#291. 6 Strength Exercises Every Older Adult Should Do with Professor Leigh Breen

Dr Rupy: Is skeletal muscle the biggest organ in the body?

Professor Lee Breen: Yes, about 40% of your total body mass. It's not just a series of individual muscles, but it's often considered to be an organ, yeah.

Dr Rupy: Okay. If I don't see weight loss or increase in muscle size, my exercises are not having a benefit. True or false?

Professor Lee Breen: False. Absolutely.

Dr Rupy: Is walking enough to keep my muscles healthy as I age?

Professor Lee Breen: No.

Dr Rupy: Can resistance bands be just as effective as weights or can you get stronger without stepping into a gym?

Professor Lee Breen: Yes.

Dr Rupy: Is it ever too late to start exercising and building meaningful muscle, particularly if I'm over the age of 50?

Professor Lee Breen: No, never too late.

Dr Rupy: Okay. And for anyone over the age of 50, what is the one thing you would recommend they start doing today if they're looking after their muscle health?

Professor Lee Breen: Some form of resistance or strength exercise.

Dr Rupy: Okay, brilliant.

Dr Rupy: Hi, I'm Dr Rupy. I'm a medical doctor and nutritionist. And when I suffered a heart condition years ago, I was able to reverse it with diet and lifestyle. This opened up my eyes to the world of food as medicine to improve our health. On this podcast, I discuss ways in which you can use nutrition and lifestyle to improve your own well-being every day. I speak with expert guests and we lean into the science, but whilst making it as practical and as easiest as possible so you can take steps to change your life today. Welcome to the Doctor's Kitchen podcast.

Dr Rupy: We often think of muscle as just a cosmetic thing, about looking toned and strong, but did you know that from our 30s onwards, we lose around 10% of muscle mass every decade? Even more concerning, we lose about 4% of our strength every 10 years, making everyday activities harder and increasing our risk of injury. Well today, I'm joined by Professor Lee Breen. He's a leading expert in muscle health and aging. And if you don't make the connection between our muscles and aging, today you're going to understand exactly why it is so important. He's professor of translational muscle physiology at the University of Birmingham, where he researches how exercise and nutrition can help us maintain muscle as we get older. Today, we're going to cover why strength training is essential for healthy aging, the key exercises every older adult should be doing, how much protein you actually need as you age, and whether walking enough to keep your muscles strong is actually the preferred activity or whether we need to be leaning into other activities. Spoiler alert, you definitely need to do more than walking. Today we're also going to talk about how to start strength training if you've never done it before and the exercises you should be aiming to do if you are able to get to a gym as well. Today you're going to learn so much about these hidden benefits of exercise from sharper thinking to metabolic control like blood sugar regulation. And we're also going to talk about supplements, new therapies and what is on the horizon for muscle health as well.

Dr Rupy: For me, this was essential information. Whether this is for yourself or your parents or someone you love, I really think you should share this episode with friends and family who need to hear it. And as always, let us know your thoughts in the feedback link in the podcast show notes as well.

Dr Rupy: Actually, I have an extra bonus question.

Professor Lee Breen: Sure.

Dr Rupy: If you lose muscle during an extended hospital stay or an illness, let's say, can you get it back?

Professor Lee Breen: It's a great question. And I'm going to give that that typical scientist answer of it depends. Okay. So in in in younger people, the evidence suggests it's possible to to recoup the losses in muscle mass and strength that occur with an injury or or illness that puts them off their feet for a while. It's supposedly gets harder to do that when you're older, especially if you're a sick patient with a with a chronic disease condition. It's harder to to get back to where you were before the the period of of of disuse. So so generally speaking, it yeah, it gets harder with age. It requires a more targeted form of of exercise, perhaps nutrition and regular structured routine to get back. Yeah. Whereas when we know in clinical care in in most most nations anyway, that doesn't happen. So people may get given some some loose guidance of how to rehabilitate a few sessions of physiotherapy, but the really targeted structured exercise that is needed to get back is often not not communicated clearly.

Dr Rupy: We were chatting before we started recording. I want this to be an episode that either people put into action themselves or they share with a loved one who is older and perhaps doesn't know anything about resistance training, the benefits of training, or don't really appreciate that A, their muscles are the largest organ and that they are critical for healthy aging. So why don't we break it down and start off with what we mean by skeletal muscle specifically and how this is different to other muscle types.

Professor Lee Breen: Yeah, so I think, you know, smooth muscle, cardiac muscles differ from skeletal muscles in that they tend to be found in a in in a small number of locations around the body, whereas skeletal muscles are you find them right across the whole body. And they differ as well in terms of we we we can voluntarily activate these muscles. So through our central nervous system, we can make muscles contract and they're attached to to ligaments, tendons and bones and and they control our movement as well. So that's how they tend to differ. Skeletal muscle tends to differ from other muscles in the body.

Dr Rupy: Okay. And you said it was around 40% of our mass.

Professor Lee Breen: About yeah, when you step on the scales, the number you see, about 35 to 40% of that number is is typically muscle mass. That in in bodybuilders, that number may be slightly higher, but for mere mortals like you and I, it's probably about 40%.

Dr Rupy: Yeah, okay. So 40% around mass and the the weight. And we specifically said that our muscles are organs. And you know, if anyone's done a pub quiz in the last 10 years, you know, the the sort of the answer was skin previously. And now we see our muscles as organs. What do we mean by our muscles being organs specifically?

Professor Lee Breen: Well, I guess the the simplest way to think about this is the is is is to understand the roles that they play in terms of locomotion and and metabolism and their central role. So I think when we when we talk about metabolism, we're talking about cellular reactions that control how much energy we have and our ability to to function. So that's converting food and drink into energy, helping to to create hormones and for us to repair and regenerate cells as well. And skeletal muscle plays a really, really key key role in that. So it's metabolically active, which is which is I think which is why it's appropriate, I think to to term it as an organ.

Dr Rupy: Yeah, and it's actively secreting compounds into our bloodstream and into our circulation. So it's having a a downstream effect on a number of different organs including our brain, our heart, inflammation, our immune system. And there are these things called exerkines that I'm sure you know a lot more about than me. This is what we mean by it having it's it's more of an organ rather than just something that has locomotor actions.

Professor Lee Breen: Yeah, I mean that's traditionally how we thought of it. Muscle important to to help us move from A to B and complete activities of every everyday living. The last two, three decades have really helped reinforce our understanding of how metabolically active the tissue is. And as you mentioned, not just as the site for these really important metabolic reactions, but what it produces and how that and how those factors communicate with other tissues to support our our integrative health across different systems and organs.

Dr Rupy: Yeah, okay. So if we were to zoom into a muscle, let's look at a large muscle, the quadriceps, let's say. I've heard actually there's it's not quads anymore. Is it? Is there a fifth muscle in our in our legs? Is that is that something I've just come across?

Professor Lee Breen: Well, there are lots more than five. Yeah, yeah, yeah. Fifth in the quadriceps. I guess it depends if you, you know, the the the vast eye muscles and and the rectus femoris, there's I guess there's a kind of topical discussion about where the the where the aponeurosis, so these are the the collagenous structures that sort of separate muscles from one another, where they might lie and and this idea that there may be additional additional aponeurosis that that would that would mean we have a fifth quadricep, but I I I'm not I'm not buying into that just yet. We're a long way from resolving that at the moment.

Dr Rupy: So active discussion at the moment.

Professor Lee Breen: Yeah, not not yeah, not five.

Dr Rupy: Let's let's zoom into the quadricep and if we were to look at the different muscle fibers, the muscle types, how would you broadly classify them? Because I think people have heard of slow and fast twitch fibers and type one and type two. How how do we how would you explain that?

Professor Lee Breen: Yeah, I think that's that's probably about right. And the and the quadriceps is maybe an interesting muscle to focus on because again, for most individuals, the the the divide of type one and type two muscle fibers in the quadriceps is it's sometimes 50/50, but generally more nearer to kind of 60/40 most healthy individuals. And of course, you get extreme extreme examples like highly trained elite athletes and sprinters or the power athletes who may have a higher proportion of type two than the than the general population. Okay. Um, but I think the easiest way to to to to think of it is, you know, type one fibers are, I guess they're they're fatigue resistant. They form part of or they're composed in in form part of our smaller motor units. So these are fibers that are relatively easy activated. So when you and I we rise from the chair, we would tap into those fibers in order to just their activation would support those types of simple movements as well. As I mentioned, fatigue resistance, so again, the the the metabolic flux through these fibers would support our ability to prolong exercise for an extended an extended period. And the type two muscle fibers, not as not very fatigue resistant at all, but can generate contractile power quite quickly. So for those more explosive movements, the type two fibers would be would be certainly more important. So the ability to perhaps react quickly and prevent oneself from from falling and and and hurting and incurring an injury, you might activate type one fibers to maintain balance, type two fibers to maintain balance and things like that. So that's generally, you know, how we would we would distinguish those, yeah. So type one fibers, you know, more mitochondria to support those to support aerobic metabolism. Type two fibers, fewer mitochondria, but perhaps more potent, strong contractile properties to support those quick rapid movements.

Dr Rupy: That's a really important context with regards to fall resistance and frailty with type two fibers. So if we were looking at an endurance athlete, is it fair to say, so someone who is a cyclist or a marathon runner, let's say, is it fair to say that they are focusing a lot on their type one fibers because those are less fatigue resistant and that's more about, you know, consistent power over time versus a sprinter who's focusing more on type two fibers or let's say a powerlifter that does, you know, a one rep max of 400 pounds or whatever, probably a lot more than that, but is that is that a fair sort of delineation between the two types?

Professor Lee Breen: Yeah, I mean, I think it's important to to bear in mind that the, you know, the proportion of fibers that we fiber types we have in a given muscle, it's it's generally inherent and and set. All right. Within a within a fine window, we can train that response and modify it somewhat. And of course, those people who do achieve, you know, high athletic accomplishments, performance accomplishments in in strength and power sports or or endurance sports do so because they they are genetically predisposed to having a favorable fiber type one way or the other. Um, but there are things we can do to to to to train and and modify fiber types slightly in in muscles. It's more about the it's more about modifying the properties of the fibers that we we we are born with though, really. That's the that's the key. So it could be increasing the size of the fiber or the I guess you would broadly term it as something like the metabolic efficiency. So you can increase things like the number of mitochondria that serve a type one fiber through through repeated endurance exercise training. You can make those mitochondria bigger, you can make more of them, you can make them more efficient in terms of how they they utilize and generate energy. Um, but actually modulating the number of fibers is um, it's more difficult to achieve and and it and it happens in a narrow in a narrow window.

Dr Rupy: Okay. We've mentioned the word mitochondria a number of times. How would you describe mitochondria, the organelle in our cells to someone who doesn't know anything about science?

Professor Lee Breen: Yeah, they're often they're often referred to as the powerhouses of of our of our cells. So really important in in in I guess the generation of of of substrate energy to to support to support the work we do as as humans, not just exercise, but all movement. Mitochondria are yeah, critical for critical for that.

Dr Rupy: Okay. And so increasing the number and the efficiency of mitochondria, is that possible with exercise or certain types of exercise?

