The Peter Attia Drive - #196 - AMA #32: Exercise, squats, deadlifts, BFR, and TRT

Episode Date: February 21, 2022

Become a Member to Listen to the Full Episode View the Show Notes Page for This Episode Episode Description: In this “Ask Me Anything” (AMA) episode, Peter shares his current workout regimen and how he incorporates blood flow restriction (BFR). He walks through the mechanics and fundamentals of some of his favorite lifts including squats, deadlifts, and hip thrusters and stresses the relative importance of each in the context of longevity. He touches on the relative importance of muscle size vs. muscle strength and discusses the impact of fasting on muscle mass and the potential tradeoffs during aging. Peter then dives into the topic of testosterone replacement therapy (TRT) for both men and women, starting with a clinical discussion around how he actually replaces testosterone in patients. He explains the targets of this therapy as well as the risks and benefits, and he gives his interpretation of current data on the association between TRT and heart disease. If you’re not a subscriber and listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA#32 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: Peter’s current exercise routine [2:25]; How Peter incorporates blood flow restriction (BFR) into his workouts [5:45]; Relative importance of muscle size vs. muscle strength [16:45]; Comparing squats to deadlifts and why both are important [22:00]; Squatting technique and fundamentals [31:15]; Important cues to look for while lifting weights [38:30]; Proper mechanics of a deadlift [42:00]; Hip thrusters as an alternative to the squat or deadlift [44:00]; Split-leg work for simulating activities of daily living [47:00]; The impact of fasting/calorie restriction on muscle mass and the potential tradeoffs to consider [49:45]; Testosterone replacement therapy: considerations when contemplating TRT and Peter’s approach with patents [54:30]; Data on the association between TRT and heart disease [1:04:15]; TRT for women—risks and benefits [1:06:45]; Impact of fasting on testosterone levels [1:13:45]; and More. Sign Up to Receive Peter’s Weekly Newsletter Connect With Peter on Twitter, Instagram, Facebook & YouTube

Hey everyone, welcome to a sneak peek, ask me anything, or AMA episode of the Drive Podcast. I'm your host, Peter Atia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to PeterittiaMD.com forward slash subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. Hey everyone, welcome to Ask Me Anything episode number 32. I am joined today for the very first time on this podcast by Nick Stenson, who you'll get to know during this episode,

but basically Nick has been working with me well, often on for 10 years, but he's been working with me specifically around the podcast since we decided to do this, which is got me coming up on four years ago. It was in the spring of 2018, I think when we made that decision. And Nick is gonna be taken over for Bob on the AMA.

It's a totally different vibe, but we had a field day. I felt this was probably a little bit more conversational. And the hope is that because Nick is quote unquote a lay person and doesn't have the technical background that Bob does, that maybe he'll be interrupting me more and asking more questions. And maybe that will provide a more valuable experience. So in today's episode, we talk about a bunch of things.

We started off by doing some follow-up questions on blood flow restriction, which we had some great questions following the podcast with Jeremy Linnike. I think we go from that then into talking about some of my favorite lifts, so squats, dead lifts, and hip thrusters, though not through the lens of blood flow restriction, but just more broadly talking about the importance of those lifts, how they fit into the overall ballpark of a centenary and Olympic training program. And after a pretty deep dive on all things related to lifting, we get into testosterone replacement therapy, both for men and women. So we double click on some of the things we discussed in the previous AMA on testosterone

replacement therapy, specifically around the risks of cardiovascular disease, but also we do a little bit more of a clinical discussion around how we actually replace testosterone, what are targets of therapy are, what are some of the dos and don'ts. And then we actually get into some questions about females and testosterone replacement therapy. This is an area for which we have far less data, so there's a little bit more speculation, but we also talk about that. If you are a subscriber and you want to watch the full ready this podcast, which again,

I generally recommend you do because we go through a number of figures here, you can find it on the show notes page. And if you're not a subscriber, well, I hope you become one, but you can certainly watch the sneak peak of this video on our YouTube channel. So without further delay, I hope you enjoy AMA number 32. All right, well, here we go. Another AMA, of course, I'm joined with a new co-host for this episode, Nick Stenson, and Nick will save the intros till the end. But you ready to jump into this?

Yeah, let's do it. We compiled some good questions here. I think it should be a fun one. Yeah, you showed me the list that you were working on, and it's got me a little overwhelmed. If we can get through it, I'll be super impressed. But you've got a good, great question. So just tell me where you want to start. So we got a lot of good questions following the germinoliniki and some of the exercise podcast. So I thought we'd kind of start there and there's some blood flow restriction questions. But I thought it might be helpful for people before we get into some of those specifics. Just what does your current exercise routine look like

each week? I know it's always changing, but if you can give people a rough overview, I think that will be helpful as we get into some of these other questions. Yeah, I mean the actual macro structure of what I do has not changed much in the last year. The microstructure has changed a lot,

meaning the exercises have changed a lot. But the microstructure is that on, let's see, Tuesday, Thursday, Saturday, Sunday, are cardio days. So Tuesday, Thursday, Sunday are zone two. Saturday is either a zone two, followed by a zone five, that's kind of a separate workout. So each of those are 45 minute zone twos is either a zone two followed by a zone five, it's kind of a separate workout. So each of those are 45 minute zone twos

