, you know, sleep hygiene, exercise, diet, you will need half as many medications. Like, and even him as like the most biologically oriented psychiatrists I know will say that to patients. Yeah. So, okay, yeah, let's talk about, let's talk about the neurobiological effects of exercise. Anything else you want to put out there as you, like, looked at this? One of the studies that I found interesting, so we talked about the levels of the, like, BDNF, and there's also the other down-regulation.

factors. But there was a recent study that I was looking at that was a functional MRI study that was looking at the effects of exercise on inhibitory control. And so they were looking, they talked about inhibitory control as a factor that is seen in ADHD, bipolar, schizophrenia, and some substance use disorders. And they were using, it was a meta-analysis of a bunch of different studies and looked at what they called the activation likelihood estimates and found that there was higher connectivity in the frontoparietal network. And so in the frontal lobe, you're thinking about things like executive function. And then with BDNF, what we've seen in the past is differing levels in the hippocampus and how that is impacted in depression and other mental

health disorders. And so their functional MRI studies also showed changes in the HIPA campus, as well as the temporal lobe, which is also seen in inhibitory control tasks. Let me just read this because I think it's like someone's going to nerd out the details here. So Wu et al-2020 conducted a meta-analysis of fMRI studies looking at the effect of exercise on inhibitory control. So they looked at an N of 397, 14 studies, and impaired inhibitory control is seen in like what you were saying, ADHD, bipolar disorder, schizophrenia and substance abuse. So all of those have impaired inhibitory control. Can you define inhibitory control? So an example that I can think of would be when you're thinking about a substance use

disorder like impaired inhibitory control could be your impaired ability to resist cravings or in depression, have it be your impaired ability to kind of do the day-to-day activities that would make you feel little better or more able to do your activities of daily living, kind of stuff like that. And then with ADHD, generally like the attention side of it, your impaired ability to kind of regulate what you're focusing on in attention. But I could be wrong there. No, I think you're right. It's one of the three core executive functions of the brain. And it basically is to find as suppressing prepotent responses to goal irrelevant stimuli and contributes.

to anticipation, planning, and goal setting. So can you suppress goal irrelevant, things that are not relevant to having your goals, right? Can you suppress those things? And so, interestingly, in this study, they looked at this and they found that exercise actually impacts inhibitory control. Right?

Yeah. So they used activation likelihood estimates to find clusters of exercise-induced neuronal changes in the superior frontal, precentral gyri in the frontal lobe, precunious region of the pridal lobe, and temporal lobe, and the caudate in the temporal lobe and the posterior cingulate gyrus, and the pre-hypochampal gyrus in the limbic system. So that's probably why you didn't. Yeah. say all those things because for a lot of people it's a mouthful.

So this study highlights the connectivity of the frontal parietal network with activation in the frontal lobe associated with motor and cognitive control and the pre-cunnius region and the pridal being essential for attention selection. They also note the importance of regions of the temporal lobe being active during the inhibitory control tasks. They also propose that the posterior cingulogyrus and the parahypochampum, Chyrus of the limbic system structures underlie the mechanism of exercise improvement of cognitive control function through spatial information processing and object recognition as well as being one

of the locations of changes of BDNF levels. So all of that saying like your brain is activating in helpful ways to inhibit things that would derail you from your goals, which is a very very very common thing in ADHD bipolar, schizophrenia, substance use disorders and borderline precise, or I would say as well. Yeah. So that's really cool. That's a really cool study. And because it synthesizes all of those data points.

Yeah. And I think it's a really exciting time for neuroimaging as a whole, just as we get better and better at, yeah, neuroridial. I suppose. And so it's cool saying a review and meta-analysis because I haven't seen these methods before. Mm-hmm. Yeah. So it seems like baseline strength, physical activity, and depression are like linked. And tell me about this, tell me about this study, Muhammade at all, 2022. Yeah. And so kind of similar to the hand grips. hand grip studies that we talked about. So, Mamoudi at all, they did a systematic review and meta-analysis looking at both

aerobic and resistance, exercise training on depressive symptoms, quality of life, and muscular strength in older adults, so those over 60 years. And it included 18 studies, and they looked at studies that had both a pre-and-post and non-exercise control. And this included over 1,300 participants. And they found that exercise training significantly declined depressive symptoms and led to a significant reduction in bodily pain and body mass. And that this was mediated by significant increases in mental health, physical functioning, and general health subscales of the quality of life metrics, as well as upper and lower limb strength. And, you know, that's all important because we know the stronger you are, the better you feel, like, anecdotally myself.

That's how I personally feel. And for older adults, this is especially important because, as we talked about with the all-cauls mortality, if someone is weaker and they fall and break a hip, their chance of dying is so much greater. and their quality of life drops dramatically. Yeah. Yeah. It's a lot of older people, they don't realize the importance of strength training, I think. It's like, oh, I'll just go for a walk or I'll just do, like, stretching.

And so I have that conversation with this group of people where it's like, actually what we need is a progressive plan to get you stronger. because eventually that will lead you to be in a much healthier body in a much healthier mind. What about this study Marquez-at-all-2020? Tell me about that one. It's a big study. The N is really big, right, the number of people is 32,000. Yeah, so instead of this being a review, so a lot of the studies that we've talked about have been reviews,

This is a cross-sectional and prospective study looking at middle-age to older adults and varying levels of physical activity and then their depression symptoms. And this was in 14 European countries and a four-year follow-up. And so they found that moderate and vigorous physical activity at least once a week was negatively related to depression. And then this remained significant in the fully-adjustice. and models, which included their self-rated health and socioeconomic characteristics and then the presence of chronic diseases. And one of the benefits of this study that they looked at,

so that was with the cross-sectional results. So despite your initial physical activity level, prospectively. So if they started becoming physically active and then at the end of the four-year follow-up, the present physical activity level decreased the odds of having current depressive symptoms. So, you know, this is great for patients that want to start being physically active because it's not just whether you have been active four years ago. It's also that, you know, you can make these changes and improve your depression symptoms over time. Yeah, so they looked at past activity and current activity. And if you were currently, you know, doing at least one time per week, right?

It doesn't seem like pretty low bar, right? That decreased your odds considerably. So, yeah, that's another sort of data point. Okay, let's talk about how increasing strength has. the biggest impact on depression. Now, I was not expecting to see this, okay? And for those of you who think I'm only into strength training, like I row, which is largely cardio.

So I row three to four days a week. I strength train two days a week. But this exercise, or there's a series of studies, and let's really focus on this really new one, this 2003 article called Exercise as Medicine for Depressive Symptoms, a systematic review of med analysis with meta-review. regression. Tell me about this one. Yeah. So this study by Heisel et al was looking at depressive symptoms and this included 41 studies. So it was a pretty large study,

meta-analysis with over 2,200 adult participants. And they were looking at specifically pre- and post-intervention studies. And they excluded studies with mind. body exercises, which I think is really important when we're thinking about depression and anxiety, because we do know that those have a strong benefit for that as well. And then they also excluded studies that had medications and psychotherapy unless the treatment was over three months ago. And they found moderate to large effects of exercise on depressive symptoms, even when limiting the analysis to low risk of bias studies. And the main analysis of all the pool data from the 41 studies showed a large effect size, so a standardized mean difference

of negative 0.946. And that was even increased when they excluded studies that had less than six weeks of intervention. And the standardized mean difference for that was negative 0.959. And then they further separated aerobic and resistance training. So aerobic, just being more cardio-focused. And the standardized mean difference for that was negative 1.156 and resistance training negative 1.042. And so those are both qualified as large effect sizes. which was not seen in the study when they mixed both aerobic and resistance training, which had a smaller effect at negative 0.45. One of my favorite parts of this meta-analysis was that they calculated the number needed to treat.

And so for the main analysis, the number needed to treat was only two individuals, which is very, very low. And one of the studies that I looked at, this was a 2009 paper that was looking at the number needed to treat for antidepressants, both TCA's or tricyclic, antidepressants and SSRIs, so the selective serotonin reuptic inhibitors, was the number needed to treat for TCA's range from 7 to 16 with a median of 9, and SSRIs was 7 to 8. And I'm not sure this was 2009. So obviously there could be more recent data. But having a number needed to treat of two is very effective. I think it's hard to compare the Apples to Orange's in this because effect size is really determined based on your control. And a lot of these exercise studies, the control is not doing anything.

So whereas in medication studies, the control is. is a placebo, which comes with a relationship. And placebos can be really, you know, effective. Like sometimes in studies, like 50% of people got better on the placebo. It's like there's more than going on than just taking the medication at that point, right? So the study here, though, is really powerful because it shows that this effect sizes, is really powerful. Like even if there is no placebo,

like an effect size of one, basically, for cardio or strength training. There were some other earlier ones that looked at strength training versus cardio that showed that kind of leaned more towards strength training. But this one seemed to kind of lean towards both of them are really independently good. And so if the person is more amiable to do cardio, it's like, great.