Professor Lee Breen: Yeah, absolutely. So endurance aerobic exercise, um, at a certain intensity and threshold can can increase mitochondrial content and also mitochondrial efficiency as well. So the ability of mitochondria to to to yeah, to to use substrate and generate energy to allow us to work and move for for for longer is absolutely possible through through exercise training. So that's in terms of skeletal muscle, those types of factors are are very modifiable. And I think, you know, one of the reasons I'm interested in studying skeletal muscle is is due to its its high plasticity. You know, of all our organs and and tissues in the body, it's the one that is the most adaptable to the specific demands that we place on it. So primarily exercise, nutrition, or kind of lifestyle environmental factors can modulate our skeletal muscle morphology, I guess.

Dr Rupy: Yeah, okay. Um, so if, um, I'm going to use my parents as an example here. My parents love walking. My dad in particular loves walking, doesn't do as much resistance training. So is it fair to say that from muscle fiber types and mitochondrial number, he's doing a good job with the type one side of things, but in order to have the best protective response, he should introduce some resistance training to that milieu of exercises that he would do every single week.

Professor Lee Breen: I think that's fair to say. Yes. So aging muscles are characterized primarily by atrophy or the deterioration of type one and type two fibers. So when you say atrophy, reduction in size. Reduction in size. Yeah. So so type one and type two fibers reduce in in um, primarily in size. Some say also the number of of of each of those fibers deteriorates as well, although not as markedly as the as the size decreases. Um, it seems to be targeted more towards reduction in the size of of type two fibers compared to one. So when we look at an older muscle, typically it contains a relatively higher proportion of type one fibers to two fibers than somebody 30, 40 years younger. Those type one fibers might also be be enlarged in in the muscles of an older person as well. So when other fibers around die and degrade and waste away, it's possible for kind of type one fibers to to um, to kind of to kind of rescue them. So the the the neurons, these these things from our central nervous system that innovate and and talk to our muscle fibers, it's possible for some of those neurons to connect to dying fibers and effectively kind of keep them alive really. Right. Um, so yeah, an older muscle is characterized actually we we call it the the slowing of aging muscles. So they um, predominantly type one muscle fibers, fewer type two fibers, although both are both are in decline. It's just the relative ratio at which they decline differs slightly. Um, so you know, yeah, in in terms of using your dad as an example, so somebody who maybe goes out and gets their 10, 15,000 steps in every day, um, you know, doing great things, not just for their muscle health, but we also have to think about cardio respiratory health in this as well, which is a major risk risk factor for, you know, a whole host of disease conditions. So doing a great job on that front. But actually we get the the the greatest benefit in terms of health protection and risk reduction from disease when we combine both modes of exercise. So that is physically active living, some form of structured, more intense aerobic exercise and resistance and strength training as well. You get the greatest added benefit for overall health when you are able to combine those two. So I would always encourage somebody who maybe spends two, three hours a day going out for a long walk. I would ask them maybe, you know, could you do that that walk over 60 minutes and perhaps increase the intensity of the walk and then maybe spend a little bit of the time you've saved doing something that that looks like strength and resistance exercise as well. The public health guidelines for for the for for for resistance and strength exercise for for older adults in the UK, they're not that hard to achieve, I believe. You know, the recommendation of two or more times a week. Yeah. So every every three, four days, you've got to try and find time in your day, 30, 45 minutes to try and do some strength and resistance exercise, you know, across all major muscle groups in the body.

Dr Rupy: Yeah, yeah. That's really interesting. I didn't realize that about type one muscle fibers almost resuscitating some of the other areas of skeletal muscle as we age, even though both are in decline. From what I'm hearing, it's important to get that resistance training. We'll go into some of the compound exercises a little bit later to ensure that you're getting a good balance of both type one and type two.

Professor Lee Breen: Yeah, absolutely. Yes. So so the I mean resistance, strength training, I mean it it it does tend to target um, both fiber types. They they they will see adaptations. So in terms of the the the size or or um, you know, certain kind of metabolic properties of type one and type two fibers, you'll get a response with both to to strength and resistance. But the general thinking is that that those type two fibers that that sit within these larger motor units in the in the muscle, which are bundles of of of fibers and neurons all kind of um working together. Um, there's a that those larger motor units with the type two fibers contained within seem to be particularly responsive to to to the heavier tensile loading that resistance and strength training places on our muscles.

Dr Rupy: Okay. Um, we mentioned that word metabolism again, and I just want to come to a slightly left field question around menopausal women. And I often hear from members of our community and on social media and just, you know, um, uh, friends and friends of my parents that their metabolism has quote unquote slowed. Um, I understand this might be a bit of a misnomer, but I'd love for you to unpack that. But a very clear and recognizable phenomena is that particularly postmenopausal women, they find that they put on more weight and they struggle to shift it as well despite the number of different diets. So my question to you is, why is it that menopausal women struggle with weight and they tend to put on more weight after the menopause?

Professor Lee Breen: It's a great question. Um, so I think if we address the the kind of the, you know, the concept of metabolism slowing first of all. So that's the, you know, metabolism being the or metabolic rate being the the speed at which all of those cellular reactions occur. I mean, I think within a narrow window, these things as an inherent part of aging naturally slow somewhat. Um, but, you know, but but but I think that's generally kind of it's quite misleading because the extent to which that happens is quite is quite finite really. We're not talking about, you know, a major slowing of of these reactions. You know, during and and and following menopause, it's, you know, it it it becomes more difficult. Those those hormonal alterations do make it difficult for our tissues to kind of to regenerate or respond to something like a dietary intervention or or an exercise regime that someone, you know, might have incorporated into their life. Um, a bigger part of it though, I mean, the it's more the aging process itself. I mean, the, you know, men aren't aren't immune to these um, changes, hormonal fluctuations with advancing age and and that having an impact on the metabolism of their of their tissues. So I think postmenopausally, um, but also in older men, um, um, you know, hypogonadal old men in whom testosterone is is starting to decline as well. Um, it's not that metabolism slows as such, but it's more the ability of tissues to kind of adapt and respond to the to to the things we the lifestyle interventions we try to add becomes more more challenging. So I think that's how I would generally, you know, generally unpack that. And and that and that also that translates to fat fat reduction as well, right? So not only is it become a little bit more difficult to build muscle, um, but also in terms of, you know, metabolic flux of of our fat cells, those things are impaired as well. Um, yeah, by the by the hormonal alterations.

Dr Rupy: Is it worse for women?

Professor Lee Breen: It's it's different. I think it probably it's different. Different time frames. You know, most most older men will reach a, you know, hypogonadal state or require testosterone therapy at a much later age than women will generally advance into menopause. So so so I I I think it's fair to say that women probably live with the the burden, the kind of metabolic health burden of those those alterations in hormones for a much longer period than than than men generally speaking as well. Um, tends to be a little bit more severe. So we're talking more about kind of for most men, it's, you know, gradual, more subtle reductions in testosterone. Whereas in in, you know, women going through the menopause, things can change quite drastically and quite quite quickly and over the over the space of just two or three years, you can get really profound alterations in the hormonal status. Whereas it tends to be more gradual in in in older men.

Dr Rupy: Okay. And so appreciating that there is this massive reduction in hormones, estrogen and testosterone. I always sort of try and make a point that testosterone is very important in women as well. Are there any adaptations that women should be taking to protect themselves further given that it's very different for for men?

Professor Lee Breen: Oh, I mean in terms of lifestyle.

Dr Rupy: Yeah, in terms of exercise specifically.

Professor Lee Breen: Yeah, I mean, I again, I I'm sound like a broken record on this one, but I mean, you know, it's always the combination of exercise and and nutrition. So I think the not just postmenopausal women, but I I mean any women kind of advancing towards that stage, you know, pre, peri, post, whatever it may be, resistance and strength training really, really important. I mean, we you know, we've we've spoken about muscle and fat and the and the impacts of the menopause on on those tissues. We've got to think about bone as well here, right? Um, so in terms of risk of osteoporosis and and and complications from that further down the line, um, bone health is is really severely um, affected um by the hormonal fluctuations that occur during menopause. And we know that resistance and strength training puts a really significant load through our bones and it's a great tool to help remodel and and and adapt that tissue. So again, you know, emphasis on trying to if you are physically active and and and and out and about moving and and walking lots and and doing your aerobic exercise, I think about can you can you allocate a portion of that time to doing something that's that's strengthening?

Dr Rupy: Yeah. Um, across both sexes and a lot earlier than I perhaps appreciated before, sarcopenia is something that increases over time, um, and can be found in as early as our 20s and 30s from what I understand. Um, why don't we unpack what sarcopenia is, um, how we define it, and why this is such a big concern for for everyone.

Professor Lee Breen: No, happy to do that. Yes. So I mean, broadly translated, sarcopenia is it's often thought to mean the poverty or a paucity of the flesh. That's kind of that's where the Greek. Oh, really? Is that where it comes from? That's where it comes from. Poverty or paucity of of flesh was the So it's so, you know, by by virtue of the fact that it has its roots in in ancient Greek, you can you can tell this is a phenomenon that that it's not new. People have recognized that that our phenotype, our body shape changes and it's something about the um, I mean it used to be I mean there was an idea um, when sarcopenia was first defined in the in the in the late 80s, early 90s, 1980s, 1990s that is. Um, the term sarcoccia was also thrown around, which means softening of the tissue. So there was an idea that muscles perhaps got softer as we age as opposed to wasted away and and we lost that muscle mass. We now understand that we our muscles don't unfortunately just get softer and we can't just tense them up again. That's maybe that would be easier than than losing muscle. So yeah, sarcopenia that's what it means. It's uh it is a recognized disease condition. It you know, it has an ICD code. It's recognized by the WHO for going on 10 years now, which has really helped in terms of, you know, how we identify, diagnose and and and treat treat the condition. And but it refers to the the gradual loss of skeletal muscle, um, strength, mass and and and function. So we think about those three kind of parameters really.

Dr Rupy: So strength, mass, so the size of the muscle and the function.

