Exercise AMA 

Paul: [00:00:00] Hey Howard, we're back and we're, for some crazy reason revisiting the same topic. .

Howard: [00:00:04] It was a popular  topic. It's a, certainly a very important topic. So I'm glad we're back here.

Paul: [00:00:10] we were talking, muscle mass and strength longevity, and it was remarkable how many people were, I had people tweeting at me emailing at me. I had no one stopped me on the street, but I did have someone screen grab a text from a friend and say, I just listened to that latest Kedrosky-Luks thing. And it was great.

Howard: [00:00:29] It's good to know is resonating with some people.

Paul: [00:00:32] Yeah, I'm big in the texting crowd apparently. So

Howard: [00:00:36] but we got a lot of questions from it. So I thought that was fascinating.

Paul: [00:00:41] So I'll S I'll spin the magic wheel of questions  and start us off. So one of the questions we got was if I can do only three things. What would they be? And I said, why three things for what? Like to get stronger, to get more powerful, to be build cardiovascular fitness. And he just, basically the guy tweeted back at me. Yes. Which is great. Where would you start?

Howard: [00:01:10] Yeah. So, Obviously, I need to know who the question is coming from and what they're optimizing for. Right. So we spoke to dr. Sam Milan, and he was fantastic and he made it clear that we need to 90 minutes zone two episodes a week to.

Build, on our mitochondrial base, right. To ink to increase the number. But how realistic is that? It's not for most of us, at least for those of us who work every day. and honestly, unless you're planning on. Cutting your hundred mile bike riding time substantially, or you want to try and rank and Hill climbing.

It's probably not that important. most people aren't maintaining the mitochondria they already have. So I always ask people, to focus on some aerobic exercise and it's really important. To remember that all the studies showing a decrease in all-cause mortality associated with walking revealed that it only needs to be 6,000 steps a day.

Paul: [00:02:25] Yeah, it's not a huge number.

Howard: [00:02:27] know, you could be a busy person. You can park in the furthest parking spot from work. you don't have to walk a straight path from your car to the front door. Same thing. When you leave,  you can take it dog out for a 10 minute walk and you're going to buy that by the end of the day, have 8,000 steps.

You don't have to jump on a bike for 60 minutes. You can jump on a bike for 20 minutes. you can pick up a pail of water and walk around your basement and you're getting your balance. training, by doing a semi farmer's walk while you're getting some aerobic work. So you have to be creative in these situations.

You have to figure out what time you do have, and you focus on what you can do, of the three things aerobic you want to get at least six, 8,000 steps a day. And, if you're. Over 45, you want to work on balance and of course, strength, and strength. If you're going to be very limited, some bodyweight squats, some bodyweight deadlifts, some calf raises.

and I think you're good.

Paul: [00:03:38] Yeah. Yeah. And then I think that's a. A great simplified view of it because it's, it's, it's got this misnomer that if you can't put in all of the hours, then I might as well put in none of the hours, which is just, I mean, a toxic relationship to have with your own health, right?

Howard: [00:03:55] Oh, it's terrible. cause it just compounds itself. and it's interesting. Cause there was someone at work who listened to our podcast and he's about 60 and he was professing. Look, I've had no changes. I don't know what you're talking about. I'm like, well, besides being a doctor, I'm like simple. Do you find it harder to open jars now than you did a few years ago? Yes. Yeah. Okay. Then I don't have anything else to say.  these things, they creep up on us just as we discussed.

Paul: [00:04:26] Yeah. And all of a sudden, as you said, yeah, then it's there. Okay. So a quiz question, by the way, I was just looking after your comment on steps. How many steps did Paul have today? One, two, three go.

Howard: [00:04:38] 12,500.

Paul: [00:04:41] Well, that's a pretty good guess. 14, eight Oh five. I just noticed here. That's very sweet. That's very to use this term, the technical term, very steppy.

Howard: [00:04:49] So I had 11,400 and I operated all day.

Paul: [00:04:54] Yeah, that's amazing. What will you do? Will you just pacing around the theater?