If the person's more amiable to do strength training, great. You know, it's like finding that. And one of the things that I think is interesting in this study is they also found that it was more effective if the exercise was supervised by professionals. So I know both of us have utilized coaches and trainers in the past. And for myself, I know that my growth and motivation is higher when I have a coach. And I think from my experience with aerobic training, have it be running or rowing, it's a lot easier to do it yourself. You know, there's a whole you can buy a pair of shoes and go for a run versus there's a little bit of a learning curve with resistance training.

and weight training. And so I do think the resistance training effect size would be higher if everyone had access to professionals, which we know is limited by cost for a lot of folks. Right. I imagine someday insurance will figure this out and be like, yeah, we'll pay for you to you know, go to a strength trainer, someone that's going to help you work out. I have had much more success long term with patients that are willing to get a good coach. You know, I know of a couple coaches across the U.S., and so people reach out to me and I'll be like,

you really should pay for a coach. And a lot of them balk at the price, but it's like, hey, this is your mind. you know, this is like, this is your ability to, you know, improve your chances of longevity, of cognitive longevity, of not having as many depressive or anxious episodes. So I really consider it as like part of the treatment, or we'll get into this later, but even with like my patients with schizophrenia, it's like maybe not when they're in the most psychological. place will I get them to start exercising or will they be you know available to receive that input but eventually like that's like a part of like what I think it means to just you know invest in yourself yeah definitely yeah and we'll get to that um yeah so it sounds like from these studies just wow I'm just you know just to let you guys know who don't know what an effect size of one is or a number

needed to treat. Number needed to treat is like how many people giving this recommendation before one of them has a remission, right? So number to the needed treat is two. That means you make this recommendation to two people. One of them is probably going to go into remission. The other one's going to have some benefit, but probably not full remission. And then effect size is comparing, like, is looking at how many standards. deviations you're moving from where you started. So if you have a group of depressed people who have maybe they've they are one standard deviation away from normal, you know, they move back towards normal. Okay, that may be confusing. We'd have to draw some bell curves for the

understanding. But basically, like everyone in the population is in some sort of bell curve or like a mountain. And if you want to move people more towards normal, then you're, you know, how many standard deviations are they starting from normal? So a more severe depression may be a couple standard deviations. And so medication may move them a little bit towards normal, but it's not going to completely resolve their symptoms. But hopefully it moves them enough that they're then able to exercise and go to therapy, which is going to continue to move them more towards normal, even better.

So, okay. And I know one of your interests, obviously, is psychotherapy. And similarly with engaging in exercise, one of the benefits I think I've heard you talk about is the role of pharmacology can be just to get people to engage better in other treatments. Right. And being able to have. all these different tools in your tool belt to better take care of your patients.

Absolutely. Good psychopharmacology supports doing therapy and doing exercise. So, for example, I saw a patient with schizophrenia or some psychotic episode. They were put on too high of a dose of the antipsychotics that they were having some aceshesia. It wasn't like, it wasn't. it wasn't an intolerable level of aceshesia, but it was like they were pacing around a lot.

They were more anxious, so it's like we drop the dose to about 40% of what they were on, and the acesia is gone, and now we're exercising, we're doing therapy. It's like, so can we have a lower dose without the psychotic symptoms coming back? If the psychotic symptoms came back, I would switch the med to a med that maybe wouldn't cause

this height of acesthesia. or add on an adjunctive like mertazepine or perpanol or clinazepam to try to like lower the acesetia so they could tolerate the med. But ideally they are exercising and that exercise provides some of the benefit that may be the, so they can be on a lower dose. right yeah so okay um and sometimes you know you may be listening to be like wait you can be on a lower dose of an antipsychotic if you're schizophrenic on if you're doing exercise and i think we'll get we'll get to a schizophrenia more so hold on we'll get there but in short i would say um well sometimes people are overdosed in the first episode maybe where they need to be and so it's it's like outpatient function of finding the minimal dose and working closely with the patient and their family

so that you know when you're when you've gone down too far and making very small adjustments, right, and watching them closely. Okay, let's keep going. So, yeah, which study do you want to talk about next? There's one that the Susani at all, 2003. Yeah, so Susani at all, and this is a 2003 cohort study of older adults who experienced a significant life stressor. And they define this as the loss of a spouse or a child, heart attack, divorce, job loss, or developing a disability. And then they looked at their depression trajectories using linear modeling. And they found that the baseline level of exercise promoted. or predicted resilience following the stressor at the follow-up. And so then the resilient,

they called this the resilient group. And so they had higher levels of exercise before the stressor. But then they also looked at individuals that increased their level of exercise following the life stressor. And they grouped this in the improving depression group and showed that increasing exercise following a stressor, improved your tolerance to significant life events. And I think as psychiatrists, having this knowledge, you know, is crucial because we're always going to have people that come to us after the loss of loved ones or the loss of a job. And sometimes people don't know what to do in those situations. Okay, yeah.

I think for me, I lost my dad six years ago. And being in the gym was one of the things that helped me get through that because it was the most challenging thing that I've dealt with. And so this paper really resonated with me because at least for me, I find strength training to be empowering. but then to see that it also, you know, does this for other people is one of the big reasons why I think I'm here is because I love talking about this and I love, yeah, how much it helped me. Yeah, that's a huge loss. It's huge loss. You see lost your father. Was it suddenly or?

Yeah, it was an accident, yeah. Oh, that's awful. It's really awful, yeah. And, yeah, so having exercise be one of the things that. that I was able to choose to do and be able to find enjoyment in. It kind of helped you work through some of your... 100%. Some of the...

Yeah. Just the grief. Yeah. Thanks for sharing. I mean, that's like... Yeah, I can think of, like, things that have gone on in my life where it's like, yeah, exercise is like one of those things that sometimes you don't want to do it in the moment, you know, but, you know, it's been...

kind of like part of the process of the healing. And it's something that's like a constant thing that you can tap into to take time for yourself, to take care of yourself. And there's not a lot of space in our busy lives that we can often do that. Yeah. Yeah. So were you like at that time six years ago, were you strength training or cardio or what was it? No, I was actually mostly doing a lot of yoga and cardio.

And I do truly believe that yoga has a great huge benefits for mental health and especially like the breathing aspects of it. Oh, yeah. And yeah, I actually went on a yoga retreat after my dad died. And it was, you know, one of the best things that I did for myself. I call it my eat, pray love tour. But. But then when I got back and was starting medical school, you know, the stress of everything really built up. And I found that strength training actually was what was most helpful for me.

And, you know, I'm a huge proponent of being open about our mental health. And, you know, I was prescribed and I depressants when I was in. medical school and after strength training I do prescribe I mean you know obviously this is 100% anecdotal but right I fully believe that it was one of the best things that I did for my mental health and no longer needing to um do some therapy as well yes yes yes I definitely did therapy what was that experience like um it was good I feel very very lucky that my school had access to both psychiatrists and psychologists. And so I was able to do medication management with the school psychiatrist while also do psychotherapy with their psychology team. And it was incredible. And one of the

reasons why I'm here, like both here in this office and then also just in medical school. Like you were able to keep going. You're able to like here as in like physically here or here as an interested in psychotherapy and psychiatry. Yeah, here's interested in psychotherapy and psychiatry. I always had an interest in neuroscience. That's what I did my undergrad in in, like, 2014. But, you know, just having that experience and truly seeing it for myself how beneficial psychotherapy was, because I feel like it's something that you need to see for yourself

to really truly understand how it can save your life, right? Because that's like what we're here for. What did you like about your therapist looking back at that time? What did you appreciate? Like, how was it helpful? I think it's the things that you don't realize are helpful until later. I had a very, very hard time even talking about grief or, like, the experiences without having, like, significant emotional reactions. And, like, now I can.

Like, now I can talk about death without, you know, being too overwhelmed. And she gave me so many little tools of how to incorporate acknowledging my dad into little parts of my life. Like having one of his names is like my computer password and just like all these like little tools that help you just like get past the hugeness of the problem. And I just, yeah, she was very comforting and very creative in how I feel like she helped me. Thank you for letting me derail about my personal life a little bit. No, it's, we're honored for you to share. And, you know, it shows the completeness of this journey is like there was some medication, there was some therapy, there was exercise, and eventually you were able to taper off the medication. Yeah.

And then you were, you know, you were getting sort of more of that lifestyle type of treatment. So that's really cool. And then it was helpful enough for you to be like, you know what? I want to go into psychiatry next year. Yeah. When did you decide to go into, you wanted to go into psychiatry? I thought I was, so this, I went to my medical school for two years prior to starting because I did my master's in public health. So I was lucky to have a very long relationship with my psychiatrist and

psychologist. I was six years. And so when I started medical school, I knew I was interested in mental health, and I didn't know if I would go into family medicine. I also really liked emergency medicine. And I kind of flirted with those specialties a little bit and did rotations, but I kept coming back to psychiatry. It still was at the end of the day what I was most drawn to and most passionate about. I did a lot of work around local homelessness and addiction as well. And those are two other areas that I'm really passionate about and mental health. underlies those two, you know, areas of social distress, like so acutely that I felt like it just made sense.