Professor Lee Breen: So our ability to to conduct tasks of of everyday living. So there are I mean depending on which region you you're in um, geographically, there are various definitions that um, used to to diagnose sarcopenia. So different different sets of criteria that involve measuring the size of the muscle, the function of the muscle and the and the and the strength of the muscle as well. In in Europe, generally speaking, if you're if you're identified as somebody who has low muscle strength, which can be which can be assessed using a simple grip grip test. Um, if you have if you have low muscle strength based on, you know, criteria that have been developed by observing thousands of of of people across the life course, it's, you know, you're you're generally classed as pre-sarcopenic. So you're you're you're on this this this kind of this slope towards sarcopenia, full-blown diagnosis, but not there yet. Okay. If the mass is also low, which can be again can be measured by a number of different um, investigatory techniques, scanning techniques. If you have those two factors, the strength and the mass are low, you are, you know, you are defined as having sarcopenia. If the function is also impaired, so your ability to to rise from a chair and walk a certain distance, um, you know, could be to to balance on one foot for a period of time. Um, to rise from the floor. If those tests are um, um, you know, below certain threshold criteria, the definition is severe sarcopenia. Okay. So those are in Europe anyway, those are generally the three criteria that we go off. Why is it a big problem? We're progressively aging societies. Um, unfortunately, we're not necessarily physically active as well. So we're not doing the the things that will protect our muscle health. Um, so generally speaking, if you took if you looked at community dwelling healthy older adults, so those who aren't in hospital or or in an institute of care home, for example, you'd find, you know, somewhere between 10 and 20% of those individuals would would have a diagnosis of sarcopenia. A full-blown. This is this is at the age of 60 and over. Over the age of 60. Yeah, between 10 and 20% of of those individuals would would would reach a diagnosis of pre or or full-blown sarcopenia, not necessarily severe. As you can imagine, the the the incidence of sarcopenia increases with advancing age. So the as you mentioned before, from our kind of 30s and 40s onwards, it's it's possible to to to detect decline in skeletal muscle mass. As we age, the the the the steepness of that trajectory, that curve, it it drops off. It gets even more rapid. Right. So that's why we see, you know, really high rates of of of um sarcopenia prevalence in the over 80s in the over 80s, for example. So, you know, 50% and upwards of the over 80s reach those diagnostic criteria. Um, it's an expensive problem to treat. So it's not just the the effect it has on our ability to kind of move and ambulate is one thing. So locomotory abilities is poor poorer if we are sarcopenic. But actually low, you know, as you as you can imagine, an an organ that comprises 40% of our body mass must play a really important role in maintaining, you know, whole body homeostasis. Yeah. And if we're losing this really important tissue, our risk of almost every non-communicable disease condition you can think of is increased. Okay. So it's a risk factor for disease as well, having declining or low levels of skeletal muscle mass, strength and function. So it's not just the the cost associated with and the burden associated with treating the muscle loss itself. It's the impact it has on our on our risk of of yeah, these whole host of other conditions as well. Not just that, but if we are unfortunate enough to develop a non-communicable health condition, a disease, a chronic disease, our prognosis or our clinical outcomes in that condition will be much poorer if we are somebody who has low levels of skeletal muscle and we are reaching those those sarcopenia diagnosis as well. So, you know, it's an extremely expensive problem to treat. The estimates on how much it costs are really, really variable. Um, I mean somewhere around, you know, 4%, um, 4 to 5% of of all health and social care expenditure in the US, in the UK is is estimated. Um, so we're talking, you know, we're in we're in the we're in the billions of pounds here to to to to to treat the health conditions associated with with with poor levels of muscle mass, strength and function with advancing age. So it's an extremely expensive problem and it's set to become even more expensive. We've got, you know, in excess of 30 million adults across Europe will present with sarcopenia in in about 10 years time. That's the estimate. So it's it's a problem that's not going away anytime soon and it's an expensive issue because of that knock-on effect for um, yeah.

Dr Rupy: Outside of the clinical environment where someone could be tested with, you know, either a grip test machine or a more formal assessment of whether someone is sarcopenic, how might one be able to tell that they're either pre or full-blown sarcopenic, um, at home?

Professor Lee Breen: Yeah, I mean it's a difficult one. Um, because we have busy a lot of people have busy lives and so don't necessarily take minor changes in their ability to function that seriously. I think the the easiest way is um, is maybe over time to try and understand how difficult certain tasks of daily living become. So you know, a lot of the older people that that we meet who who come to participate in our research will anecdotally tell us things like, I you know, I find it hard to to carry the extra shopping bag back from the store down the road now, right? I can't I can't carry as much as I used to be able to. I can't get up the stairs in one go anymore. I have to stop halfway. I find it hard to rise from a chair without using both hands on the arms and and a significant effort or two or three attempts to to wrench myself out of the chair. Um, I can't I can't for example, raise the raise the heavy tin above my head and put it in the top shelf in the cupboard anymore, um, you know, when when when I'm home from the store. These types of of um, functional tasks can change quite significantly in a relatively short space of time with advancing age. So a big one is always um, is always retirement as well seems to be a point at which things things start to unravel for people. So particularly if you've had a relatively physically demanding kind of engaging profession and you stop doing that all of a sudden, it doesn't take very long for things to start to unravel in terms of muscle health unless people are able to maintain high levels of well, not even high levels. Some form of of you know, of um, of exercise and physical activity that that's quite demanding.

Dr Rupy: Yeah. And the issue I guess, you know, speaking from both experience in in clinical practice, but also just chatting to people is that it's often confounded with a whole bunch of other issues like arthritis, knee pain, uh, musculoskeletal issues, back pain, for example. And I think there is a tendency to blame those things first rather than uh a lack of muscle mass, particularly for folks who are not used to going to the gym and understanding their um, their ability to exert force, you know, in terms of back squats or leg extensions, etc. If you're not used to doing that and you can't actually see that you're losing your ability to push weight, um, it can be sort of palmed off as, oh well, it's because I've got this issue. It's not sarcopenia.

Professor Lee Breen: Yeah, yeah, absolutely. I mean, I get it is the sarcopenia is is an interesting one because the it's a condition that sometimes can be quite well masked in older adults. So we we are losing muscle mass at an increasingly, it's an accelerating rate as years go by. But a lot of the time there's also the the the kind of concomitant or the co-occurrence of increasing fat mass. So actually when we some people over 10 or 15 years will report, hey, I can still get into the same my waist size is the same. I can still fit in the same clothes and and perhaps even the weight on the scale hasn't changed an awful lot. But actually if you um, if you were able to to to to put someone in half and look at their tissue composition to that the the ratio of fat to muscle has changed quite quite dramatically. And that's the thing that has a big impact. It it can often be a really scary hidden condition that people don't notice. And we again, we think about we we typically think of appendicular muscle mass, skeletal muscle mass when we talk about sarcopenia. So the the muscle in the arms and the legs is playing a really, you know, a really big role in our in impaired function. But we we often forget that things like the the diaphragm or the muscles in our um, in our hips and pelvis. So the the the diaphragm, for example, is the skeletal muscle it atrophying can increase our risk and complications associated with respiratory diseases, for example. Hips and the pelvis, the atrophy of those muscles might lead to things like urinary tract infections. So it's not just our ability to to to move around and and and you know, push and pull heavy objects and and and complete these activities of daily living. There are lots of consequences that we often attribute, hey, it's part of aging. It's just ah, that happens. But actually it's um, it's uh, it's likely um, driven or at least strongly influenced by skeletal muscle changes.

Dr Rupy: I'm embarrassed to admit that I haven't ever really thought about that. I haven't really thought about the atrophy within those different areas of the body where of course we have muscle as contributing to that increased risk of complications associated with pneumonia or viral illnesses or you know, urinary tract infections that we see all the time in accident emergency and general practice. Um, but that's so, so important. I don't think I've really appreciated that.

Professor Lee Breen: Yeah, that's why it's such an enormous problem. Um, I mean and I think as well when when we think of exercise, we and ways to counteract sarcopenia, we think about exercising our arms and our legs and we don't think about maybe what we can do in terms of core strength, you know, um, and and supporting, you know, yeah, muscles in the torso as well. Um, but but it all feeds into this this this heightened disease risk with as sarcopenia progresses, yeah.

Dr Rupy: Yeah. Um, and this idea of I mentioned this word powerpenia before, but maybe you know it as something different.

Professor Lee Breen: I think I know it as dynapenia.

Dr Rupy: Dynapenia. Okay. What is that? Is that or cratapenia even if you want to go one further.

Professor Lee Breen: Cratapenia. What is cratapenia?

Professor Lee Breen: Dynapenia and cratapenia were to well, cratapenia, I don't know that that term ever really manifested. Um, dynapenia is is certainly a bonafide criteria. So dynapenia is um, is actually teasing out the strength component of sarcopenia. So dynapenia refers specifically to the reduction in in muscle strength output with advancing age. So less of a focus on the the kind of holistic mass, strength and function. Sarcopenia is more of a global definition for those those different parameters. Right. Dynapenia is is often um, is often used to refer to specifically to the the strength loss. Cratapenia, I think was touted for power, specifically for muscle power if you really want to get into the difference between strength and power.

Dr Rupy: Yeah, yeah, yeah, yeah. And is that something to do with creatine? I.e. the cell's ability to recycle phosphocreatine?

Professor Lee Breen: No, no, cratapenia, it it it what it's uh, the best of my recollection, it wasn't creatapenia. It was crat. Okay. Cratapenia. And I would need to I would need to go and to dive into my to my ancient Greek to to to find out where where crat I don't have crat to hand.

Dr Rupy: Okay, yeah. Yeah, yeah, yeah. Um, and this idea of uh losing muscle strength on average, just sort of uh riffing off the powerpenia or dynapenia. Uh, on average it's 4% each decade. Is that true?

Professor Lee Breen: Yeah, it's it's much more pronounced than the rate at which um sarcopenia. So the the the the loss of the of loss of mass generally is thought to occur somewhere between 0.5 and 1% per year after the age of 40 is is what's often touted. Yeah. Now that sounds quite slow and and I guess if you're if you're lucky enough to stay free of you know any major health complications, chronic disease and you can be physically active and engaged in structured exercise, there's no reasons to why sarcopenia can't be a relatively slow and insipid process. Now none of us can avoid it. It's an inherent part of. So we're all going to get it. We can't avoid it. It's an inherent part of of aging, but we can do an awful lot to slow to slow the trajectory. Um, we can do an awful lot as well in terms of, you know, how we um, how we prepare for that. So so actually banking good levels of muscle mass, strength and function at a relatively young age gives you a higher starting point from which you know, you can afford to lose something if you if you do become ill. Um, but getting back to the the yeah, to to the point around dynapenia. Um, so the loss of strength occurs at a much quicker rate. So we've got muscle mass at 0.5, 1%, quite a slow and insipid decline. Dynapenia is often thought to to to occur at a rate that's, you know, anywhere between kind of um, five and 10 times quicker. So you know, again, we we we have figures of 3 to 5% per year losses of strength. The so I mean to think about it quite simply, the the the strength of our muscles, the ability to produce force, it's dependent to some extent on the size of our muscles and the fibers and the fascicles that that that are in there. Um, but it's also determined by um neural components as well. So our central nervous system, effectively the brain muscle communication is really important. And we know that system also deteriorates with advancing age. So you've got these two interconnected systems, our central neural central nervous system, the brain, the neurons communicating to and sending, you know, electrical activity to our muscles to allow them to contract. So if the muscles the muscle size is is declining and the efficiency and the um, and I guess the structure of that our nervous system is also deteriorating with age, you have in in effect a double-edged sword for muscle strength, which is generally why those rates are observed to decline at a much more quickly than the than the mass itself.

Dr Rupy: Can I actually increase my muscle mass and strength uh as I age if I'm really regimented with exercise? Is that possible?