Howard: [00:04:58] so I do a lot of walking around the hospital between cases. I won't sit, I'll walk the floors, I'll walk outside. I park in the furthest spot from the door. I just push it.

Paul: [00:05:10] Yeah, but that's, that's really, I mean, to be more serious, that's a really instructive example though, right? Because you're, you're tied down to whatever you had two or three cases today that you were operating on and, and you,  you've got other things going on and yet you still managed to get in, Oh, well, well over 10,000 steps in the day.

Howard: [00:05:28] Correct. You can do those.

Paul: [00:05:30] So the next question spinning the great wheel of questions again. and this is one I hear a lot and I had people say, say it to me on something else that we did. I don't remember what it was, but anyways, they basically said Paul you're freakish. You're motivated. I'm not motivated. How do you, how do you stay motivated now? I'm going to give my own partial answer to this right away. Cause I only realized this is classic me. I only realized relatively recently how freakish I  am about this stuff that I enjoy suffering when I'm running or biking, I actually find that hugely pleasurable. If I'm just,  rolling along with the wind, tousling my hair, it mostly makes me miserable. But if I can, if I feel like I'm working hard or at least working on a system. Stain basis that I'm putting in a real effort to the point that I can't think about too many other things other than what I'm doing, whether it's a run or a ride or whatever else.

Now, this is just cardio stuff, but it applies in some similar ways to weights. I'm not very happy. I used to think that,  the problem was that most people just haven't discovered the wonders of suffering because if they did, they'd be converted like me, but I've realized to my chagrin that I'm just wrong. That most people actually, even when you reveal the eternal wonders of suffering, they just say, yeah, no, not for me. That's not my thing. So that's hence this question about how do you stay motivated is not my problem, but I, a hundred percent is a legitimate question.

Howard: [00:06:56] it's a very legitimate question and it's really hard to incentivize some people to do it.  hell I look at pictures of my kids every day. we know how. Pretty terrible. This world is. And how often they're calling us or writing us and asking for advice. so certainly my strongest motivation is to be around longer, for them, and be able to interact physically with them a second.

I don't want to have to be walking around with a limp, with a cane on five different medications, and just watching my scale go up. so I find that motivation, to live longer and live healthier, and promote my lifespan and health span together simultaneously. Very motivating. and look, we won't get through to everyone deep down.

Everyone knows they need to do it. I think deep down, most people want to do it. the key is to just. Get them to start, because a lot of them will get hooked, whether it's that, pain that you feel. And I feel we  like on some strange level or just the feeling that it's easier to walk up and down stairs. You're not sure to breath. It doesn't feel like an effort. and you start to see the gains.

Paul: [00:08:25] What about short-term stuff? Cause I said something similar to someone recently about,  your kids and this and that. And they said, yeah, yeah, that gives me a motivation in the long run, but like it's Tuesday at eight o'clock and I don't want to do.

Howard: [00:08:36] do

Paul: [00:08:37] Anything what's like a daily motivation I could have.

I said,  and this, you just alluded to it right there, but just the idea of one to start. I mean, I don't know whether it's Snapchat or Instagram. I get Snapchat. One of them has this idea of a streak that everyday it rewards you and says, Oh, this is your umpteenth day in a row of sending out something dubious on Snapchat. They don't use the word dubious. I do. And, I said, think about it in those terms. Think about how the little dopamine hit you get from a streak of continuing to do something that, that same idea, but just in being active, that's why this idea of a street can apply a perfectly well to just your day to day motivation to continue doing what you did yesterday.

Howard: [00:09:20] W,  w we game-ify everything. We can certainly gamify this and, and kudos to Peloton for  nailing it. Now,  they added these high fives and. You go on a ride and everyone is high fiving. You and the only people who I high-five are the people who I'm about to pass. but,  it D it, it is, is motivating, I guess, on some level.

