#196 - AMA #32: Exercise, squats, deadlifts, BFR, and TRT

Hey everyone, welcome to a Sneak Peek, Ask Me Anything or AMA episode of the Drive podcast. I'm your host, Peter Attia. 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 peterattiamd.com 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, off and on for 10 years, but he's been working with me specifically around the podcast since we decided to do this, which is, God, we're coming up on four years ago. It was in the spring of 2018, I think, when we made that decision, and Nick is going to be taking 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 layperson 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 Lenicke. I think we go from that then into talking about some of my favorite lifts. So squats, deadlifts 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 centenarian 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 our targets of therapy are, what are some of the do's 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 video of 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 peek 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, we'll 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 group of questions, so just tell me where you want to start.

So we got a lot of good questions following the Jeremy Lineke and some of the exercise podcasts. 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 macro structure 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 as 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 erode strength training gains.

Peter, what happens if you miss a day? Cause 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 if you miss Wednesday, do you just scrap those exercises and then just continue with your program or are you trying to make up in the interim?

No. Like yesterday, Sunday would have been a. A ride followed by lift day, but I was on the track the whole day and I knew, you know, I knew that in advance. So I just ended up doing that lift on Saturday, but obviously was shortchanged on the zone two 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, 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, just around 7:15, 7:30, that's when I'll typically lift.

Got it. I know from the Jeremy Lineke 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 your 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 occlusive 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 Katsu one. But my guess is there will be no bigger jump than the one I took from going from basically $20 junkie 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 group. 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 bicep set and a tricep set. And I'm always doing it in the way that we discussed on that podcast. But just for folks to REM, 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 here's 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, just bands. You don't really have a sense of what 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 occlusive 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 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 used 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, 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're like 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 the other 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 kind of 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 trying to squeeze this thing again. I would just York on them really hard until I would. My guide was, once it hits 7 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 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 really are getting the true occlusive effect.

And what are you using to measure the difference there? Or how do you know it's working? How can you tell? Does it just feel 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 tends to be 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 and 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 still do something after this, but I'll do a dead hang is usually the very, very last thing I'll do. So kind of mixed up a bit.

You'll never do a dead hang with a BFR cuff on.

I tried. It didn't matter. 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 3, 3, 10. But that's at the end of a workout and I think 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 2, 2, 3, 0 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, yeah. That thing is painful. Super painful. Gives you a new respect for those climbers.

That was the first 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. But 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, just to just lift yourself up?

If I can do four sets of two, three finger pull ups at the end of doing 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? Have you ever played around with that?

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