That's cool. Yeah. I, yeah, that's great. I actually want to do a topic on homelessness. One of my good friends is this is like full-time job. It's just being on the street and like creating connection relationship with them. Like he has a nonprofit and that I support. and I might have him come on eventually and talk about his work

because he's like he's not someone who has any limelight. You know, very few people know that anyone would choose to do this. He has like a PhD, you know. He's like a very smart person. And so he thinks about these things deeply, but it's just a calling for him. Yeah. And...

Yeah, street medicine, street mental health services are absolutely incredible and integral to getting people into recovery. Yeah. I've seen the full spectrum of like people who are homeless on the street, getting effective treatment, and then being able to go back to college, go to graduate school. One of my long-term patients is actually graduating from, like, graduate school this year.

and yeah it's really meaningful to see that when someone has like suffered at that level you know so yeah wonderful well um great i think i think we should talk about let's see have we talked about high intensity interval training and strength training is the best combo is that is that what the data that you found still points to yeah yeah so high intensity interval training is I suppose in the name. It's when you're doing more repetitive movements at a higher, higher intensity level, and usually for a shorter period of time. And so you might be doing...

The assault bike. Yeah, the rowing machine. Yeah, quick. You're going 30 seconds to one minute hard and maybe like a three-minute break. And if you're using weights, it's going to be lighter weights, higher reps. I actually think that sometimes I feel like that high intensity interval training feeling from doing pretty heavy. I think you have to be at your upper level to get that closer to what it's called one rep max to be able to get that kind of feeling, at least for my experience. It feels like high intensity interval training sometimes where I'm just like out of breath.

you know it's like it could be a minute you know you're under the bar um anyways so yeah it's like i was i was watching this this video on like the assault bike everyone's favorite as like a torture as like like if god were creating a torture device it would be the assault bike right i i used to think it as the rowing machine like oh i hated it so bad because you know it was just it was just an awful, awful, awful amount of pain and suffering. But after rowing, you know, four years in college and stuff, I've tried to like regain like just a general appreciation of the rowing machine. You know, when I can't get out on the water, like the wind is above 15 miles per hour or something. There's thunder out there. I'll jump on the, um, the road machine. It's unpleasant. Okay, so take me

through the studies. Yeah. So, um, so, um, So one of the studies, we can go through first a meta-analysis, as we were talking about earlier. There was a meta-analysis that was done by Marinus et al-in-19, and it looked at 17 studies and showed that strength training and combined aerobic strength training increased peripheral blood BDNF, brain-derived neurotrophic factor. And so that's something that, you know, we've been talking about. throughout this in the last podcast being known to impact depression while and then low to moderate just aerobic exercise alone did not have the same impacts on BDNF levels.

And so from a neurobiological standpoint, this is really cool to see that this was done in a meta-analysis or seen in a meta-analysis. So this is also a little bit helpful. I was going to say it's a little bit sad, but hopefully, helpful because it tells us clearly that it's not enough just to do a little stroll. You actually have to stress your body and get a stress response and do something difficult. Yeah. And I think when we talk about, you. about stress responses maybe to the general population, they might think that as like a bad thing and you don't want to stress your body. And I feel like the ideas of like too high of cortisol is too, like the adrenal fatigue and all these things that I feel like are really

popularized on, you know, social media and general population things. But it is good to stress your body. We do know that occasional stress have it three. high intensity interval or strength training is showing these benefits. I would add some nuance there. Progressive, small increases in stress. So, you know, the mistake if you're in your 40s and you used to work out, but you haven't for like years, it's to get back into it too fast. Like if you have been working out, any stress is a good stress.

So my patients who are completely bedbound and I look at their Apple Watch steps, day and it's like 1,000 to 2,000. So they're pretty much not moving at that level. You know, I don't go for any walks or anything and I move like 7,000. Yeah. Just by living life. So 1 to 2,000 is like not moving much at all. Yeah, like around the house. Around the house, going to the bathroom. Yeah.

You know, getting up to get the remote control, going back to the couch. And so those people, a stress may be 3,000 steps per day. And so, you know, I think of stress as like a very sequential thing. So it's like 3,000 steps a day, maybe the goal every other day for the first week. And then let's go up 500 to 3,500. And if they're a compliant patient, they'll do that happily. If they're not, then maybe they're still too depressed, right? So it's like patience is a virtue for kind of like the long game and getting someone healthy.

So yeah, stress is like very, very important. But at your level, stress is like one pound to your deadlift maybe. Yeah. Right. Oh, gosh, yeah. Adding just one pound to my bench as a cisgendered woman, bench is the hardest thing to increase. And so anytime you can add a single pound to your bench press is like the best day in the world. But yeah, I think we're talking about progressive overload in strength training.

or progressively increasing your walking is what is going to be the most effective and just most helpful for your body. You don't want to hurt yourself essentially. Yeah. Well, you've got to start somewhere, right? So maybe the ideal is someday doing a combination of strength training and, you know, one day of high-intensity interval training. Because I do think if you look at as well professional athletes, usually it's once a week

that they'll do more of the high-intensity stuff. You heard that episode that I did. Yeah, and because there are the people that are doing these high-intensity classes that, like, don't want to call any out, but like six days a week, and that is very stressful on your body. And we do know that, you know, doing too much of a good thing is no longer a good thing sometimes. Well, it's just not even what professional athletes do. professional athletes usually have like around 10 workouts per week and most of their workouts are in a heart rate zone that's like somewhere on 65% of that zone 2 area which for them it's like a talking pace and it's enjoyable and so when we try to emulate professional athletes by doing high intensive interval training every day it's just not the best it's not the ideal in my mind so yeah i'm glad we're specifying what this means but that's being said, these studies do point to BDNF increases with brain drive neurotrophic factor. BDNF increases with the strength training and the high intensity stuff.

Yeah. Right. Yeah. And this has been seen in other non- like systematic review meta-analysis. So there was a large population study done by Benny et al in 2019 that was looking at aerobic and muscle-strengthening exercises and depression severity, and this included almost 18,000 adults and found a combination of the aerobic and muscle-strengthening exercises, so more of the hit-style workouts, was associated with the lowest likelihood of reporting depressive

symptoms compared to just aerobic only or muscle strength training only. And so then there was another cross-sectional study that was out of the same. of Australia that was just looking at 5,000 women that showed a combination of resistance training and aerobic exercise. So the hit style also showed lower probabilities of depression compared to just aerobic exercise alone. Yeah. And so you may be seeing a theme at this point that it seems like both are important to do both together is ideal. I consider it like different medications, right? If someone's only willing to do

the aerobic stuff, it's like a medication of sort. There's data to support it, but if they're willing to do both, it's like two medications. Yeah, a combination. It's a combination of medication. You know, it's like, yeah, keep going. What other studies jumped out at you is important here. Yeah, and so there was another, you know, a larger meta-analysis. that was done by Brett at all. This was 2017. And they looked at 21 studies comparing the changes in strength and hypertrophy between the low versus high load resistance training protocols.

And so they found that heavy loading had a greater advantage for gains in one rep max, which is kind of what you would expect just from a strength training perspective. And they didn't actually look at depression in this one. No, but I think the key here, because there are other studies that I've seen that show the amount of strength you gain is actually important. And so it's like as we consider, what is the best way to gain strength? Here's a study that clearly shows you have to be closer to your one rep max to actually get increased or to get the largest increase in muscle strength. size will increase with lower weights, but not necessarily strength. And so...