and then kind of like a 30 minute zone five as a separate workout that's done almost immediately after. So basically getting out of bike clothes and putting on stair climbing clothes. Alternatively, I might just do a longer bike ride on Saturday and make it more of an anaerobic workout. Then from a lifting standpoint, it's Monday, Wednesday, Friday, Sunday is lifting and about, I don't know, nine months ago, I switched to an upper body lower body split. I used to lift three days a week and do upper body

lower body every day, so each day I was doing kind of pushing, pulling and hip hinging. And now the lower body component, I think, is Monday, Friday. The upper body is Wednesday, Sunday. And I always lift after doing cardio because I think the reverse has been demonstrated to a road strength training gains. Peter, what happens if you miss a day? Because I noticed you didn't say day one, day two, day three, you were very distinct on the days of the week.

I know you typically don't miss a day, but I was on the track the whole day and I knew that in advance. So I just ended up doing that lift on Saturday, but obviously was short-changed on the zone too for yesterday. So I will pretty much will never compromise a lift. I will always get those four lifts in during the week, no matter what. And sometimes it just means moving the days around or doubling up on a different day. And what about timing? Do you have a preference morning, afternoon, evening?

Is that flexible as well within kind of your schedule? A little more flexible on weekends, but Monday through Friday and pretty much no flexibility. Those lifts have to be done first thing in the morning and not first thing in the morning. So morning routine is kind of more about the kids and stuff like that. But once they're out the door to school, around 715, 730, that's one I'll typically lift. Got it. I know from the German Lennike podcast, you were talking about how you were starting to incorporate blood flow restriction. So I think one of the main questions we saw from subscribers after that was, how are you utilizing that into interior exercise program?

Is that something you do every day? Is it days like you mentioned where you were just not really feeling it and it was injury prevention or if you had an injury, you were trying to recover? How do you utilize that throughout the week? So I have really enjoyed blood flow restriction, especially since I got new cuffs. So when I started, I was doing it purely ghetto style. And I still, I enjoyed it, but I wasn't even coming close to tapping into sort of what the potential of that was.

For the last, oh god, probably three months, I've been using the brand is actually called Smart Cuff. And it's a night and day difference. So they're kind of absurdly expensive. I don't remember how much they cost. I want to say like $600 for the four cuffs, two upper body, two lower body, plus the device, which is what really makes it so essential,

meaning the device that is measuring inclusive pressure and pumping each time. But it makes such a difference that in my mind, it's just totally worth it. I do plan to try a couple of other devices out. There's even more extreme versions of this that apparently have better features, like the Katzu one, but my guess is

there will be no bigger jump than the one I took from going from basically $20 junky bands to these ones. And so I do BFR every day that I lift and I just do it at the end of the workout. I'll typically do one to two exercises depending on the muscle. So today, for example, at the end of a leg session, I did a BFR leg press set. At the end of an upper body session, I'll probably do a biceps set and a triceps set. And I'm always doing it in a way that we discussed on that podcast, but just for folks to remember, it's 30 reps,

rest 30 seconds, 15 reps, rest 30 seconds, 15 reps, rest 30 seconds, 15 reps. That is the standard prescribed procedure for BFR. You're doing this at a weight that is 30 to 40% of your one rep max. So the easiest way to calculate that is to take the weight that you can barely get 10 reps with. So what is your best 10 rep weight? Divide that by 0.75. So your best 10 rep weight is about 75% of your 1 rep max. And then you multiply the resulting figure by somewhere between 0.3 and 0.4 depending on how strong you are. So use an example. If your best 10 rep of curls is 40 pounds, you would divide 40 by 0.75, which what is that that takes you up to 57 or something I'm guessing. And then

you would multiply that by somewhere between 0.3 to 0.4. I typically tend to go closer to 0.4. That becomes the weight that you'll use for the BFR. With these smart cuffs, you have a whole additional variable, which is it comes at three different pressures. So it calculates the pressure. And again, just for the refresher for folks, the purpose of blood flow restriction is to operate at about 30% of the occlusive pressure, the arterial occlusive pressure, which when you're using kind of crap, you know, just bands, you don't really have a sense of which your occlusive pressure is, unless you're applying a Doppler signal to your distal extremities, which is very cumbersome. Instead, when you use these cuffs that come with an inflation device, they're actually measuring the inclusive pressure.

So the first time you do it, it takes a little longer. And then it says, okay, now I know what it is for your arms and your legs. Do you want to go at the highest level of intensity, medium level intensity, or a lower level of intensity, which basically just adjusts the pressure? And you mentioned Doppler signal for your other bands. Can you just remind people what that is in case they're using this with cuffs that don't have kind of what yours have? Yeah, the Doppler device.