Professor Lee Breen: Increase muscle mass and strength with absolutely possible. Yeah, yeah. So I mean, we often we talk about the kind of the the severity and the consequences of of sarcopenia progression and and ultimately diagnosis. And we often miss the the it's a negative story and we often we often neglect to tell the to try and focus on the positives and that a little bit of exercise, structured exercise goes a long way in terms of of of preventing but also treating and reversing some some of that muscle aging, that sarcopenia or dynapenia that that has occurred. So there's an awful lot that can be done. Um, you know, I mean some of the earliest studies on this in in the late 1980s demonstrated that just 12 weeks of of quite structured um, tailored and frequent resistance strengthening exercise was sufficient to reverse years of muscle aging. Um, so the so the effectively two groups, one were studied long-term to to assess how muscle mass and strength declined. Another group were were were effectively taken and um, and studied over a 12 week period. And and and the gains they saw in just 12 weeks were equivalent to to what to to the what the other group lost in 12 years. Oh wow. So there's, you know, there's a lot there's an awful lot you can do. Yeah. Um, now, it's important to bear in mind that achieving youthful muscle or neural adaptive responses to to the exercise we do is very difficult. You know, when you're young, you as soon as you push the the door open to the gym, it seems like you start to gain muscle or you get fitter or you adapt. That doesn't happen when you get older. It there's a there there's a we we refer to it in in in the field as it's anabolic resistance. Okay. Um, an impaired ability for muscles to respond to to anabolic stimuli. Not just resistance exercise, but um endurance exercise, protein nutrition, which is key for muscle remodeling. Our muscles don't seem to to to sense that that growth stimulus as well as as we age. Yeah. Um, but but but that response doesn't disappear. It's still there. And there's some really, you know, some really interesting studies in the last two, three years have emerged to suggest that, you know, individuals even beyond the age of of 80 years can still see significant benefits. And these are people who may never may never have necessarily been engaged in exercise for 80 years previously. You put them on a structured resistance strengthening program, they get huge improvements in mass, strength and and their ability to function, which is most important. Yeah. Because that's directly linked to quality of life. Um, cost to health and social care expenditure. So if the function is fine, independence, quality of life, health care expenditure all are all improved as well.

Dr Rupy: That's a really good positive story that I kind of want to underline there because I think it can seem doom and gloom and almost as if this is inevitable in terms of our loss of function, strength, mass. But the fact that there are studies, obviously these are quite regimented in terms of structured exercise and the input, but the fact that you can stress the muscle to uh either rapidly um uh significantly slow the decline or even increase the the size of muscle is something that I think people need to to to appreciate. And on this idea of anabolic resistance, what do we know if anything about the changes to the muscles itself that lead to that anabolic resistance such that if you give it the same amount of protein, the same amount of stimulus in terms of resistance training, it doesn't have the same effect as if that muscle was in a 20-year-old's body.

Professor Lee Breen: Yeah, it's a great question and and anabolic resistance it has various definitions, but it the simplest way to think of it is age-related muscle anabolic resistance. It occurs at lots of different levels. So it's the it's not just how muscles sense that that exercise that we do and communicates that and and creates a growth a growth signal or or a remodeling signal. Actually occurs at lots of different levels. So even when we, you know, our ability to to consume and digest protein. So when we think upstream of muscle before we even get there, actually our ability to chew, to swallow, to digest and absorb protein and how much of that protein appears in our bloodstream, how our muscles senses that, all of those factors are changed. So there are multiple different levels to to anabolic resistance. But if we think intrinsically within the within the the muscle, um, the molecular networks that control these growth responses, I mean, generally, it doesn't matter which research group you go to, which continent, generally people find age-related impairments. Now, these are really complex networks, really, really interconnected. It's difficult to disentangle the these these signaling um molecules from one another. But by and large, if you study responsiveness in a young versus an old group, you'll you'll note multiple differences in in the I guess the ability of these signals to kind of switch on and create that that growth remodeling response in in in muscle. So as I mentioned before, you know, it it appears to be apparent in exercise. So when we train, the the ability, the the growth response that occurs in the hours and days and weeks after after that exercise training seems to be lower in in older people. And it and we think that explains why they don't build muscle as effectively as a younger person. Gotcha. Same can be said for protein as well. So if we if we do a if we feed somebody a protein rich meal, generally speaking, an an older group will will experience a lower response to that that protein than a younger group. But actually we we've found in our work that if you combine the exercise and the protein together, um, you you get something in an older muscle that looks it looks almost youthful for the most part. Now, again, that's really context dependent because if you are a if you're a 70-year-old who is super active, engaged in resistance exercise training, perhaps you're a master athlete, somebody who's exercised, you know, with with a high level of structure with kind of competition and performance for a long, long period, most of your life. Yeah. Um, you're lean, body fat levels look like a 25-year-old. There's evidence to suggest that that your muscles may not be may not experience this age-related anabolic resistance or you can offset you can offset a lot of that. Okay. So if you're if you're highly engaged like that, um, the same time if you are somebody who's, you know, obese, smoker, chronic disease conditions, you know, polypharmacy, you're taking lots of different drugs for lots of different conditions. Perhaps that anabolic resistance is even worse in that person. So old age is is is a broad term. But it's really, really complex. No no two old people are the same in our research studies. Um, yeah, and in terms of all the factors that come that come with them and influence muscle muscle adaptive remodeling. So, um, it's really context dependent. But yeah, as I say, if you if you are a lifelong exerciser, we we've done these studies in master endurance athletes, triathletes before. Um, and master cyclists as well. Um, generally speaking, they, you know, when we look at their muscles under a microscope, they actually they they don't look closer to somebody the same age who is untrained. They look closer to somebody who is in their 20s. Phenomenal. That's phenomenal. But there is still some deterioration. So an old an old athlete isn't, you know, um, then their muscles still what they won't be quite the same as their muscles were when they were 20, but the context here is they they had a higher starting point in the first place, right? Yeah. Um, the rate of decline is probably quite similar between athletes and non-athletes in terms of how your muscles deteriorate over the years. Um, but by and large, if somebody who's been engaged in lifelong exercise training will always be in a superior position because they started from that they had that higher starting point in the first place. So, you know, an an 80-year-old athlete who's managed to stay free of disease and in terms of their not just their muscles, but their their I guess their whole body physiology, different systems, um, will will look 30 years younger. You know, so they'll be superior to somebody who's 50 but who was never never engaged in exercise. But that 80-year-old will still not look like they did when they were 40. 40. Yeah, yeah. So we have to appreciate that there is always going to be some decline in the quality of your muscle. But from everything that I've heard you say, it pays dividends to, using your terminology, bank that muscle uh size and and and health and and function as early as possible to sort of offset that decline. And obviously give the continual stimulus to those muscles as you age as well. That's going to give you the best bang for your buck.

Professor Lee Breen: Yeah, absolutely. It's like, you know, it's like saving for a rainy day. It's the it's the muscle mass and strength bank account. Save for the rainy day when you need to splurge thousands on an unforeseen bill or whatever it is. Which which you know, and the equivalent of that in in in these terms is a period of illness or hospitalization where we know these things unravel really quickly and muscle deteriorates. So if you're pretty well banked and you've got that, you know, you've got the nice buffer there, then you can afford to eat into that. And and and and the chances are you you you'll do much better on the other side as well. So you'll be able to get back to where you were perhaps more efficiently. Um, you know, you'll lower your risk of of of readmittance back into hospital, um, you know, other complications that that that could occur. Um, yeah, that could occur as well. But I I want, you know, I think it's important here that we talk about banking muscle mass. It doesn't always mean that it doesn't necessarily mean that everyone needs to get as big and pack on as much muscle mass as possible. I always think that's an important message because um, you know, there's a certain threshold probably that that that everyone should reach in terms of um, you know, strength, function, the amount of muscle relative to fat mass that you carry in your in your body. And going beyond that to very extreme ends of the spectrum where you know, body fat is virtually, you know, is is down in the single digits and muscle mass is extremely large as as would be the case for a bodybuilder or you know, any other, you know, um, kind of you know, elite strength or powerlifter, weightlifter. Um, we don't need to get to that point to be relatively well protected. Yeah. Um, you know, and if anything, I'm I'm not sure in terms of health risk reduction, what happens at those extreme ends, we can't really comment on that. But um, you're probably pretty well protected. You know, if you're if you're you're moving into your 40s, body fat hasn't changed an awful lot maybe from your your early 30s. You feel strong. Um, you know, you you feel like you've got good levels of muscle mass for your physique, then you you're probably quite well protected and you you are doing, you know, you're making great strides in reducing your risk.

Dr Rupy: Just to double click on the protein subject, particularly for older people, what are your thoughts on protein amounts that we should be aiming for in that, um, and I'm using over 50 as an arbitrary cut off, but maybe maybe that is the correct um, time frame uh after which you'd want to really think about increasing your protein. What what are your overall thoughts on that?

Professor Lee Breen: Yeah, I mean, I think um, yeah, without doubt as we again, if you look at a whole, you know, a large population, um, across the life course, you would see that protein intakes generally decline as we advance in age, generally. So that doesn't mean that everybody goes the same way, but across, you know, across thousands of individuals, you would see protein levels declining in middle age and then and dropping a little bit further in older age. Again, the the vast majority of kind of healthy community dwelling older adults who have who are maybe have, you know, um, chronic conditions but are generally independent and consider themselves healthy. These individuals actually across the course of a given day consume at or above current recommendations for protein. So you know, in terms of the the FAO, the WHO, those guidelines for protein are generally met and to some degree surpassed for most healthy older adults. Yeah. But, you know, those guidelines were they are based on the concept of avoiding deficiency, not optimizing health outcomes. So there are two different things to consider here. Yeah. There's a very there's a great difference between avoiding deficiency and the health issues that come with that and actually, well, if I went a bit higher, could I achieve something that looks more optimal here? Yeah. Um, so then we then we start to look at, you know, the the the amount of of protein that older individuals consume. So we we've done these studies in in older individuals, acute kind of metabolic investigations where we use stabilized sub tracers and muscle biopsies to study protein synthesis.