Yeah, so it's the difference between a lot of times you think of like the more bodybuilding workouts which you're doing like the lower weight, higher reps versus if you're closer to your one rep max and doing as heavy as you can do, that progressive overload to increase your one rep max is what's going to increase your strength the most. Yeah. Yeah. That's good. Okay, let's talk a little bit about this idea of exercise and resilience, stress reactivity, and fear extinction. And so we talked about one study, but let's talk about the other studies that we found looking at this. Yeah. I was definitely interested in this, the whole idea of resilience and response to adversity, kind of like what we talked about earlier. But also when we talked about, the fear of squats, so like the idea of fear extinction. And when thinking about these combined, just like how exercise can impact, you know, your response to PTSD and anxiety with

different stress and trauma-related disorders. And so there was one study that was a 2002 study by Newman et al, and it was a longitudinal prospective study that looked at physical fitness and resilience. They did exclude schizophrenia and bipolar disorder as well as substance dependence and then severe Axis 1 disorders. They measured fitness with cardiorespiratory fitness through a VO2 max. And so this was kind of talked about in the last podcast as well. And then composite strength with the hand grip, which we talked about earlier, and then as well as the standing long jump, which is more of a measure of power. And then the sum of metabolic, like equivalent minutes per week, so met minutes, and this looked at just moderate activity,

so carrying light loads, biking, swimming, walking, and then vigorous activity, which they include as like lifting, fast running. And for resilience, they looked at stressor reactivity in response to critical life events, as well as just daily hassles, and they monitored quarterly for nine months. And so they found that both muscular and self-perceived fitness were positively associated with stress resilience, and that self-reported physical activity and the cardiorespiratory fitness did not independently predict stress resilience. So then when they were looking at this further, they examined the impact of self-efficacy. So since they were both looking at like the self-perceived fitness and how stress resilience was

mediated by general self-efficacy. And so I thought that was really an interesting component of this evaluation, just how exercise can increase just your general sense of like being able to do things and being able to handle stress and tolerate these life events, have it be, you know, the critical life events, but also just general daily hassles that we can't get away from. Right. So it's like, was it the amount of strength or was it the amount of fitness? Or was it that people who are exercising are practicing a way to increase their self-efficacy? And, you know, of course, like, it's hard to control for one or the other because it's like we may be looking at the same thing.

it's like because you may be increasing self-efficacy through strength training or strength training may be increasing your self-efficacy. But I think what they're what they're pointing out here is that the increase in the self-efficacy that comes from the exercise actually led to the ability to be more resilient. Yeah. And I really like how they described it. So they said this was proposed to one's own perception of fitness closely relates to the concept of self-efficer. and the capability of acting.

And kind of like what we were talking about with inhibitory controlled set, you know, being able to impact these things like self-ethicacy and the ability to do things can have such a strong impact on just your day-to-day functioning. Yeah. I think there's a, it's like a, you know, stoic philosophy to practice hard things, right? And you practice hard things for the day that something. something hard comes. And I think that, you know, 10,000 years ago, you would be practicing hard things every day just by the nature of living. House cats don't really practice hard

things, right? And it's like they live longer, but, you know, like there may be a benefit of us practicing hard things. And therefore, like, when something really does hard, that's uncontrollably hard. It's really interesting that you say that because I don't know if everyone has little mantras that they say to themselves, but one that I say to myself regularly is that you can do hard things. Like, you've done hard things in the past. You can do this hard thing in front of you now. And that's what I said to myself at my meets. You know, I don't know if you've, you know, gone into a competition, you're like have those like pre-competition nerves and you're just telling yourself things like you can do hard things. Yeah. Yeah. And yeah. Yeah. I think that's such a

beautiful mantra. And you know, like most of our suffering on a daily basis is like by choice. But there are occasional things that are suffering like your father passing or like things like that. like where it's like yeah that is real suffering and you didn't choose that and or like I recently um I may do a full episode on this but um we've been going through some just some like real medical things and close family in our in our household and um it's been it's been like the hardest thing you can imagine like I mean harder the hardest thing and um just like not just like not Nothing prepares you for that, but still having suffered in different ways and chosen to suffer may have. Yeah.

Prepared me not to dissociate and crawl into a ball, but instead like, okay, we're going to keep fighting. And that ability to keep fighting is something you practice every day that you do your strength training. You know, it's like... And it's the idea of, you know, when you put yourself in hard situations, you are controlling. what you can control. Like you are able to use that tool to kind of, when things you can't control, you just can recognize that you cannot control them and then move forward, hopefully. I mean, be able to handle things a little.

Yeah. With grace. Adjust to the unknown, you know, or stay. I like that. I was telling my wife, who's been the one going through this, and I think she's open to me talking about this. We talked about that and how we're going to, we're going to, we're going to, we're going talk about this publicly, but the way that she was kind to the doctors, you know, and just gracious

to all the staff in the midst of the hardship that she's been going through, it's like, that to me was really amazing. That's strength. And it was strength. And, you know, like one week before she had surgery, it's like she was playing tennis at a high level and actually won this local tennis tournament, you know, and, you know, she's, so it's like having that sort of like, okay, you can do hard things, you know, and then how do you, you know, and if you're listening to this and you've been through surgery and you're like, I was not

a nice patient. It's like, okay, that's okay. Like, it's okay to be where you're at, but I don't know, I was honored that she was so gracious to the doctors. And so, okay, we'll keep moving. So here we go. PTSD. Should we jump to? Shall we? Oh, the one thing I was thinking about with fear extinction that I wanted to point out as well is my own experience of like as I get under the bar more, I'm less afraid of getting under the bar. Yeah. So I no longer have this like physiologic, psychological, like dread of working out. I don't know if you're the same way. Yes and no, because I think so for me, for my most recent competition, I started dreading getting under the bar. Bell more because I failed at very heavy squats. And then the more, like, the more scared you are,

the more you're likely to fail because you get in your head. And so I think for me, I had to utilize kind of like what I know about fear extinction is doing it and not failing over and over and over again until you convince yourself that you are not going to fail anymore. And yeah, and I think that was one of the interesting things about some of these studies. is being able to kind of utilize exercises a way to experience fear in a safe way. Yeah. Yeah. Yeah.

And to go up against it in a very sort of sequential pattern. And with a good coach, I think that's really helpful as well. Yeah. And having trust in someone that is. Yeah. Yeah. He's watching you. he knows what you're capable of.

Yeah. I trust my coach Natalie more than most people. Yeah, that's cool. That's really cool. Okay, let's go through PTSD and exercise. We looked at several studies, but is there a general kind of takeaway that you have from these studies? Then I'll tell you what my takeaway is. Yeah.

So my kind of general takeaway from some of these, both smaller studies and reviews, is that exercise does improve PTSD symptoms, have it be through potentially the sphere extinction, modulation that we're talking about, but also just, you know, have, yeah, and like the idea of exposure therapy, since we know that's kind of a beneficial, that is a beneficial treatment for different forms of trauma.

Yeah, I think one of my take. takeaways was there's not a lot of big studies. But in general, like, we can talk about mood. We can talk about anxiety. We can talk about, of course, like neuroplasticity. So it would make sense to me that it would be important, but we're looking at pretty small studies here. And you guys can check them out on the website if you want to look at those in more detail.

Okay, let's jump into physical activity and anxiety disorders. I'm going to move a little bit quicker to get us through this. You can tell we're both excited about talking about this. Yeah, and so one of the studies that we looked at was by Zika and Becker's, a 2021 study, looking at social anxiety in both clinical and non-clinical populations. And it was a systematic review and meta-analysis. And for these studies, they excluded the mind, body, or relaxation-focused interventions that we kind of talked about earlier. And then they compared group versus individual, endurance versus resistance. assistance training, and then also the presence of a trainer therapist.

And one of the meta-analyses that they did, that included a control group, they looked at four different studies, and they showed that the pooled effect was not significant, but that the social anxiety disorder symptoms were lower in the physical activity group. But when they did a subgroup analysis of the pooled effect for what's called a fear of negative evaluation, they showed that there was a medium effect size. So it's a Cohen's D of negative 0.48, which is just an effect size measure. And then when they increased the number of studies to include studies without a control group, so that increased the number of participants from 750 to almost 30,000. So we got a lot more. power in that meta-analysis, it showed that there was a significant medium effect size of negative 0.2. And then when they looked at cross-sectional studies, the pulled effect side was small, but still significantly different from zero. And so, you know, none of this is perfect,

but it is showing that generally there is some improvement for social anxiety. One of the limitations that they talked about this is when you're studying large groups of social anxiety disorder studies, it can be really hard to get those patients to engage in therapy just based on the nature of their disorder. It can be really hard for people to come in for these follow-up visits, to be part of these clinical research studies and exercise programs just because of the fear of a negative evaluation and things like that that they may be experiencing. Yeah, I think my takeaway from this study is that there's benefit. It's not as large as with depression, but this could, like you said, be a harder population to study.

I've definitely seen some case examples in my own practice, people with social anxiety who have improvement. And specifically doing things that maybe are hard, like group activities, you know. So someone with social anxiety, you know, to exercise with a group may actually be part of the fear extinction of interacting with other people. And maybe exercise can decrease the anxiety a little bit of doing that. Maybe it increases if they're really out of shape. So it's like working with individual people, you'll probably have a better effect size because you're tailoring the treatment to that particular person and progressing it over time with therapy as well, being a part of it. Yeah. Okay, any other studies on anxiety that you want to? Yeah, there was one by Dong at all in 2022. It was just a cross-sectional study, not a systematic review.

And so they were looking at executive function and state trait anxiety in college students, and so they had about 248 students that they did this study with. And so anxiety from my understanding is, into both state and trait anxiety. And so state is the more transient response, whereas trait is the kind of stable level of anxiety that someone may have that is associated with more of a disordered anxiety or depression state. And so in their study, they found that vigorous physical activity had a direct impact on effect on low trait anxiety and that moderate physical activity and low physical activity was mediated and the like benefit the effect of this was mediated through executive function as well.