Yeah. but  it's at first, when I approach it with them, I tell them I don't want it. You to necessarily be motivated at first. You're not going to be okay. right. We get used to our Monday and tasks and our schedule. We get used to rolling out of bed and grabbing coffee and looking at our emails.

You have to force it, you know? So the first few weeks you force it instead of, instead of turning on that computer, go down to the basement. Or go outside, schedule it and do it. And for most people they're going to like it and they're going to stick with it some aren't and it's going to remain the grind. And I'm sorry for that, but

Paul: [00:10:23] not my problem. Sadly, maybe it should be more of a grind. My wife asked me the other day, she said, what are you training for? I'm like, what do you mean my training for nothing? Just, just training for being,

So the next question spinning the great wheel of questions again I had a funny question, which I didn't. I think until just now that your, your, your last comment reminded me of, which was, I didn't even know how to answer this.

They said, what does it feel? Like I said, what do you mean? What does it feel like? What does it feel like to be fit? And I said, yeah, it's a really interesting question. What, what does it feel like to be fit? And I said, And this is my answer. Not obviously steeped in any particular sense of, of your metabolic health or anything else, but I said, it feels like possibilities open that most things you might want to do on a daily basis. Go for a quick, you go for a walk, go for a bike ride lifts. You're not, you don't feel apprehension about things and possibilities open up for me. That's. One way, at least as a, as an opening of saying what it feels like to be fit, but because I'd never really thought about it before they said what's, what's gonna feel different for me. Well, how does it feel like to be fit? It's an interesting question.

Howard: [00:11:36] I liked that. I liked that a lot. I haven't thought of it like that. like you said, it it's,  the orthopedic floor Laura's on the sixth floor of our hospital. And I wear an N 95, which is a very uncomfortable, tight fitting mask. I can run to the sixth floor up the stairs and not be short of breath and come right out from the door and go see my patients and talk to them.

I like being able to do that. I like it. That it's effortless to walk up a long staircase or to go out with a hike with my kids, and not have to worry about finding a stick, or holding them back. Right.

Paul: [00:12:13] So it's just, it's an opening up feeling, right? The possibilities that go from being theoretical to practical that I could go up these stairs, but I choose not to no, you just go, right. I can just go and go up the stairs, go for the hike or, or whatever. But I like the question though. I think it's a really interesting one.

Howard: [00:12:31] I do like that

Paul: [00:12:32] Okay. The great wheel of questions. D-d-d-d-d-d-d, that's a ridiculous sound. and this one's  maybe I should have done it earlier, but someone said to me, and this is a great, by the way, literally out of the title of a fantastic book by a Canadian, Alex Hutchinson, who's got a book called, Which comes first cardio or weights.

And this was a question I was asked almost word for word, which comes. Which comes first and this isn't particular oriented toward the over 45 crowds. So let's just say that right away, but which comes first cardio or weights?

Howard: [00:13:05] well, I don't look at them as being mutually exclusive. Right. Cause you can weight train, in a cardio-metabolic way. So you could do lightweight training. You could do. When I do kettlebell swings with a lightweight, my heart rate gets up and it will stay up. so there are certain ways to exercise with weights to maintain cardio benefits, and. But I would have to side with cardio, in terms of all cause mortality, there are benefits with weights. Yes. it depends on how they're executed and how it's done and if you do it right and often enough, but I think cardio and just keeping it really simple and focusing on six, 8,000 steps a day. I think that's the answer for 90% of people. for the other 10%, we can break that down further.

Paul: [00:14:04] I, yeah. And that's, it's been a while since I read Alex's book, but the, the gist of his argument, as I recall, it was that essentially the one you've made with the proviso, that weights could come first for many people, if they did it. At a higher level of intensity,  the way you're describing your kettlebell swings and turned it into a cardiovascular activity.

But the trouble is most people when they're doing weights, it'll be,  a five pound dumbbell and a couple of quick raises and whatever it's not really doing, I'm not saying it's not doing anything for muscle. It could be great in your particular case, but it's not doing much in terms of a joint cardiovascular strength exercise.