Dr Rupy: Can you just explain what a stable isotope um

Professor Lee Breen: Yeah, so so these are um, so so these are um, substrates that um, they naturally occur in our body just in very, very small amounts. Um, even the stable isotope version. Um, and what we do is we we effectively we can infuse them into the forearm vein or we can have somebody consume it in a drink. And we we increase the amount of of of the stable isotope version of a of a substrate in the body. And if we do, if we increase the amount of it, it means we can see it, we can detect its presence in tissues. Okay. And if we sample tissues, we can look at how those tissues remodel and adapt and turn over in response to could be exercise, nutrition, disease, aging, you know, a whole host of different different factors. So we've done these experiments and and and other others have, you know, again across different continents and and the finding is that older adults seem to require a higher dose of protein in a given meal in order to to support a really um, a robust, significant increase in muscle protein synthesis that that's roughly equivalent to a to a younger person. Um, in terms of what that amount looks like, for a younger person who weighs about 80 kilos, um, the consumption of, you know, a meal containing about 20 grams of protein is a great hit for their for their muscles. For an older person weighing 80 kilos, it's probably closer to 35 grams of protein needed to to mount the same response as that that 20 grams did in in the younger muscle. Wow. So those intakes, yeah, generally jump up quite, you know, 30 grams plus. Um, and again, we've got to appreciate that there's a challenge here because it becomes it becomes difficult to do that in older age, right? Because of um alterations particularly to to appetite regulation. All the factors that feed into to how satiated and full we feel or our our desire to eat, all those things change. Um, you know, to some degree, protein rich foods might become less appealing with older age and they're also dental issues and other things that feed into this that mean that, you know, people might not eat the the high quality cut of meat. Um, you know, um, and and I think a contemporary issue around this is, you know, perhaps um, um, planetary health and food choices as well. I think there is an older generation now, it's not just the younger generation that are becoming more aware of their food choices and the environmental impact, but also older adults are starting to kind of feed into this legacy now as well. So what that can sometimes mean is perhaps a change of dietary choices towards lower quality protein sources, you know, moving away from something that's that's animal or meat-based. Um, to something that's that's that's plant-based. And and may not necessarily deliver the same amino acids and nutrients that your muscle really needs. I would caveat that by saying, I think it's perfectly um, perfectly possible to achieve sufficient protein and amino acid intake from a plant-based diet before I go any further. I don't want to yeah, yeah, of course, yeah. Yeah, kick kick plant-based diets. So yeah, older older adults need this this this, you know, more protein per meal to support their their muscle muscle metabolism. But it but it's difficult to do that. Um, and so, you know, the the general guidance is the current recommendations to to avoid deficiency, alternative position statements have been produced that suggest older adults try to to aim to consume 50% more than those recommendations in order to support their their muscle health. Okay. So they're thinking about those recommendations are to avoid deficiency at the whole body level. So they don't think about optimizing health and also they don't focus specifically on muscle health in older adults. Yeah. Yeah. So the the current guidelines at the moment, um, are 0.8 grams per kilogram of ideal body weight per 24 hours. What you're saying is particularly for older adults who will experience this anabolic resistance phenomena, we need to increase that by at least 50%, potentially even more so, 75%. So a baseline of 1.2 grams. Yeah, moving towards 1.2 grams per kilogram of body mass a day is a is a great starting point. Wrapped up within that is the consideration about how you distribute protein as well. Another level of complexity. So we know older adults, again, taking a population wide view, older adults tend to consume breakfast and perhaps lunch meals that are very low in in protein, generally kind of cereal carbohydrate based breakfasts. So these are great opportunities to add more protein in um into the day. The evening meal generally tends to be protein rich. Again, if we think about when we would consume meat, yeah, you know, meat meat in a day that that that would tend to fall in the in the evening meal for a lot of people. Yeah. So there's there's things, you know, there's things older adults can do there. Um, you know, this kind of consideration of, you know, trying to aim for sort of 30 grams of protein per meal throughout the day. So every every several hours, you know, four or five hours, 30 grams of protein going into the system, supporting that that muscle health response. But there's there's only so much you can achieve and I I'm a firm believer in this that that you you can't, you know, you you can't simply push more protein into the system and expect an older muscle will continually respond and adapt to that as well. There's a there's a ceiling limit. There's an in there's an intrinsic and inherent, you know, um, defect in in aged muscles that mean they are unable to to continually respond to increasing amounts of protein. So you can push more protein into the system and you you might be able to to get a little bit more um, a little bit more in terms of a a growth response in muscle, but you can't just keep doing that. A great way to to make more efficient use of the amino acids from the protein we eat is exercise. Yeah. An exercised muscle that you know, that has been contracted and had that that kind of that exercise demand placed on it is more responsive to the protein you consume in your diet. So more of that protein will be incorporated and built into muscle. Yeah. if that muscle has been exercised. So again, it's that that combination of, you know, to quote Jack La Lane, the or maybe one of the first fitness influencers from the US in the 40s and 50s, exercise is king, nutrition is queen and you put them together and you have the kingdom, right? So it's always that thing there. Um, and without the exercise, simply increasing protein nutrition might give you an added bump. Yeah. But I don't know in terms of, you know, long-term muscle health protection and risk reduction, exercise needs to be incorporated as well.

Dr Rupy: Yeah, absolutely. And and just to round off this discussion around protein and older adults adopting a more plant forward uh approach or even a plant-based approach. I share similar concerns actually because when you consume more fiber in the form of beans and lentils, legumes, etc, um, it's great for your gut microbiome, big fan of those, but if it's at the expense of higher quality proteins that are easier to digest and absorb, you could fall into that trap of actually being protein deficient even at the level that the current recommendations are set. And so I think it's pertinent to to get people to think about quality sources of protein and introducing maybe even higher protein uh containing plant-based products like, you know, nuts, seeds, tofu, tempe, all these kind of higher rather than beans and lentils that are great from a fiber perspective, but they are typically lower in terms of their amino acid profile.

Professor Lee Breen: Yeah, you're right. I mean a lot a lot of those foods can be used as as a great meat substitute. Um, and you can give you, you know, a meal that kind of feels satiating, tasty. But you're absolutely right, you know, these a lot of plant-based sources are deficient in one or more of the essential amino acids that our muscle really needs. Now, that that's, you know, when we score the quality of these proteins and we we stack them up and compare them against one another, that's you you would generally animal proteins would would jump out as being a much more high quality. But we don't as you know, we we're humans, we're complex. We don't eat food in single sources, right? So we we have multiple plant foods together as part of a as part of a mixed meal. Um, you know, maybe it is the mix of animal and plant proteins together as well. But certainly, I think a lot has to be done in in, you know, education and and communicating the the message about a a diverse range of of plant sources in a vegetarian and vegan diet as well, right? Ensuring that protein is coming from a yeah, a variety of of different sources. Um, and you know, and again, fiber, fantastic. It's, you know, sometimes people talk about fiber being as, you know, anti-nutritional and and and um, anti-nutritional factor that slows the ability to digest and absorb protein into the into the to to the body. Um, I think you can, you know, you can add something like fiber and the the health benefits, you know, we talk about the gut microbiome, inflammation, immune health. Those benefits far outweigh any any minor effect that might have on on the ability to get protein into circulation. Um, yeah, sure when you add other components in, you know, complex foods with a, you know, in with a whole food matrix as we call it, you know, different um, macronutrients in there can certainly slow down, you know, the ability to digest and absorb protein and amino acids, but the effect that has on muscle is thought to be relatively negligible. Yeah, it's not a huge huge deal.

Dr Rupy: Let's talk about key muscle groups that we should be training for healthy aging and longevity. Which ones would you concentrate on either at home or or if you get the opportunity to go to the gym?

Professor Lee Breen: That's a great question. I'm I'm um, there's a there's a complex answer, but I will I will break it down. So so I would say so the the the the muscles um, our appendicular skeletal muscles, so those are the muscles in your legs and arms. Um, I think, you know, generally we we the associations with activities of everyday living are really tightly linked to to, you know, muscle mass and strength in in the arms and the legs. You know, we we especially the legs, I think the the ability, I mean we we have such a large amount of muscle mass in the lower limbs. It is super important and we we've noticed over the years that, you know, as soon as a as soon as somebody of an older age loses the ability to rise from a chair, which is again predominantly driven by the the the quadriceps and hamstrings. As soon as that ability becomes compromised, things unravel really quickly in terms of their, you know, their their health risks and and the consequences that that come with that. So, um, yeah, super important. Um, again.

Dr Rupy: So so if someone's listening to this and they either know someone or they are that someone where they're getting a little we're sat on chairs right now. If you struggle to get up off your chair, that's a sign.

Professor Lee Breen: Yep. Okay. Yeah, especially if that that is something you've noticed has come on over a over a few the last several years. It indicates a sign that, you know, the the the those muscles are atrophying, wasting away really quickly. And again, we when we when we look at how quickly muscles deteriorate with advancing age, different muscles across the body, the the legs seem particularly susceptible. Yeah. Really susceptible. And it might be because we are we are up and about, we load our the muscles in our legs, we've evolved to load them for a large proportion of the day. We stand, we move. Um, and as soon as that, you know, our standing and our movement, our physical activity levels decline, it might explain why the muscles in the lower limbs seem really susceptible to to to age-related age-related loss. So they are, yeah, um, they're very sensitive to that. We lose muscle mass in the legs quickly and that's why those types of functions that involve the lower limbs can you you can notice changes there quicker than you can perhaps with the upper body as well. So, um, I think, you know, urging people to to to I mean, focusing on the the arms and the legs. I don't think a a resistance strength training session should um, especially, you know, with advancing age for somebody who's perhaps new to this, should involve focus on one muscle group, one limb. Um, but if there's emphasis, you know, beyond the age of 65, so if there's emphasis on the lower limbs, I think it's it's it's a really smart strategy. That doesn't need that doesn't need to involve going to the gym and doing very complex compound movements like a squat for a barbell squat with a you know, the bar on your back, for example. Um, it could be something simple like actually just rising from the chair and and repeatedly throughout the day. So perhaps if you're finding that task particularly challenging, maybe several times a day just rise and sit, you know, 10, 20 times, whatever is comfortable or or whatever feels like it has as created, you know, a level of kind of demand. Um, so if it feels somewhat fatiguing and you feel like you're getting some resistance there and a a little bit of additional demand, you know, do that 10 or 20 times. Okay. Or well, 10 or 20 times is is going to differ for for for certain individuals. So people who are relatively healthy will be able to to do that over the age of 60 heartbeat. For others, 10 might seem like, wow, that's that's a really unaccomplishable goal that's way in the future. But so it's so the number is is whatever works for the for the person. And again, initially that might need to be assisted, so using the arm rest to to to um, to to move yourself from the chair. But actually just practicing that movement, I think is a great it's effectively a squat. Yeah, yeah. It's not a million miles away from a squat that you would do in the gym with the barbell on your back and Yeah, yeah. and that those are really complex movements. So the the sitting and uh sorry, rising and and um and then sitting in a chair, a great exercise you can do around the home.

Dr Rupy: Okay.

Professor Lee Breen: As well. You know, stair climbs also fantastic.

Dr Rupy: Okay, so we've got so sitting and rising from a chair, this is home stuff without any equipment. Stair climbs.

Professor Lee Breen: Climbs is great, yeah.

Dr Rupy: So going up and down stairs.

Professor Lee Breen: Yeah, you know, things like um, you know, if if people are able, um, something like a lunge again, it doesn't need to be a full range of motion lunge where the knee is, you know, right down on the floor and you know, you can hear the knee joints cracking. I mean, these these can all be partial movements as well. So the range of motion, the the um, through which the joint is moved, it doesn't it doesn't need to be full. Um, again, it depends on the person's starting point. Some people will find those movements virtually impossible. Yeah. Others it'll be a little bit easier. You know, there are things you can do around the kitchen, you know, lifting the shopping bags, the the tins of beans for those sorts of things for the upper body. Push-ups leaning against a wall to do a sort of partial push-up or a a push-up on your knees on a comfortable carpet or a mat. All of those things can can really help as well.

Dr Rupy: If we were to drill down and let's say this is literally something that I want to start doing uh during my week, which days in the week should I be doing it and how many reps and how many sets of each of those different exercises, let's say?