So increase like what we were talking about before in the MRI study, increase in frontal the function, you know, will allow someone just in a similar way as like cognitive therapy will you attack those negative anxious thoughts better, right? And so, yeah, having the vigorous physical activity and increasing the frontal lobe function over time allows for lower trait, anxiety, trait being more of the chronic, like, feels like it's a personality type thing. And you'll see this as well with people for whatever reason who stop exercising all of a sudden. Maybe they get to medical school and they're like, I don't have time for this.

Their trait anxiety may increase and it may look like, wait, did this person just develop generalized anxiety disorder? It's like, no, they just stopped doing the things that would normally decrease their trait anxiety, such as vigorous exercise six days a week, you know? Yeah. They just don't have time. I can keep up with my routine and intern year next year. Oh. It's a commitment. Yeah.

It's a commitment. I mean, if you made it through medical school, there's how. There's hope. Maybe not on my off service months. As much. Yeah, I think you could, you could, you know, for me, I only lift like two days a week now and I'm able to actually still get stronger slowly. And so maybe it's just like less frequent workouts. Yeah. We'll see. Okay. All right. So we're going to talk about schizophrenia and exercise. And there was a couple studies that we looked at, but I really just want to focus on this one study. Brendan at all 2021 because it was so well done. And the thing that I liked about this study was, first of all, this is a meta-analysis looking at the effects of aerobic resistance and combined aerobic and resistance exercise on schizophrenia symptoms. And they looked at the positive and negative syndrome scale.

And specifically, you know, when we think about positive symptoms, negative symptoms in schizophrenia. The negative symptoms are harder to treat with medications. Very hard. And yet in this study, it was the negative symptoms that had a bigger effect size. Positive symptoms, not that much, but the negative symptoms. So tell me what you learned about this study. Yeah, and one of the strongest effect size that they saw through their meta-analysis was that

aerobic training specifically had a significant decrease in the negative symptom scores, which was up to negative 2.28. So that's the highest effect size that I think we've talked about today. And then a total effect set is so the total, so it's the positive and negative symptom scale. So both positive and negative, the effect size was negative 2.51. And... But that's really...

The biggest was the negative pans. Like if you look at the negative pans, like that's where the impact is really, really significant. Yeah. Go ahead. Yeah. So, yeah, the total effect size was driven by that... It was driven by the negative pan score, not the positive pan score is kind of what they're talking about. And that resistance training alone did not lead to significant. effect on the positive or negative. But then they did admit that the interventions were shorter. So an average of 12 weeks and had smaller sample sizes. But despite this, yeah, the impacts on the

negative scores was definitely the highlight of this study. I was surprised. I mean, this is 126 people over four studies looking at the impact on the negative pans. So negative pans, is like the executive functioning decrease that we see in someone with schizophrenia. Yeah, which makes sense when you think about, yeah, the cognitive impacts that we've talked about just throughout this one in the last podcast on dementia and just how impactful it is to increase someone's executive function. Right. It's like what we were talking about with the MRI study and what we were talking about with

the impact on that frontal lobe and the BDNF and how exercise uniquely affects that place. So, yeah, that was really hopeful for me. And actually the fact that it was cardio mostly was interesting as well. Definitely. So I'm going to be recommending that to more of my patients with schizophrenia for sure. Okay. let's jump to ADHD. And this kind of ties in, I think, to what we were just saying.

So go ahead. Definitely, yeah. So the study on ADHD was another review, and it was by laying it all 2021. It included 21 studies, and the meta-analysis included 15, and it had almost 500 patients. And so they looked at trials that studied exercise interventions and executive function. And this was in children and adolescents with ADHD. And they found that all exercise interventions they looked at improved overall executive function with a standardized mean difference of 0.611 and a moderate's large positive impact on inhibitory control,

which we talked about earlier at 0.761, as well as cognitive flexibility at 0.78. and then moderate, to vigorous physical activity, and both chronic exercise significantly moderated the effect size for all of these. Which could, like, increased the effect size, yeah. Yeah, so the more you exercise, the more the effect size improved. Yep. So, like, sometimes I'll recommend get the kids out exercising before school, you know, as hard as that can be as a parent. sometimes I take my kid, we'll do sprints up the hill, I'll chase him, just to get that brain activated for school, get him ready for school, get him ready for learning.

Another study that was really fascinating to me was this, Cadre et al-2019. It was called the Effect of Taekwondo practice on cognitive function in adolescence with ADHD. And this is something that impressed me because it was a longer study. And the effect size were huge. So tell me what you took away from this study. Yeah, yeah. So the effect size is one and a half years, which is really great for any study. Wait, wait.

Say that again. Sorry, the intervention was one and a half years. Yeah. Which, yeah, it's really great. My apparently, exactly, function is decreasing as we go further into this podcast. Yeah, and so the Taekwondo group compared to the control group showed significant differences in the Stroop test, so that's a test of executive function.

The color word interference test, and so both of those, so the Stroop test had an effect size of 1.2.6, and the color word interference test had an effect size of 2.16. And so both of those were just looking at the improvements essentially in executive function. Can you focus and read

when it says, Okay, so it's like you'll have colors, and so you'll have to either name the color, but the words are a different word or the colors are backwards, you know? So you're basically trying to focus and concentrate, and it's like very hard to do, actually. Especially while doing it fast. Doing it fast, right? So go ahead. Yeah. And so their hypothesis at the end of this was, as we've talked about before, physical training and

improves cognitive function through several mechanisms, such as hippocampal, long-term potentiation, neurogenesis, and hippocampal, a neocortical neurotrophin MRI expression. And so this is similar to the BDNF and the MRI studies that we're talking about. And so for them, specifically, they felt like Taekwondo incorporated both the physical and mental components kind of needed to drive these improvements in executive function because you have to do both. You have to have the physical and the mental connection. Yep. And I think it's very like center specific. So with families, I'll ask like what what are some good options with good coaches, right? And Brazilian jiuitsu, I often will recommend just because I know it's so actually what works with fighting.

So as well as like preparing the kid for, you know, in case of like a bad situation happens. It's like defensive versus like offensive. Yeah. It prepares them for a bad situation. And so I've had parents who have kids with ADHD like successfully get them to a better place with physical exercise. Or it's like part of the treatment, you know, or it's if they need medication. Yeah. But sometimes it's enough.

And that's what you're seeing here. These effects sizes are huge, you know. It's great to give parents these tools when sometimes it can feel like you don't know what else to do. Yeah. You know, we also looked at borderline per size order. And it seems like, once again, it's that frontal lobe optimization. It's that, you know, both ADHD and borderline personality disorder are characterized by affective instability, impulsively. impulsive behavior, and impairments in executive function.

So both benefit, of course, from exercise. Yeah. And similarly with schizophrenia, one of the big downsides is that there aren't studies that are looking at borderline personality disorder and exercise. So I look forward to hopefully seeing more research in these areas. I know practically people who run partial programs for borderline personality or will often have it be one of the goals for every patient to start exercising. And that's like just a part of what it means to be in that sort of IOP partial level of care as like a goal.

So, yeah, I think it's obviously important. Exercise interventions in autism spectrum disorder. We also looked at some articles there. Anything you just want to throw out quickly as we kind of like wrap up? I think just similarly, you know, all these things we're going to, we're talking about. is the impacts on executive function, right? And so, yeah, there was a laying at all, 2022 systematic review that, yeah, showed that chronic exercise interventions improved cognitive flexibility and inhibitory control

and working memory and all these things that, you know, we've been seeing time and time again in these large studies that are looking at these different populations. Mm-hmm. Yep. So we'll put that on the website if you want to dig into that more. Let's briefly talk about addiction, substance use disorder, and exercise interventions. Yeah. Once again, no surprise, right? I mean, like if you think about inhibitory control being a big part of addiction or the lack of inhibitory control.

And so this showed similar thing. Yeah. Go ahead. And when thinking about dual diagnosis, there's so much comorbid mental health disease with addiction. And so anytime you can target. both of those in one intervention were going to see positive effects. So yeah, there was a study by Jimenez, Meseigua at all, sorry if I mispronounced that in 2022, that looked at physical exercise and then quality of life, abstinence, cravings, and then mental health. And so they did show

effect on, like a positive impact on cravings and stress and anxiety and depression and things like craving that inhibitory control as well as, yeah, super important. So something to recommend for patients that are trying to start their recovery process. Yeah. So one thing that someone may say is like, well, but isn't powerlifting dangerous? Yeah. Right? Isn't strength training dangerous?