Howard: [00:14:45] Right. I would agree with that. and if you like me with kettlebell swings,  I'm down really light now about 30, 40 pounds. I had a 75 or 80 pound kettlebell.

Paul: [00:14:55] Huh? You're a monster.

Howard: [00:14:57] I swung that. And on the sixth swing, about six months ago, it left my hand and it did not end well for my basement.

Paul: [00:15:06] I was going to say, I feel a drywall repair coming. I've been there with that one. Yeah. Yeah. Flying 70 pound kettlebell. If all you have wrong is drywall, that'll be the, be a good outcome.

so let me go on to the next question I have here, which I got actually got today from someone who had only just listened to the, to the episode, but. And I never thought about this before. They said I hurt all the time when I exercise. And I'm always worried that I've hurt myself. How do I know if I've hurt myself doing this stuff?

Howard: [00:15:37] Yeah, it is.

Paul: [00:15:39] we're we're we're w we feel like if we hurt there's, a non-zero possibility that is actually an injury. And w as we get older, there's more apprehension about the consequences of injury. And so all of a sudden, there's this weird mental dance of is this good, hurt, bad hurt, injury hurt. And so what do we know?

Howard: [00:16:01] Right. so you're describing my office hours every day.

Paul: [00:16:07] Right. I'm sure I am.

Howard: [00:16:08] the, the vast majority of people who walk into my office with pain and likely with an MRI that shows something, think that that pain is caused, mechanically by the issue that showed up on the MRI. And most often it's not. All right. So deconditioning hurts joints that are not supported well by strong muscles, above and  below are going to bother you.

If I put you in a cast, one day and you have no pain in your knee, we take the cast off and we let you start. To, to walk around a few weeks later, your knee, will likely be very sore and hurt you. And when you train back to your normal strength, that knee pain will go away. I think it's really important.

this is really a critical question. When you go to a physician for shoulder pain, knee pain, elbow pain, whatever you need to ask. If I continue with my activities, am I going. To be hurting myself. because usually the answer is no, even if there's a meniscus tear or small rotator cuff tear, the answer is no.

And as we've said, a hundred times on this podcast already, osteoarthritis is not a mechanical process, so you're not wearing away your cartilage. It's not a, it's not a cheese graded, rubbing away cheese or sandpaper, rubbing away wood. most of the crackling that you hear inside your knee is due to inflammation and it's not a mechanical issue.

Exercise will not make your arthritis worse. So there are certain pains that people are going to worry about.  the knees getting stuck, caught, But if you're getting a general ache in the front of the knee, especially sometimes in the back of the knee,  nine times out of 10, you're just fine.

And if you worried go to an orthopedist, hopefully you'll get an exam and a good discussion. perhaps an x-ray, hopefully not an MRI in most situations. And you'll be told that you're good to go.

Paul: [00:18:20] I, I always joke that if I run long enough, every part of my body below the hip hurts, at least once.

Howard: [00:18:26] once,  when I get out of bed in the morning, I,  if,  if, if I showed my nest cam of me getting out of bed and going to the bathroom, you'd be, you'd be astonished that I have my running shoes on in 20 minutes and I'm out the door. I could barely move.

Paul: [00:18:46] you haven't even done anything yet. Wait, just wait till later. Right? So. Yeah. So I, and I don't know if this is wrong so you can correct me, but I always say that if, if something persists, it's probably worth looking at, but most post-exercise related discomfort, pain, whatever is, is within reason is, is, is normal.

If it goes away within 24, 48 hours even, or even less usually. and, and it didn't. It doesn't persist. it doesn't, it doesn't usually it doesn't swell. These are all signs my way of thinking, that this is something that's transient and probably not worrying about particularly much. And obviously, as you say, you can always feel free to see.

See an orthopedist about it, but at least these are at least signs that this is something that's potentially just,  muscle reconditioning as a result of, post-exercise inflammation or whatever else. But it's not something, an acute injury that you've done to yourself necessarily.