Professor Lee Breen: Yeah, so I think if it's it's somebody who's over the age of 60, never engaged in strength or resistance exercise training, start aiming for two times a week. Okay. Again, so spaced by three or four days. So you you know, it could be a, you know, it could be a Tuesday and then, you know, you're doing your next one on a Saturday, something like that. Um, if you've never engaged before and you're uncomfortable going straight into sort of the the the gym environment, I think doing something around the home, setting aside, you know, maybe 30, 45 minutes. So that's an hour and a half total over the the two sessions in the week. Each of those 30 to 45 minutes, it should involve um, you know, two to three exercises on on um of the upper and the lower body, I think. Keeping it relatively relatively simple as a as a starting point. In terms of how many, so so that could be, you know, the again, the the partial push-ups that I mentioned, the the squats from the chair, the the stair climbing. Um, in terms of how how many and and and how you monitor the intensity, how you know you've done enough. Those things are really, really difficult. And again, it will it will differ depending on the on the individual. But I think, you know, you a good guide is generally to try and do several sets of each exercise. So I mean, we we typically talk about three, three or four sets of of each of those exercises. Um, the reason we suggest generally is multiple sets is that it it seems to take a few efforts, a few sets in order to get the level of activation in the muscles that we know is a really important driver for that that growth remodeling response. It's difficult to achieve that in one set unless you're perhaps if you're younger and you go to the gym and you go all out straight away, you're safe, you're not going to get injured. But it's difficult in older age. So that's why we would generally recommend a few sets to get there. The last repetition, the last movement in each set, you should if you think about a a 10-point scale, zero being super easy, 10 being the hardest thing I've ever done. I could I couldn't do another one. Yeah. You want to generally aim to be at sort of the the I think the seven to eight range. Oh, okay. You know, so you feel like you've done a a high level of work and and it's been relatively demanding is the is often what we tell people to look out for. So if you do that three or four times for a given exercise, let's say the squats, by the time you've finished that third or fourth set of of squats, the chances are that the how you rate that on the the scale of effort is probably closer to a nine because you've done it a few times. Right. Hey, actually the the first time it was a six or a seven, the second set was a seven or an eight and now wow, yeah, boy, I feel like I've done something there. It feels relatively demanding. Now we're not we're not telling people to go to the point where you feel as if, you know, you're about to to, you know, to dislocate something or or or have, you know, get a muscular strain or an injury. It doesn't need to be that excessive. We always call it the point of near fatigue or a high degree of demand. These are the the terms we we we tell people to try and get to. Um, again, how many repetitions that involves will be really different for for different individuals. What I would generally say is if you're if you're getting to that point where you feel like there's a high level of demand and it's taking you 40 or 50 repetitions to get there, not only is that not very time efficient, but I would start to argue that, you know, you're um, you may not be um, providing sort of adequate stimulus to to the muscle. So then I would start to think about, well, are there ways you can increase the resistance so that you get there in fewer repetitions. So if it's the if it's the rising from a chair, perhaps all of a sudden you stop using the arm rests. Um, or perhaps you hold something a little heavier. Um, you know, it could be a a heavy item from the kitchen you hold just to increase the the amount of weight you're trying to move from the chair. So there are ways, you know, there are simple things you can do to increase the resistance to ensure you're getting there that point of demand in an efficient way.

Dr Rupy: Yeah, yeah. I think that this is a really, really clear and I think it's really accessible for a lot of people, particularly those who are intimidated by going to the gym or they're just not at the level where they need to go to a gym and this is a great starting point. So if I was to zoom in into one of those exercises that you would be doing in um, in a day, twice a week, getting up from a chair without any weights, if I can do 10 and at the 10th one, I feel like I've done like 80%, I could probably push myself more, but I'd really be going for it. I'd want to try and do at least three sets of those spaced up by a few minutes to give myself some recovery.

Professor Lee Breen: A couple of minutes, whatever works. I mean the the amount of rest you take in between it's, you know, really variable. I think the generally a two or three minutes is advisable just just to again to ensure that by the time you get to the end of the fourth or the third or the fourth set, you've achieved that that level of that level of demand. You've not completely recovered is what I mean. You don't want to completely recover between sets. It's a cumulative effect you're trying you're trying to achieve. And again, it's resistance exercise, especially for for new starters. Yeah. Even even new starters beyond the age of 60 who will adapt quite quickly. Yeah. It needs to be progressive. So you know, doing the same thing week on week, the same the same moving the same amount of load, the same number of times, those things will will will all of a sudden become very easy. Yeah. So it's about kind of it's about continual adaptation as well. Now, some people might not feel comfortable with that. Um, and actually just getting to a point of maintenance is absolutely fine. There's there's there's great benefit in terms of risk reduction and and supporting long-term muscle health that you can achieve just doing the same the same thing. Yeah. But most people will want to I mean and then, you know, things like motivation and adherence will be will be poor because people will feel like they're going through the motions and ah, it's not it's not hard anymore, so I'll just stop. Yeah. So it needs to be progressive. Think about what you can do to make the the work a little bit harder. And I think when somebody's been doing something around the home maybe for for several months, perhaps they'll notice changes in their body body composition, you know, the number on the scales or when they look in the mirror or all of a sudden they can do new things they couldn't do before. They can complete tasks that they haven't been able to for 20, 30 years. Maybe they get to the point then where they want the additional challenge or they feel comfortable going into a gym environment and and speaking to a trainer who can help them incorporate more complex exercises in into their routine involving, you know, free weights and machines as opposed to household objects. Um, I think generally people, you know, people get to that point. And it's there are, you know, numerous great classes out there now in almost every health and leisure facility tailored for for groups of the over 60s. You don't need to wander into this strange environment that's quite intimidating surrounded by it could be young influencers filming themselves or whatever. I don't know what goes on these days in those. But that's that's awfully intimidating and you walk past a, you know, a stack of protein shakes on the way in. Yeah, yeah. And you know, pre-workout powders and um, it doesn't need to be that way anymore. You know, there are there are fantastic kind of tailored groups where you can be with like-minded people of a similar age. The training is is personalized and specific to to an older generation. Yeah. So there are lots of mechanisms now. It's just about getting out there and and accessing that when you're comfortable.

Dr Rupy: Yeah. Let's double down on that. Um, so, uh, there we've talked about folks who, uh, want to start off by doing some of those body weight exercises at home using the equipment that most households will have. Um, let's say you have an individual in their 60s, let's say, who is fairly active, they walk, they might play tennis, uh, like once every two weeks or so, once every week, they do a bit of their gardening, but they don't do resistance training. Um, what exercises when they go to the gym should they really be thinking of? If we could choose, let's say, I'm going to put some limits on this for you. Let's I'll give you eight. Uh, yeah, I'll give you eight exercises that people should that if there were eight things that you can do in the gym, what what do you think those eight?

Professor Lee Breen: I'm not even sure I need to go to eight.

Dr Rupy: Okay, brilliant. Well, that's even better. That's great.

Professor Lee Breen: But it's nice to have a ceiling. Yeah, yeah. Um, the squat. Okay. Undoubtedly. And again, it doesn't need to be barbell on the back. The the there are lots of variations of the squat that can be that can be done. It can just be a body weight squat without any resistance. Just simply moving through the squat.

Dr Rupy: With the bar? Is that what you mean? Or just literally?

Professor Lee Breen: It doesn't need to be with the bar. Yeah, you can do it with the bar on a on a lifting platform where it's so it's a it's a free weight. Yeah. You can do it on something called a Smith machine where the the bar is fixed um and it's kind of a it's a sort of controlled motion. Um, you can do it holding a dumbbell, you can do it without any weight. You can just stand there, um, you know, hands on on each opposing shoulder and just work through the work through the squat motion, move your own body weight. The squat's probably the the number one, I think I would I would recommend.

Dr Rupy: Number one. All right. Everyone should be able to do a squat.

Professor Lee Breen: Well, yeah, yeah, I mean and again, it's it's you know, various you don't need to do the full range of motion. So the you know, your backside, your glutes are nearly touching the floor there. It it how comfortable somebody feels, it it will differ, especially amongst, you know, older individuals who might have sore joints, pains in joints in certain places. Um, but the range of motion will improve the more you do this. That's the important thing to say as well. And things like pain that they experience, all those things should should be well controlled the more you do them. They shouldn't get worse. If they if they get worse, something is going wrong.

Dr Rupy: Yeah, yeah.

Professor Lee Breen: So the squat. Um, and then next I was, you know, a version of a deadlift. Okay. Um, again, it doesn't need to be, so we think about the deadlift as the the you know, we think about strong men like Eddie Hall who can shift hundreds of kilos and you know, with a belt and chalk and and and so so but when we think of the deadlift, it's the bar on the floor with the with the plate stacked either side. But actually the the the movement itself of just, you know, being in that that that that crouched that crouched position um and being able to rise with and and move a load as you do that is a really important exercise. So it doesn't need to be the the barbell deadlift. It's is a version of that, but but there are lots of different versions, you know, lots of different ways of working through that. That again, a really important compound movement. You you can understand actually, it's a in a sense, it brings in, you know, a lot of aspects of the squat, the deadlift because you start from that crouched that crouched position. Um, but because you're holding something in in your hands as well, it incorporates a lot more kind of upper body postural muscles as well. So a great compound exercise to try and to try and achieve. And then beyond that, I think um, you know, things like a bench press are um, can be difficult, you know, they can cause joint pain and um, especially anyone who's had shoulder issues, if you if you are introduced to bench pressing at an older age for the first time, I don't know that that's always the the best strategy to to go down. Um, again, the the the benefit of that exercise or the adaptation, you can achieve through through something like a press-up. And again, there are lots of modified versions of the press-up. It doesn't need to be the, you know, 200 press-ups doing claps in between and a really complex. There are lots lots of modified versions, really simple to to do, you know, including leaning against the wall and and and pushing pushing away. Um, so some version of that. But again, I think most of the other exercises I would recommend as as key, especially for the for the the older adult would be um, would be movements that involve moving your own body weight. You know, I think things like a pull-up, any version of that. So it, you know, whether it's geared more towards activating and tapping into the biceps or whether it's actually a you're using a wider grip and you're and you're working, you know, the the the back and the shoulders. Yeah. Being able to move your own body weight is is really key. You know, so there's no single machine really that I'd recommend in the gym that's great. I think just being able to move your own body weight. Um, you know, again, we we we talk about for the upper body things like dips, depending on how comfortable you are with that, they some older adults may report joint pain initially when doing something like a something like a dip. Lower body, we come back again to, you know, we spoke about squats, we spoke about the deadlift that incorporates a lot of lower body muscles. Um, something like a lunge again, you know, great in terms of tapping into the hamstrings as well. Um, yeah, um, and you know, things like a there are different versions of the deadlift. So there's something called a Romanian deadlift, which sounds incredibly elite, like it's geared towards. Yeah. But there are versions of that you can do in older age and it, you know, um, very simple movement, just keeping a um, keeping a relatively straight straight back and a um a small amount of bend in the knees and just really um, activating the hamstrings. It's a great exercise for for flexibility and and um and muscle mass and strength in the hamstrings as well. So I think those those will be the four or five. Yeah. Um, I think maybe a plank. Again, I don't, you know, I think just the ability to sort of hold your own weight in the in the plank for a for a short period of time is is is probably useful for a certain a certain age. I don't know that it's a great, you know, kind of exercise for you get super adaptations to when you're, you know, healthy young exerciser that people should be sat in the plank for 15 minutes. I don't I don't see a lot of value there, but in older age, um, I think it can be it can be a really useful tool. It's really interesting when you, you know, you look at the government kind of guidance on what can constitute resistance and strength exercise. And you know, on that list is something gardening is in there. Yeah, yeah. You know, actually you've got to go quite far down the list before you see things like the gym and weights. Yeah. It's kind of surprising. I think I see why that's done. It's designed to make it more accessible. It's designed to, you know, to to make people feel like that these things are readily achievable, you know, carrying the shopping, gardening. Yeah. Um, things like yoga and Pilates are on there as well. Great in terms of, you know, postural control, flexibility. Um, but I think the exercises I've mentioned on my kind of hit list would be things I would I would encourage people to try and incorporate.