Yeah. It looks dangerous, right, when you're deadlifting that much. And most injuries happen in a meet. So if you're not going to compete, then. then your rate is probably even lower. But we found one study. Yeah. The risk of, yeah, so there's a review that showed the risk of injury and weightlifting

was only 2.4 to 3.3 injuries for every 1,000 hours of training. And 1 to 4.4 out of 1,000 hours of training and power lifting. So weightlifting is a different movement. So it's where you're doing things where you're throwing the bar over your head like snatches and versus powerlifting, which is the bench squat deadlift. And so both of those are comparable to non-contact sports. And so the risk of injury in weightlifting and powerlifting is considerably less than contact sports. So football is 9.6 injuries for every 1,000 hours of training. So less than half.

And soccer is huge. 53 injuries per 1,000 hours of training. Competitive soccer because, you know, all the ACLs and getting hit in the head with the ball and all that stuff, right? Yeah. So, yeah. And then we talk a little bit about like other benefits of strength training, like bone health. Yeah.

Yeah. And anytime you're loading. weight on your muscles, you are also strengthening your bones. And as a woman, I'm really excited to see that there are more women in resistant sports, like lifting more weights. And I hope that this translates to less osteoporosis as people get older. And so one of the studies we looked at showed that it's beneficial for any gender in any age group. And that biweekly resistance training over a year showed maintained or increased bone mineral density and postmenopausal women. And so typically you would see decreased bone mineral density and postmenopausal women.

So even just maintaining your current bone density is an incredible intervention. But this showed it either maintained or increased, which is really cool. Yeah. And then, you know, antipsychotic treatment and metabolic syndrome. So, I mean, we could go into detail here. In short, yes, it can help. Mm-hmm. Right?

Do you want to say anything more detailed? Yeah, yeah. I think, you know, people won't be, there's a large study that was done by Pallinger at all in 2020, and I don't think people will be surprised when it looked at the different antipsychotics. And clasapine and olanzapine were associated with the largest degree of metabolic dysfunctions. And so they looked at everything from weight, B.M. my cholesterol, both and then LDL and HDL cholesterol, triglycerides, and then fasting blood

glucose. And then they also showed some that performed better in the metabolic measures, which included the chryprazine, halperidol, lorazidone, and things like that. Yeah, and so, you know, as you are thinking about optimizing someone's metabolic health, Chlozapine and olanzapine, some of my favorites for, like, severe psychosis are actually, you know, having the largest degree of metabolic dysregulation. So, you know, I mean, this is where, like, the difference between outpatient and inpatient, right? Sometimes inpatient, you're just trying to get them out of psychosis, whereas, like, outpatient maybe of the time to try to optimize metabolic health long term as well. Yeah, and I'd be really interested in hopefully sometime in the

future since we do know that there is such an impact on metabolism with these, you know, life-saving medications that there are studies that look at potentially combining exercise with these medications. So cross your fingers that that might happen. Right. Well, you know, we do have studies though that show that exercise decreases diabetes. Yes. Risk, right? And we do have exercise that show that exercise improves cardiovascular health. So it wouldn't be too far. It's not a leap. Currently, it is not a leap in my mind to recommend exercise to a patient on an antipsychotic as a way of decreasing their risk, as well as other things. Okay, sexual health. We looked at that briefly. Yeah. So when we're looking at sexual health, so one of the things,

that people are commonly concerned about when starting antidepressants is like the impact on sexual function. And one of the benefits of resistance training is that it does have this association with increasing testosterone and improving sexual function. And so when someone is worried about having a decrease in sexual desire or rectile dysfunction, being able to offer this as potentially mitigating that is a great, you know, way to have that conversation with your patients. Yeah. I think, you know, sexual health, it's like the more medications you take, the worse, your sexual function, desire, ability to orgasm will be. And so with a lot of patients, outpatient, it's like the only thing they care about when they come in is the severity of the

depression, anxiety. It's like they have no. sexual interest whatsoever in the more severe in the more severe places when they come in eventually all they care about is their sexual health right it's like hey I'm not feeling anxious or depressed anymore but like what's going on um you know my libido inability to orgasm and then so it's like this like consideration of okay which medications are causing this or worsening this how do we minimize those medications? What other options for medications are there? And then are there other things that we can do?

Exercise being the main one that I'll recommend at this point. And so that's sometimes the conversation I have that motivates them to be like, okay, so if I exercise, I don't need as much medication. I'm like, yes. Okay. And if I don't need as much medication, it's like sexual dysfunction with SSRIs and SRRIs seems to be dose-dependent.

So it's like the more serotonergic, the medication, the more of the medication you have, it's going to be more potently inhibitory towards your sexual function. So, yeah, go ahead. Yeah, and I think we talk about testosterone supplementation, both in like males and females to be treating this. And a lot of studies have shown that even just one strength training workout, can increase your testosterone levels. And so without needing to take any exogenous hormones, I suppose, having that be something that you can do to improve your own sexual function.

Right. Yeah. And so, you know, one of the things that we looked at, and since now we're in the end of the episode here, this is the last section, was testosterone therapy for sexual functions, specifically. specifically in women. And there are patients that I have found elderly patients that I've found a little bit of testosterone. I'm not talking about like a male dose of testosterone. I'm talking about like a little bit of testosterone.

Will improve anxiety, depression, libido, energy levels. Tell me what you found when you were throwing studies around and stuff. Yeah, I think one of the. biggest things that I found was that it is safe and it does improve sexual function. I think with hormone therapy and women, a lot of people are concerned about just, you know, risks. And so there was the Aphrodite trial that showed, like looked at the safety profiles of testosterone therapy and showed that 150 to 300 micrograms of transdermal testosterone per day was the safest. And when following those protocols, postmenopausal women with loss of libido showed that it significantly

improved multiple facets of sexual functioning, including libido, sexual desire, arousal, frequency, and satisfaction of sexual encounters. And then also they found that addition of angiogens improved what they described as sense of well-being and other psychological factors. So, you know, we know that sexual health is important for people's general health. And so being able to have these conversations with patients and have things to offer is great. Yeah. So we'll put these studies up. You can take a look at these a little bit more in detail. You know, I actually first learned about this from a cardiologist who would see a lot of elderly female patients. and he was like testosterone was one of his like secret tools.

Yeah. His toolkit to making people feel better, to getting them exercising again. If they exercise again, they're more likely to have less cardiovascular events in the future. And so he got me interested in it specifically for elderly women, elderly men. And I find that it's like another tool in the toolbox. But before you just go out and prescribe it,

check out these studies, like do your own research because it's a little bit off label at this point and it also takes a little bit of nuance. If you are less maybe interested in doing it yourself, connecting with a local endocrinologist, having a conversation around what they would recommend or when it would be effective or not would be probably the best person to coordinate with. I myself feel comfortable doing it, but I would, and I haven't spoken about this, but I think before, as one of the small things that I'll recommend. Just because, like, for me, if they're working out and if they have a little bit of testosterone, it can make a big difference, or getting a male back into, like, the 50th percentile of men.

It's like you're not going, like, most people when they think of testosterone, and they're thinking about supra-super physiologic levels, that's not what we're talking about here. We're talking about getting people into the 50th to the 75th percentile of what it would look like for a man or a woman. And so, you know, if you're interested, read these studies and look at the safety data that's coming out. And maybe in the future I'll do a full episode if people request it. Wow, that was a lot. If you're still listening to this, like, send us a message on Instagram.

What's your Instagram handle? Rachel Anjene, R-A-C-H-E-L-A-N-J-E-N-E. I'm bigger on Twitter than, or more on Twitter than Instagram. We'll put those at the bottom of this so people can connect with you. If you follow the link to the Psychiatrypodcast.com to the article that goes with this episode. there's an article every episode. And if you want to get CME for this, neither of us have any conflicts of interest. And we are more than happy to have you join our monthly or year.