Howard: [00:19:43] right. when I discussed this with people, what's important is what brought the pain on. Right. Was, was this a sharp, Oh my God. Immediate pain in the foot. When you've only been running for a few weeks, you have a stress fracture and you should see someone was this just a dull ache, that just occurred in the middle of a run or a ride or a walk.

Go ahead, walk it off or run it off and see what happens. and if it goes away great, if it comes back again, I'm sorry, keep going. But another great thing is how you feel the next day. So if you. Push what you believe to be hard or a little harder than usual, and you wake up with more pain the following morning, then you probably did too much the previous day.

so that's a good barometer,

Paul: [00:20:39] but it does, even if you have more of though, it's not necessarily a sign you've injured yourself. You've just pushed too hard.

Okay. The great wheel of questions So, I got a funny question here, and this was from someone who I won't out, but should know, should know this question was I don't like to do cardio because when I run, if I weigh myself before and after, I've almost always lost two or three pounds, I'm trying to build muscle mass. I can't do cardio.

Howard: [00:21:15] you're outing. yourself.

Paul: [00:21:17] Yeah. Well, I could be myself here too. I'm a victim of this, but I've at least I know, I know what's really going on here. So I thought that was really interesting. And I, and I, and a brother-in-law of mine has, this, has, this has the same. I'll call it weird pathology that he doesn't like to do cardio, because he's, he's convinced that if you weigh him, weighs himself after a run, he weighs less. I must be losing something that's bad. I'm trying to build muscle mass. I want to be like,  He-Man bro at the beach. So cardio's out. it's apparently a thing. I had no idea that a lot of people feel this way.

Howard: [00:21:55] yeah. So I try to get people to avoid weighing themselves every day. I mean that average person. Can weigh as much as five pounds different day to day or within the same day. and if you're heavier, that can go up to 10 or 15 pounds and.

The reasons are the reasons are numerous, right? You could have had a high, salt food. Yeah. You could have had some soup or some pretzels or something. And you brought in a lot of water with you. So you weight went up, you went running and you, you, you ran off that, extra water weight. so you, Wade is now down.

If you eat carbs, right? Bread, pasta, rice, starchy carbs for every gram that you eat, you're going to keep three grams of water inside your body, just in order to store that fuel.  the food that you eat is going to affect. Your weight, your exercise affects it again because you, you can lose 25 to 40, 25 to 45 ounces or so of fluid per hour of exercise.

Paul: [00:23:07] Yeah, it's crazy.

Howard: [00:23:08] So,  your body is going to, it's like monitoring your blood glucose, right? You can't look at one blood glucose and know what your average is for the day. Cause it fluctuates by the minute, same thing with your pulse and your blood pressure. so. You need long-term trends. You shouldn't be weighing yourself before and after exercise, unless you've gone for a 50 mile run.

And you're really worried that you dehydrated yourself. there's really very few indications for that.

Paul: [00:23:41] Yeah, I, I, you were giving me a hard time earlier. I, and I, I think it's because I was telling you that, what was it, I guess a week or so ago, I went for a run and I was, I don't know, 153 pounds before and just recreationally, weighed myself after. Cause I knew I had sweated a lot. I think it was like one 49 or 48. I lost like five pounds. And it was no question of yeah. 98% fluid obviously. Right. I mean, there's not. It's not an, I was running for an hour and a half or so, so yeah. I sweated a boatload as, as I was running and, and that's just a laundry problem. That's not a problem with respect to like, suddenly I've, I've, I've, I've lost my triceps or something. Right. It's not, that's not what's going on there.

Howard: [00:24:26] No. If your protein intake is adequate, you're not losing protein. You're not losing muscle mass. You're losing water, weight. Yeah. And your weight is going to fluctuate up to five pounds per day. if you have a normal BMI, that's a lot of weight.

Paul: [00:24:42] Yes, a lot of weights and it's best not to pay attention.