Dr Rupy: Yeah. Those are awesome. I think even for people who go to the gym regularly, you know, unless like you're um, an athlete or you are a bodybuilder or you're really interested in aesthetics, you shouldn't really be doing those single exercises for like single muscle groups, especially as we're all time poor and we want to get the most out of our gym sessions. And that collection of exercises, I think is not just great for older adults, but generally as well. So we can actually create that muscle bank, that sort of pension, if you like, um, for when we are older and you know, we have that protection, that buffer. Um, and you know, the um, the squats and deadlifts, there's so many different variations of that. And it sounds intimidating, but you don't necessarily need to use the bar initially. You can just start off by doing those movements in a gym or at home and then working your way into the gym and doing it with a barbell.

Professor Lee Breen: You can eventually graduate to that if you're comfortable. But you know, those areas of the gym, yeah, sure, there's there's chalk there, there's lifting platforms, there are big people shouting and and and they're generally quite friendly. There's big people. They're often the friendliest people in the gym. Yeah, absolutely. Yeah. So, you know, that I appreciate that can be um, that can be intimidating. But I I think, you know, for for if you've never done this before and you're going into it, um, you know, the general rule of thumb targeting the major muscle groups. So what I mean by that, those three or four muscle groups in the in the upper body, um, three or four muscle groups in the in the lower body. Yeah. Trying to to do some strength or resistance training on those muscle groups twice a week with a little bit of spacing between is a is a great starting point. Yeah. And you're right, I think some of the um, some of the isolated resistance strengthening exercises are are great for a, you know, it could be an aesthetic or there could be a specific functional performance need need to do that if if somebody is is competing in in a given sport or event. Um, but for the most part, if we're talking about risk reduction and and and supporting good muscle health with advancing age, then I don't I don't see any need. I mean, a mistake I see a lot actually is um, say a mistake as I see it, um, is you know, sometimes older folks move into a gym facility and um, will concentrate on something like a bicep curl, you know. And occasionally because it's everyone's seen that. And it's easy, it's easily accessible. You can kind of walk over to a rack of dumbbells and pick something light and stand and do that exercise. And and I think most people when you think of resistance strength exercise, you you think about people curling a bar. And there are other examples as well of those single joint, you know, exercises quite isolated, smaller muscle groups in terms of their their relationship to to physical function and healthy aging is is quite weak. Yeah. So that's often a mistake you would see. Um, it's through no fault of the of the person at all. It's just that, you know, walking into that intimidating environment, what is it I can do that that I'm comfortable with? I'll go and do something like that. Yeah, those more complex compound movements, as you mentioned, way more bang for your book.

Dr Rupy: Yeah, awesome. Okay, so just to summarize, we've got squat, deadlift, uh, bench press or chest press, uh, you've got lunges, and then pull-up.

Professor Lee Breen: A version of a pull-up.

Dr Rupy: A version of a pull-up. Yeah, pull-up and dip. So there are these machines where, you know, a pull-up might sound quite intimidating to someone who, you know, can't even hang on the bar. Um, but there are these machines that you can put your knees on if you're able to, and then it will give you some resistance.

Professor Lee Breen: Yeah, you can get an assisted. Yeah, you can get an assisted one. Yeah, or you can I think a great starting point if you're somebody who's never done a pull-up before is actually to find a way to kind of elevate yourself or raise yourself to the bar and do what what I would call a negative pull-up. So you you start in the motion as if you're already up at the top of the bar and just let yourself gradually lower yourself down. Yeah. and step on the box floor, whatever it is, and and and repeat. Yeah. and just do some negative um, you know, that that negative motion. I think it's a great way to start. And eventually, you know, you will feel comfortable attempting, you know, your first full Yeah. your first full pull-up. It's all about that.

Dr Rupy: Because I guess there's a lot of attention on the concentric movement, either shortening of the muscle rather than the eccentric movement, which is the elongation of the muscle. And I guess both are just as important.

Professor Lee Breen: So yeah, I mean people have tried to in in healthy young exercises, there's been some really interesting work from, you know, some colleagues and friends that have tried to tease out the the um, the the I guess the importance of the the type of muscle contraction for for how it develops. I should you focus more on eccentrics versus concentrics. And I um, I don't I don't know that there's a really strong rationale at the moment for focusing on eccentrics. The eccentrics, so this is the lengthening of the of the muscle. Um, so if in a bicep curl, that would be the weight being lowered, lowered to the floor. Um, you know, they seem to to introduce quite a lot of mechanical load to the muscle and and seem to be quite potent in terms of how they activate and communicate to those molecular signals that that that control growth. But I think if you're doing with most of the exercises I've mentioned involve an eccentric component. Yeah. Yeah. Um, and I think in terms of, you know, if we think about kind of balance and and, you know, posture control, good muscle health, I don't know that it's sensible to neglect the concentric the shortening aspect of the muscle. As I say, I think most of those compound movements involve all of those compound movements would involve both concentric and eccentric actions. Um, and I think if the if the goal is healthy muscle aging or perhaps reversing some of this sarcopenia that has occurred, then um, I think focusing on the on the whole range of motion, concentric, eccentric is is the way to go.

Dr Rupy: Brilliant. Um, and let's say I've graduated from my tennis and my gardening and walks and I'm I'm going to the gym confidently now. In an ideal scenario, and I know there's no such thing as an ideal scenario, but just uh for someone who is optimum or uh exercising using resistance training to the best of their ability, what kind of volume and set load are we are we really thinking about in terms of all these different exercises and how should we be spacing them out in the week?

Professor Lee Breen: Yeah, good question. So I think, you know, the example we use, the the you know, the person who's quite physically active, has the tennis, you know, if they if they were able to achieve two of those resistance training sessions a week and and they were targeting the whole body. So let's say it was each session was six or seven exercises, three or four for upper and and lower body. Again, each of those exercises with with multiple sets, um, you know, repetitions as well. In terms of how they how they progress, I mean, it's really difficult to put, you know, volume is the training volume is the product of repetitions times the number of sets multiplied by the load you lift. So it's hugely variable for for for each individual. Um, one person's volume might, you know, it might be high volume for one person, it might seem really small small for for somebody else. So I think, you know, generally it it it there are a number of ways so you can be really regimented in in how you track your volume. So week on week, you could you could look at the cumulative volume that you've achieved in your in a given muscle group, which you know, could be hundreds or thousands of kilos when you multiply all those factors together. Um, and generally, you know, generally speaking, you would look to you would look for that number to to stabilize or perhaps even increase week on week and that that's progressive resistance exercise training. Um, so you know, and the same for an older person, it you know, now nobody, you don't necessarily need a notebook and you don't need to write down reps, sets, weights and be calculating everything in between your workout or or when you get home. It's a it can be a bit simpler than that. Sometimes it's the knowledge that, hey, last time when I was on my fourth set of of of squats, I um, I could only manage with this weight, I could only manage eight and today I've done nine. Um, so the the volume of that of that given exercise has increased. Yeah. Um, so so there are simple ways you can monitor it like that. And then and then of course, you know, you it's always a you know, interesting to think about when do I, do I simply if I find it easier week on week, do I just do more of them? Do I do more repetitions or or do I stop and actually increase the increase the weight? Or do I try and do both? And and and you know, that will differ for each individual. But I think as long as you are progressively increasing volume, which is you you know, you are doing a little bit more, a few more repetitions or you are able to alter the weight and adjust it and and pop it up slightly, then that's great. And it doesn't need to jump hugely as well. You know, within starting a resistance exercise training program beyond the age of 50, 60, one thing people will notice is that they will get strong quite they'll get strong quite quick. Um, so within three or four weeks, people will feel noticeably stronger. So the the the the workouts they were doing four weeks previously will seem, ah, quite easy now. Once that initial stimulus and that neural adaptation has started to occur and also things like damage have have subsided. So the soreness you feel after the first few workouts is can be agony if you've never exercised these muscle groups, it can be really sore. That subsides over time. It it never stays the same. There's something called the repeated bout effect, which means you're your muscles will never be as never experience the same soreness and damage again as they did the first time you did the you did that movement or that exercise. Right. So damage gets easier and goes it gets less and less. Uh-huh. Um, yeah, so so all those things will will um, will change. Um, and I think as long as you, you know, you're working out and you feel like you're achieving that high level of demand and you you're keeping an eye on the load and the repetitions and those things are creeping in the right direction, then great. And people will experience times away from the gym. You know, it's going to be the Christmas holidays or the summer summer vacation or a period of ill health. And things will either stabilize, plateau or go backwards. Um, and so it's, you know, all of us, you know, in the space of three or four years, you know, somebody wouldn't be, you know, 500% stronger, for example, unless they were very very sick at the start of the training regime. Um, because there are, you know, we we have lives, busy lives to lead and things happen. We sometimes we feel like gymming, sometimes we don't. Sometimes we're away from it, sometimes we're sick. Um, yeah, so I think generally as long as somebody after three or four months of training, perhaps in the gym as well and you've got quite strong and you'll notice that the gains are going to plateau. It's going to be harder to achieve the same types of leaps you did in the first few weeks. That's that's not just aging, that's any of us. It gets a little bit harder. And then maybe it becomes a little bit about almost accepting a degree of maintenance, you know, or perhaps if you want to push yourself and and achieve higher levels of strength and muscle mass, then maybe it's about thinking about, you know, different types of exercises. What can I do? Maybe I should do something with my nutrition to get that added, you know. As I said before, you know, nutrition, exercise king, nutrition queen, it can be the sort of cherry on the cake in a sense. And all of a sudden if you start to think about your nutrition around training, that that could be the key to give you a little added benefit as well. But generally speaking for most of us, young or old, things will adaptations will start to level off. Yeah. And then it's just about exploring ways to to try and squeeze a little more juice juice out of that. Yeah. If people want to get into a great level of muscle mass and strength and then stabilizing and maintaining that. That's great.

Dr Rupy: That's fantastic. I mean to echo what you were saying at the start, you don't necessarily need to have a really big muscle or change in your muscle or even change in your weight to still uh accrue the benefits of training, any sorts of training, let alone resistance exercise. So, um, you will still be having those metabolic health benefits, those cognitive health benefits, those cancer protective benefits. Those are all things that are absolutely. We we I mean the the term we sometimes come back to is that we don't believe there are there are any true non-responders to exercise. And what I mean by that is that the benefits are so um are so myriad, there's so much to to benefit from that almost everybody will benefit in some way, shape or form. So if you're over the age of 60 and you start the gym with your, you know, it could be somebody from your swimming class, you decide you're going to go to the gym and do some strength resistance exercise. You may notice that your your friend gets stronger quicker and maybe they gain a bit more muscle, maybe they lose some some body fat and and those things don't happen as quickly for you. Yeah. That can be pretty demoralizing. And it's a major reason why people quit strength training. They think, ah, you know, I'm I'm sore, I'm aching, my joints hurt because they've just started. Yeah. And also, it's not for me, it doesn't work for me. Nothing is happening. But actually the the hidden health benefits of of of any structured exercise training, but resistance and strength strength exercise are really, really profound. Again, in terms of, you know, what you're doing to to to minimize disease disease risk there is super important. You know, again, bone health, that's not something you can quantify or or measure. You know, we don't typically see or feel that benefit. But you know, um, stronger, more robust bones, that can protection for um, that protection against a fracture if you fall, for example. Yeah. Um, you know, making muscles, although the the muscle may not be getting as big as you want, it's if it's contracting and it's working hard, it's more insulin sensitive. So your risk of cardio metabolic diseases like type two diabetes is going to be lower. Um, things like improved cognition, brain health, all of these benefits are kind of wrapped up in that. So I wouldn't be too discouraged if people don't see um, bigger, stronger muscles as as quickly or as pronounced as they as they expected when they strength train. The chances are you are benefiting in in a number of other ways.