It's a yearly membership for CME. And you can get CME for this. It's probably going to be more than what. This is about two hours. So maybe about two CME. It's one CME per hour that you can get. And so I hope you enjoyed this. reach out to us, let us know, tweet at us, that you checked this out, that this was helpful,

and we will be enthusiastic that you listened and that you paid attention and that you have some thoughts to share with us. So it's always good to get feedback. And yeah, we'll leave it there. All right, if this wasn't already long enough, I had a thought with my assistant here, Trent Jones. he's my audio engineer and he's also a strength coach he's been a strength coach for a number of years and we've journeyed in strength together and we were listening to the episode he had edited the episode and he was like you know i think one of the things that's missing from this is just kind of a theory of how to get strong and what it might look like to work out in a progressive way that would optimize your chances to get strong. And so if you were, if you've, if you've listened to this

far, you know, you may be like, well, I don't, I don't really have any background. Or maybe you do have a background in some sort of like sports in high school. But I didn't really learn this stuff till after, you know, much further after being an MD. And so we're just going to talk in generalities. So Trent Jones, welcome to the podcast. Hey, thanks for having me on. It's been a few years. Yeah. Trent Jones was on on a prior podcast if you want to go back in the catalogs and listen to them. It was on strength training as well. That's right. Yeah. Yeah. So since then, I have, I've been coaching people myself as opposed to just being a lifter. And yeah, I've been doing that full time for the last few years. So yeah, I thought it might be helpful to talk today about

what does a Strength and Conditioning Program look like in terms of sets? reps, what kind of weights do you do, what kind of exercises would you do, for those of you who aren't familiar with how this process works. Yeah. So let's kind of start with maybe a healthy, you know, 20 or 30 year old and then we'll progress to someone who's older. Yeah, I like that. Yeah. So we'll kind of sketch this out as here's what's optimal. If you could do the full shabang and get the most out of your strength training. Here's what's optimal. And then later on, we can talk about how you would adapt the program

if, for whatever reason, you can't do the full progression. So first of all, we should talk really quick about a common term that we use in the strength world that means something a little different than what it does in other field. So when we talk about training people, most people who are coming to strength training for the first time are novices. right and they're novices not because they're brand new to strength training they're novices because of the way that they can progress so we consider a novice in this field to be someone who can lift can do the main barbell lifts and add weight to the bar and progress on a regular basis every single

workout right and so that's important to know because um most people i'd say you know you know 99% of the people you're going to run into are novices. And like myself, you may have been in the gym for 15 years prior to starting a true strength training progression. And just because you have that experience under your belt doesn't mean that you're not a novice. You're still a novice until you have run a progression to its conclusion. Right. So let me say that a different way. It's like a novice is someone who can work out Monday, like maybe squat three reset to five, and then on Tuesday they take off, and then on Wednesday they squat again, and they add five pounds to the bar. And from Monday to Wednesday, they've recovered enough

to be able to add that weight and to be able to progress. And then they can lift again Friday, and they can add another five pounds to the bar, five pounds more than they did Wednesday. And then they can come back Monday, and they can add another five pounds to the bar, and then Wednesday, another five-pound. And I mentioned this for two reasons. One is because a lot of my patients who go to physical therapy, they may be doing physical therapy twice a day

or even every day. And so that's not optimal actually to gaining strength. Doing the same exercises twice a day or every day is actually not optimal. Right. That's right. We have to give the body some time to recover. And so part of what makes strength training work

is that when you do an exercise, it has to be hard enough to drive progress, right? It has to constitute enough stress to drive adaptation. And the adaptation that we're looking for in this case is to get stronger, to build more muscle mass, to build more bone density, to build more stronger connective tissue in the joints, to build better central nervous system recruitment, right? you know, to build our body's ability to fire a bunch of muscle mass at once, right? And so in order for a strength training program to work, it needs to be stressful enough per workout.

And so if you're doing a heavy workout, remember heavy is going to be relative to where you are. It might be 45 pounds. It might be 400 pounds. Both of those can be heavy for different people. But if you're going to do something heavy, you've got to have time to recover from that workout. And the recovery phase, when you're resting between workouts, that's where the adaptations are actually made. That's where your muscle tissue is rebuilding. It's remodeling, and your connective tissue is getting stronger. Yeah. Okay.

So then imagine now your client is not 20 or 30, but they're more like 60 or 70. How does that change things? And one thing to say about Trent is he has worked very closely on. a podcast called 40 Fit, right? That's right. Yeah, it's called 40 Fit Radio. FortyFit Radio. And he is the co-host of that. And Darren, one of the host, is a physical therapist. And so he, like, this is all he does. And he is one of the best in the field. So go ahead. That's right. Yeah. So Darren Deaton was the main host of that show. And he's my mentor as a coach. He's been a doctor physical therapy for 30 years at this point. And yeah, both of us worked pretty extensively with people over 40. So a lot of the people I coach and I teach to

lift weights, to lift the barbell are in their 50s or 60s. And I've even coached some people in their 70s. So yeah, it's a good question. Well, you know, oftentimes someone can do three days a week of strength training if they're in their 60s or 70s. However, what you will find is that they will they will not be able to progress as long as someone could when they're 25 or 30, right? Their body's ability to recover, to add muscle mass, to grow more bone density, it's just not there anymore. And so we'll have to change the program to where they're not adding weight as frequently much earlier. That might happen in one to two months. That might happen in three or four weeks even for someone who's older versus a younger person that might be able to run a base

program for three, four, five months. What I've also found in a lot of cases is that someone who is older, particularly somebody who's in their 60s and 70s, is two days a week can be a great training split for that person. So they could train on, let's say, Monday and Thursday or Tuesday and Friday. And so therefore, they have multiple days of rest in between their strength training workouts. And that can work great because oftentimes people at that age, they feel like it takes a few days for them to feel fully recovered from the heavy lifts, in particular the squat and the deadlift. Yeah. Yeah, I see that in a similar way. And so by increasing the gaps from like one day off in between to two days, it can make a big difference. Right. But I think that most people

underestimate that they can still progress and still add five pounds of the bar each time. I have this elderly patient that I've had someone coach her. And, you know, she weighs about 120. And she is probably going to listen to this episode. And so she's very dear to me. But she broke 100 pounds on her deadlift. And she is, I will say, somewhere in her 80s, just to keep Oh, that's fantastic. So imagine someone who is not living a very mobile life, but has been able to increase her mobility quite a bit just by being very consistent over the course of about two years.

Yes, yeah, that's fantastic. And you bring up another good point. One of the things that changes from a younger person to an older person is the rate of progression. So that's one of the beauties of using a barbell to, to do strength training as opposed to a machine or even a dumbbell is that we can load a barbell with very low weights. In fact, in my gym over here, I have a wooden dowel to use as a barbell. It weighs about two or three pounds. And so I've used that before with old elderly clients that cannot press a light barbell. A lot of the lightest barbells that you'll encounter out in the

world are 10 to 15 pounds. Sometimes that's too much, right? So I, I have a wooden dowel that's weighs a couple pounds that people can use, and I can strap some small weights to it. So we can start very low. We can also start very, very heavy, right? You can load a barbell well in excess of 1,000 pounds, well beyond what any normal person is going to be able to lift. So it's extremely versatile. And that's another thing that we can do with an older client is when you're training, you don't have to add 5 pounds to the bar. You could add 1 pound at the bar.

And that's often what we do with someone that's in their 8. 80s. I imagine she probably got to a 100 pound deadlift one to two pounds at a time. Yeah. And I would say also when we think about legs, legs are a big muscle group. And so it's normal for a healthy 20 or 30 year old to add 5 pounds to bar each time for the leg muscles. When we're talking about smaller muscles like shoulders, it might be more like one pound or half a pound. That's right. Yeah. Even for your young women, it's very common to, after, you know, they may make five pound jumps on their upper body lifts for a few workouts. And it's very common, even for younger women, to move to two and a half

pound jumps after that, and then one pound jumps, and then sometimes even half pound jumps from workout to workout. Just because, yeah, the muscles are smaller. There's a longer range of motion. And it just, it takes more work to get a smaller amount of progress with those muscle groups. Yeah. So what do you think about? Let's get down to kind of the nuts and bolts of what the program actually looks like the way that we typically would structure it. Okay. So we usually start with a novice with a full body split. In other words, we're going to train the entire body in a single workout. And we do that with a few basic barbell lifts. That's our preference. And the reason why we use the basic barbell lifts are there's many reasons. One of them is one I already mentioned is that we can adapt, we can adapt the weight that we're using to a very fine degree, right? So we can start as light as we need to,

and we can go as heavy as we need to, and we can make very finely graded jumps that match whatever is appropriate for the trainee. But the other reason we use barbell lifts is because we can train the entire body with just a few movements. Whenever you do a squat, for instance, just about every muscle underneath the barbell is being loaded in some way. It's primarily a legs exercise and a back exercise.