You'd have to buy one. And that's the reason I think like if you're going to go to the trouble to buy a Doppler device, you might as well buy a smart cuff or something similar, but it's basically a medical device that we use to use in the hospital all the time. When you can't feel a pulse, like if you put your hand on your radial artery here, you can feel the pulse, hopefully, if you're healthy. But in people who have peripheral vascular disease, you can't, because their pulse is too weak. So the Doppler is basically, it looks like a little pen, you put it there with a little bit of jelly, so it has better sound conduction. And it's basically sending a sound signal to the artery and it's recording that sound.

So when there's complete occlusion, you'll hear nothing. And if there's only partial occlusion, you'll hear like a woo, woo, woo, woo, and it's sort of picking up that sound. So what you would basically do is use this device to figure out how tight to go, but of course, then you use this device to figure out how tight to go. But of course, then you're trying to figure out how tight to make the band to get to that occlusive pressure.

And then how do you even know how to back off it? So you'd have to use a cuff that at least allows you to know how many millimeters of mercury you're putting in to figure out what complete occlusion is and then backing it down. In my opinion, it's just not worth doing that. No, that makes sense. One of the things I was surprised by because I was in your gym another day and was just the difference between the two cuffs. And I think because of that, I asked you to pull them out just so you can show people. Do you have them quick? Yeah, yeah. So these are kind of what my cheap $20 cuffs were that I used for many months. You have two of these and you would

gonna wrap them around your arm and your leg and you sort of look like a bit of a heroin addict because you're sort of like, I'm trying to squeeze this thing. Again, I would just york on them really hard until, I would, my guide was once it hits seven out of 10 pain, that was probably the right spot, but I find that's very inaccurate.

The current cuffs, this is the arm cuff. So it's obviously a much more rigorous cuff and you apply this, slap it on, then a little device hooks onto here that hooks up to a little pump. That's where I program this thing and that will achieve the occlusive pressure. The other thing I really appreciate now is like, look at how thick this thing is just will achieve the occlusive pressure. The other thing I really appreciate

now is like, look at how thick this thing is just for the arm, right? Look at the leg one, like totally different, right? Because I could never get, I was never really doing BFR for my legs when I had that little blue thing. Whereas with this thing, wow, you get it, you really are getting the true occlusive effect. And what are you using to measure the difference there? Or how do you know, like, it's working? How can you tell us it just feels? Subjectively, yeah. It's not hurting where the band is compressing me. I'm feeling that

sensation of basically lactic acidosis throughout the entire leg, as opposed to just the pain of being constricted where the band is when it's a thin band. It's interesting to note the pressure of occlusion is much higher than systolic pressure because it's a function of how wide the band is. So I noticed today when I did my legs, the occlusive pressure was 158 millimeters of mercury.

Well, that's way above my systolic pressure. My systolic blood pressure is very low. I tend to run super low in blood pressure as evidenced by the fact that I face planted in Brazil last month. And my upper body occlusive pressure with those cuffs is about 58 millimeters of mercury. So you have one that's like,

or sorry, 94 millimeters of mercury. So you have one that's like, or sorry, 94 millimeters of mercury tends to be a approximate occlusive on upper body, 154 or something, 158 on the lower body. But again, it's also a function of the width of the cuff. So that's why I realize just knowing your blood pressure isn't enough to do this. Yeah. And you mentioned you always do it at the end of the workout. I assume that's purposeful. Have you ever played around with like prior to your actual workout? Maybe others could speak to it. For me personally, I just think when I'm doing my heaviest, most neurologically demanding component of exercise, I want to be a little fresher. And I don't want to be as taxed, whereas I kind of like using this as sort of a finisher, or near the end.

Sometimes I'll do, I'll still do something after this, but you know, like I'll do a dead hang is usually the very, very last thing I'll do. So I kind of mixed up a bit. You'll never do a dead hang with a BFR couple. I tried. It didn't, it didn't matter. It didn't, it didn't impair the ability to do it at all, because the dead hang is really about grip and that didn't seem to be impaired by the upper body BFR

But I have tried it once. What's your record for dead hang these days? Like a little over three three ten Cheers, but that's at the end of a workout and I think you know if you do these fresh I think you can go a little more. Yeah, do you have a goal set in mind that you want to hit? I was super happy to get over three. I mean, most days when I do it, I just want to go to two, two, 30 and not go to failure and just kind of build strength without failing every time.

Lately, I've been doing a lot of finger pull ups. I think I showed you that device. Yeah, that thing is super painful. Gives you a new respect for those climbers. Oh, that was thing I thought of because walk people through you're not doing all four fingers, right? You only are doing three and you're just straight in the pull-up position. I do both, so I'll usually start with four fingers, but that's very easy, relatively speaking. The jump from four finger pull-ups to three finger pull-ups is so much harder than I would have ever guessed. Oh, I can't imagine. And are you looking to do two finger and one finger?

Is that the goal? It's just to just lift yourself up. If I can do four sets of two three finger pull-ups at the end of doing, you know, maybe three sets of four four finger pull-ups, that's pretty good. For sure. One other question we had on the BFR was, do you ever do it in zone two training? Like have you ever played around with that? Thank you for listening to today's Sneak Peak AMA episode of the Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a member. We created a membership program to bring you more in-depth, exclusive content without relying on paid ads. Membership benefits are many, and beyond

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