Okay. The great wheel of questions.  So two more quick ones, and then we'll, we'll, we'll move on. But, and you  bridged into this one just now, were you talked about getting enough protein? I had someone say to me, I don't need to do this, this meaning cardio and weights, I guess, or whatever, building strength and cardiovascular fitness, because they said I lots of supplements that I have a great diet. I shouldn't laugh because it's actually surprised I've heard this many, many times, but I got it again in the last few days after our episode. So you get what or where to start on a question like that.

Howard: [00:25:23] Right. So what are you optimizing for? again, we'll jump back to that. So since we're on the topic of muscle mass protein intake is critical. I mean, you will, Have a net loss of protein, of muscle protein mass, just by sleeping overnight, or during the day, if you have an inadequate intake, by the time you get to our age, we need somewhere between 1.5 to 1.8 grams per kilogram, per day.

so I do like protein supplements. P protein, whey protein, you name it. there are some papers, by Philips, that have shown that vitamin D polyunsaturated, fatty acids, Omega threes, Help in terms of getting it into your gut, getting your gut to absorb it. you also need some carbohydrates there to help absorb the protein.

and then the vitamin D and the poof is, help your body utilize it. so you have a net, positive gain and muscle mass. I think that that's the most important thing in terms of supplements, I'm very, very worried about many supplements, right? When they study these things and they look at what's in them, sometimes you don't like what you see.

Paul: [00:26:43] And not only that it's not the, the proportions vary wildly, this stuff is like it's done on, I don't know at sea or something, there's just a handcrafted aspect to it where you're actually getting wildly varying, and, and, and it's got this really handcrafted aspect. So you need to at least be cautious about it.

Howard: [00:27:02] Right. People ask me all the time. What supplements do I take? and I'll say it, I, I take creatine, about two grams a day. I don't, I didn't load I don't load, two grams a day and you'll fill you creatine tanks. It's a great way to maintain muscle mass. And no, it does not ruin your kidneys. Yes.

It will increase your creatanine because creatine is metabolized into creatinine. and if you stop taking the creatine before your blood is drawn, your creatinine will be normal. I take magnesium. our foods, have really lost a lot of mineral content and, and magnesium seems to be one of them.

so I do eat a fair number of nuts, almonds, et cetera, which are a high magnesium, but still I supplement magnesium and then protein. so I get about 26 grams in a supplement. Twice a day, so that I can hit somewhere between 1.5 and two grams per kilogram, per day.

Paul: [00:28:02] right. Yeah. And those, and those are pretty Orthodox numbers. I mean, that's not out there at all. That's where I think most people probably should be, but. The key point on this question, and maybe this is a good point to stop on it. Ain't enough. You can't eat your way to fitness. And this is just a crazy, I feel like it's a crazy point to have to make, but I had multiple people tell me that this week that you know what, I really don't enjoy any of this exercise stuff.

And I hate. They have very comparable supplement programs to what you just described. They eat a well-balanced diet, lots of vegetables, fruit, they're not gaining weight. They're like, I don't, I don't need this stuff. And I just, I found that surprising and they're wrong.

Howard: [00:28:43] They're they're absolutely right. there is a tremendous benefit and a decrease in all-cause mortality with very little effort. it's easy to get six or 8,000 steps in. It's not hard, to. Drop down and do, and do 20 squats, or a few calf raises when you just sit in there and talking to people, or when you're recording a podcast, you

Paul: [00:29:09] right now. Actually. No, I'm not applying.

Howard: [00:29:12] you can do this. It can be done. It's not technically challenged.

Paul: [00:29:18] No, no, it's not. And it's people are always looking for shortcuts and pads out and strangely enough, and there's an expression in economics that applies here, but it's this idea that there are free lunches and then in a weird  way, and economics and finance diversification is a free lunch in longevity.

Simply eating well and being active is, is honestly among the freest of free lunches. There's a dose response relationship and you should just,  take it

Howard: [00:29:46] it. Absolutely. And to the contrary, you can't outrun a bad diet.

Paul: [00:29:52] well. Thanks, Howard.

Howard: [00:29:53] Thank you, Paul.