However, your upper body that's supporting the bar and a squat is getting some work, right? So it is a full body exercise. And the same thing is true of the other main lifts that we use. So let's talk about those really quick. We have basically four exercises we start with. The squat, the press, and when we say, press, we mean the overhead press, sometimes called a shoulder press. You press the bar overhead to lockout. The bench press, where you lay on a flat bench and press the bar down to your chest

and back up, and then the deadlift, where you pick the bar up from the ground up to a standing position and then lower it back down to the floor. So just four basic lifts. And a full body split looks like this. Day one, we're going to call this workout A. The trainee is going to warm up with the squat, and then they're going to perform three sets of five squats. And we call that at their work weight, right? So they do whatever warm up they need to prepare for the work weight, and they do three sets of five at their given weight. Now, if I have somebody in that's never lifted weights before and they've never done a strength training program before, the first day we're going to figure out what their starting weight is. and there's a few different ways to do that,

but it's going to be something they can perform with good technique that's a little bit challenging, but it's not super challenging yet. We want to make sure you've got plenty of blue sky ahead of you to progress and add weight to the bar. Okay, so they're going to do three sets of five in the squat. Then we move to an upper body lift. They're going to go to the overhead press, or just the press, and do three sets of five the same way,

at whatever weight is, it constitutes a little bit of a challenge, but not a lot of challenge. And then finally, we'll finish with the deadlift, and we're going to do that for just one set of five. And the reason there is that the deadlift is, you know, because you're able to use your posterior chain, your lower body, your back, you're able to use big muscle groups of the body, you can generally perform a deadlift heavier than you can, the squat, and certainly much heavier than you could, the upper body lifts. And so we have found through experience that one set of five on the deadlift is enough to drive progress for a long time. And so that's it. You just do three basic lifts. And the warm up for each of these lifts is the lift, right? So if you're

going to warm up to squat, what we do is we warm up using light squats. So, for instance, if I was going to work you up to a 135-pound squat. You would start by squatting the empty bar, which weighs 45 pounds. A standard barbell weighs 45 pounds. You would do a couple sets of five with the empty bar, and then you add a little bit of weight to it. Maybe you go to 75 pounds,

and you would do another set of five. And then you would add a little bit more weight, maybe 95 pounds, and do a set of, let's say, three. And then you finally do a set of two, at let's say 115 pounds. So we have stair stepped you from a very lightweight up to a heavier weight

and that process has prepared your body it's warmed up your joints, it's warmed up your tissues, and it's prepared your nervous system to perform your work for the day which is three sets of five at 135 pounds. And you can follow that same template

for the other lifts that we do in a given workout. Yeah, excellent. Yeah, I don't have much to add there. Yeah, so you alternate bench and press. So maybe on the first day you do bench, on the second day you do press, on the third day you do bench, on the fourth day you do press, and you go back and forth.

And that seems to work out well. So your squat and your deadlift continue to progress. And like Trent said, and this may surprise you. But novices, some often can progress for months before they stop progressing. Yeah, that's right. That's right. So think about the math really quick. I think this is really cool.

So think about the math. We'll make it easy and we'll make five-pound jumps. So let's talk about the squat. So if you start day one and let's say you just squat the empty barbell, 45 pounds, and you add five pounds the next workout. So on Monday you squat 45 pounds for three sets of five. Wednesday you squat 50 pounds for three sets of five. Friday, you squat 55 pounds for three sets of five.

Right. So essentially in that model, you're adding 15 pounds a week to the bar, right? Because the next week you're going to add five pounds, five pounds, five pounds. Well, do the math really quick. If you add five pounds every workout to your squat, that's 15 pounds a week. In one month, you'll have added 60 pounds to that lift. right in two months 120 pounds

in three months 180 pounds right so it doesn't sound like much making these small jumps but you can see that pretty quickly after a few months of this progress you'll be lifting far in excess

of what you've ever done before right and so that's the linear progression is a very that's what we call a linear progression right so we are linearly increasing the weight every single time you work out and it's a very powerful stimulus

because it's simple. It's also, it's, it's a, it's a small enough jump from workout to workout that you can maintain your technique when you lift. That's very important. We don't want to increase the weight too quickly and then risk your form breaking down during the performance of the movement. That's no good because it makes, it makes it harder to lift the weight when you're not moving the bar efficiently, and it also could predispose you to getting some tweaks or injuries, right? And nobody wants that. So by making these small jumps,

it gives you a chance to learn the movement, to perfect your technique in the movement. And then also, I find there's a mental aspect to it, too. Especially when you start approaching weights that you've never done before, you can go back to the fact that, okay, I've never squatted 135 pounds before. This is, it's scary the first time you do that. But you can remind yourself, why did I get here?

Well, last week I did 130 pounds. And the workout before that, I did 125. And the workout before that I did 120. So I've prepared myself for this moment to lift 135 pounds. Even though I've never done it before, the process that got me here gives me confidence that I can do it. and I can push myself to do something I've never done before. Yeah, and this is the part of the podcast that we were talking about,

like fear deconditioning, doing something that is progressive and a little bit scary, but over time it decreases your fear, which I think plays out in other areas of your life as well. Absolutely, absolutely. Yeah, we talked about that a little bit in an episode I did years ago about overcoming depression and finding some healthy assertiveness in my life. Yeah, and in fact, sometimes what I have done as a little exercise is, let's say I'm adding five pounds, and I'm now hitting a weight that I've never done before.

Sometimes I will go over to the rack, and I'll pull out a five-pound plate, and I'll just hold it in my hand, and I'll remind myself, okay, I've already done 200 pounds. I've done that before. I know I can do that because I already did it. It's just five more pounds. You can hold that little plate in your hand so that that's it.

That's all we're doing. We're just adding five pounds here. I can do that today. And yeah, I found that to be a very powerful exercise physically and mentally. Yep. So, okay, let's kind of, this is a short little addition to this. One thought that I have is like, let's say you are listening to this and you're like, well, I don't really, I don't really have a coach.

Can I start with something simple? And the answer's, yeah, like, what? whatever you have, you can start with. But just think about slow progression. Think about you're probably a novice until you progress. And I think it's wonderful to get a good coach. If you even do it for three months, I think it's a good investment, especially technically. Yeah.

Yeah, so let's really quickly. Let's address that. So there's a couple of assumptions that are very important that underlie your ability to run a linear progression like this. So one assumption is that you have good technique. When you're talking about lifting a barbell and doing these four basic exercises we talked about, they might be basic exercises, but they're not easy.

They're, in fact, they can be fairly complex, especially if you don't, if you've never had experience, you know, if you haven't had much athletic experience before, performing a squat correctly is not easy. And it often takes a good coach to get you to do it correctly. Now, luckily, there's a lot of good resources out there on the web where you can see videos of, you know, how to perform a squat.

Some are better than others for sure, but actually learning to perform it, it takes time. And that's part of the reason why we start people light is I don't want to start you at a weight that's very challenging day one because you're probably not perfectly proficient at the squat. it takes frankly it can take people months to perfect the squat but you can get yourself to a very good squat within the first few workouts with with a good coach and so so that's number one is your technique needs to be good because if your technique is poor you're not going to have the right mechanics you're not going to be able to move the bar efficiently enough in order to continue

to add weight to the bar your technique will get in the way of your ability to progress even if your body can adapt to the stress of the movement. So that's one caveat there. The second thing is you need to be eating enough to recover from the work that you're doing. Now, in the first month or two of a linear progression, a lot of the adaptations that are taking place are neural, right? Your brain is learning how to fire neurons in the right pattern to produce a squat, to produce a deadlift, to produce a press. So oftentimes, you know, you don't need a lot of calories and nutrition to fuel training in the first couple months. However, as the weight gets heavier, you'll find that if you're not eating enough, especially

eating enough protein and carbohydrates, then you might start to miss lifts in the gym because you're simply not giving your body enough nutrients to recover from the hard work. And it's significant. I think people who have lifted for several months have noticed that often their appetite goes way up because their metabolism is increasing with the new muscle mass they've put on their body and the higher amount of workload that they're doing day to day. So if you can't do that, you can still take these same principles that we've outlined here and use them with any training program, right? You mentioned that progressive overload. So if I have somebody that for whatever reason can't perform a squat or they can't get coaching, to learn how to do the movement approach appropriately.

You could do a leg press, right? You can do a machine that allows you to train your legs. And I would do the exact same process as I would with teaching someone to squat. I would find a weight that you can do that's a little bit of a challenge on day one and then start adding weight to it every time you work out and you do a leg press.

Yep. And you can follow that with just about any exercise. Yeah, so sometimes I'll have yeah it's like easy find easy exercises like lunches or something like that and maybe they have some weight at home like some barbells it's like okay do three sets of three

or whatever they can do and then we're just going to every other day we're just going to add one rep you know so it's three sets of four three sets of five three sets of six so I sometimes modify it for the person I mean it's not the ideal scenario but

you know it's always like what does the person have that we can use and starting there. Hey, let's wrap it up, though. This is awesome. I just wanted to get Trent on real quick to kind of just give some basics, right? Because I think with a little bit of knowledge, you can go a long ways. So yeah, any final thoughts, Trent, before we kind of wrap it up? Yeah, no, I think that's great. You know, so just remember there's basic principles that underlie any good training program. It doesn't matter what the specifics are. Every good training program is going to have. some amount of progression built into it. And that's what's going to drive progress with your fitness.

It's progression over time. Awesome. Thank you so much, bud. And we will talk soon. So I hope you enjoyed this very long episode. And thank you, Trent, for your years of editing audio. It's been, you know, I'm just waiting for one person to write a review on iTunes or something saying, I really appreciate the audio engineer. If you're listening to this and you have some love for Trent, put it on an iTunes review, and I will show it to them. So let's look at that. Well, thank you.

It's been great to share both of my passions in life with you. So thanks for having me on again. All right. Take care.