Dr Rupy: Yeah. And I think a lot of cases, particularly women, don't really want big or strong bulging muscles. Um, I mean, to get that, you you have to really make a concerted effort, right, of of training. So I don't think anyone should worry that if they do start resistance training, they're suddenly going to, you know, see a rapid change in their body composition. Um, it certainly shouldn't put people and that's a common sort of pushback I get from from people that, you know, they don't want to change, they don't want to look bulky, hence they're not going to resistance train. Um, so

Professor Lee Breen: Oh, even in your younger years, you know, in in somebody's mid 20s, it's pretty hard to achieve those types of physiques anyway, right? Because now you're talking about not just your two sessions of of resistance exercise a week focused on different muscle groups. You're talking about most days of the week, maybe every day of the week. And in terms of the volume, the and the focus on specific muscle groups, all those things really, really have to increase. And even then you have to have to some extent, you have to have kind of, you know, won the genetic lottery to some to some degree. So there's, you know, all of us have this kind of this this this finite window with which we can adapt and some people are just more fortunate than others. So it's really hard to achieve the those bulky muscular physiques even when we're young. Um, and as I mentioned before, it gets more difficult um to achieve comparable adaptations the older we get. So I I you know, the the types of frequencies, volumes, intensities we've spoken about here today for resistance training in the over 60s, it would certainly not be something that would that would result in in a person increasing their their muscle mass to to, you know, to huge amounts and and and visibly looking, you know, bulky and and intimidating or or whatever people's um, people's fears are. That that would be very, very difficult to achieve. I mean, it would often require, you know, we're not just talking about nutrition or other things to sort of get you know, in older age, you know, to to get to that level, you know, there are some really some interesting um, examples out there that's kind of appeared in the social media sphere in in over a number of years of um, you know, older older adults who might be on hormone replacement therapies, for example, who have engaged in um resistance exercise beyond the age of 60 and Yeah. and then, you know, um, these sort of topless photos of older men who are on hormone replacement therapy who, you know, you know, aesthetically anyway, or at least, you know, through various filters and you know, look good online on my on my Twitter feed or Tik Tok or Instagram or whatever. But functionally, I'm I'm not sure you I'm not sure people need to worry about that or or um, yeah, I don't think people need to worry about getting to that point. And I don't know that you get heaps of added benefit from being super muscular as well.

Dr Rupy: No, no, no. It's interesting like everyone's heard of fight a couch to 5K. Um, and I wonder if there should be an equivalent and I would call it couch to compound. Uh, so, you know, if gardening's down the list, then I I, you know, I agree with the sentiment that we need to make it as accessible as possible. But everything we've just talked about today in terms of those compound movements that you do at home, lunges, chair sits, wall push-ups, these are all things that are compound movements that you can do at home with the progression of getting into the into the gym and doing it with a barbell. I think couch to compound has got legs.

Professor Lee Breen: I think given that I'm guesting on the podcast when you mentioned that, does that mean I get a cut of the No, we'll chat afterwards. Couch to compound.

Dr Rupy: Uh, some some hot takes. Um, GLP-1s. Uh, so, uh, these drugs are flooding the market. They're going to become cheaper. Um, a lot of people are on them who, um, certainly, you know, should should definitely lean into them. I think these are powerful, uh, drugs that definitely have benefits. Um, how should people be thinking about minimizing any potential downsides of being on these drugs from an an exercise and and nutrition perspective?

Professor Lee Breen: Yeah, no, it's a it's a great point and um, yeah, you you're right, the GLP-1 uh, field, um, the number of treatments, GLP-1s and GIPs that that are becoming available is is exploding. Um, initially these these drugs were designed to to support the management of type two diabetes, glycemic regulation, but it was found that some off-target effects in terms of weight reduction were observed. So it's like, wow, hey, we've got a compound here that can that can lower weight. And so now there are lots of versions available not just for type two diabetes, but that that are marketed and geared towards um obesity prevention or reversal. Um, the weight loss you achieve on these drugs, as you mentioned, is is potent. It's huge. It's it can be comparable to what you would see with, you know, bariatric surgery like the gastric band. Um, so huge, huge amounts of weight reduction. The the mechanism behind that seems to be seems to be multifaceted. So it seems to result in weight reduction for a number of different reasons. Um, primarily it's the it's impacts on appetite and satiety. People don't feel like eating as much or can't eat as much in a single sitting. And it's that reduction in energy intake that really drives down body weight on these on these drugs. Um, but there are pronounced effects on skeletal muscle as well. Yeah. So with any weight loss intervention, GLP-1s, bariatric surgery or or even diet, you know, reducing calories every day, um, in most of the times, a proportion of the weight you lose will come from muscle as well. So you're you're achieving this fat mass reduction, but actually a a considerable chunk of that um, the number that you see go down on the scales can come from muscle mass as well. Um, with certain potent GLP-1s, it can be as high as, you know, 30, 40% of the weight you lose is is is coming from your muscle muscle mass reductions. It's really, really huge. Huge. So, although after, you know, six months of GLP-1, um, a person may be they may have a more favorable ratio of fat to muscle, I.e. they've lost more relative fat than muscle. Um, we think there are concerns here for the older adult. So, um, in older adults with obesity or type two diabetes who are prescribed GLP-1s, we know that obesity and type two diabetes accelerate sarcopenia progression first of all. So, in terms of muscle mass, strength and function, these folks may may already be hovering close to the threshold for disability. So what and sarcopenia diagnosis. So they they may be quite close to that. So there's a concern that GLP-1 treatments that result in this this body weight and muscle mass loss could be the tipping point effectively that takes somebody past that that. So although although yeah, body mass levels have gone down, actually the skeletal muscle um, function may be impaired as well. So they all of a sudden their ability to rise from a chair may be impaired. You know, can conduct those those everyday tasks of living. It's still being really poorly explored and it's one of the questions we're trying to pursue um, in in my group at the moment over the next few years. Um, and also again, you know, coming back to this idea of of skeletal muscle as this this this highly metabolically active organ that plays such an important role, not just in locomotion, but but all all aspects of of of you know, of physiology and metabolism. Um, you really start to have to ask if, you know, can we afford to lose any more of this beyond the age of 50 and 60 at an accelerated rate as well. So there are huge concerns. In terms of what can be done, um, again, the the evidence is really poor out there. People are only just starting to understand the impact of these drugs on muscle. And the development of interventions to counteract that is really in its infancy at the moment. But again, the the the group that I'm working with, we're um, you know, we're pursuing over the next few years various versions of interventions around lifestyle first and foremost. So what can we do in introducing exercise, um, dietary um, alterations as well, primarily types of protein intake to support muscle health. So again, that that combination of exercise with with increased dietary protein intake to support muscle remodeling and and effectively spare muscle mass loss really is what we're after. So I think I don't think there's anything you these drugs are so potent, I think there's very little you can do to completely prevent muscle loss. What we're talking about here is mitigating that, right? Trying to attenuate the the the loss of muscle. So we we can introduce some protective effects. What works? I mean, the from a lifestyle, you would think intuitively, structured resistance exercise should be front and center. Um, increased dietary protein intake if people can get that. Again, very challenging, not just in older age, but older age with GLP-1s when appetite really is crashing. How do you encourage somebody to take 15 grams more protein at breakfast and and lunch? Very, very difficult to achieve that. Um, you know, and then and then beyond that, there's there's big interest in the, you know, in in in the pharmaceutical space about the development of co-therapies that can be taken or injected alongside GLP-1s to support muscle health. And you know, maybe the only way to completely prevent is is to go down the pharma route. But I think there's a huge amount that can be done in terms of lifestyle, exercise, nutrition. Yeah, a huge amount.

Dr Rupy: Are those the myostatin inhibitors?

Professor Lee Breen: Yeah, there's myostatin inhibitors. There's a few others as well that target things like amylin. Um, you know, yeah, the the that can effectively stop some of these these these degradation breakdown processes or impaired anabolism that that occur in the muscle. So some of these compounds block the targets, those those molecular signals that that that yeah, control muscle wastage basically. They put the brakes on them and and and slow them down. Um, but again, you know, the the in terms of the the issues that might come with again, pharmacotherapy, the you know, taking a number of different in in individuals who may already be on various other drugs for different different conditions. You know, the management of their arthritis, the management of their diabetes, whatever else it may be. Um, yeah, it it's uh, it's difficult to see, you know, a really sort of strong long-term future in in that space. I think maybe only in in extreme scenarios, people who are entering these drugs with poor levels of muscle mass function who are diagnosed sarcopenia or severe sarcopenia, then hey, there's maybe there's probably something you can do with exercise and nutrition, but maybe in those scenarios you have to think about an an alternative and adjunct therapy as well. But you know, we'll see we'll see what the research brings over the next few years. I think there's a huge amount to be done here and I think we can do an awful lot to to spare muscle mass on GLP-1s. It's funny if you walk around most health food stores in Europe, but certainly in North America, everyone has a everyone has a section devoted to to GLP-1 um, support.

Dr Rupy: Really?

Professor Lee Breen: You know, so you go to the major health food chains in North America, there are all the supplements and the ingredients that you need to support and um, to support not just muscle health, but to support your health and avoid side effects of GLP-1s. And there's without a shred of evidence, I would add at the moment. So a lot of it's conceptual based on quite attractive theory. Um, but yeah, people are pushing these things into that space now with the recognition that there's a huge, I guess there's a huge commercial opportunity here. Um, and the evidence is is not is not there at the moment. So it's about catching up and and trying to put some some empirical evidence to to that.

Dr Rupy: I can I can understand sort of the thinking behind it because if you can't meet your nutritional needs in terms of caloric intake, protein intake, micronutrients, you know, the chances are you're probably becoming deficient in in micronutrients as well. So in the same way gastric bypass, bariatric surgery in general, they they have this sort of uh field, I think of supplementation that I I think some bariatric centers are actually promoting, you know, and in it's in the same sphere as Ensure and Complan and all those different products out there. You'd imagine like there might be some crossover, but like to your point, like without without clear evidence for GLP-1 anyway.

Professor Lee Breen: Yeah, yeah, I mean it's these things, yeah, I mean they they the the micronutrients, the the supplements, the things that are touted and out there, I mean, there's there's for some of them anyway, there's a a degree of decent evidence supporting their health promoting benefits in different scenarios. But the GLP-1 space is is completely new. And so there's a there's a bit of a rush to get to that space, I think and and um and and capitalize, exploit that opportunity. Um, so one of the things I'll I'll be doing over the next few years is trying to to put some evidence to to that as well. Um, but again, it can never be it's never going to be a um, you know, a huge uh, 10 ounce steak on top of a alongside a dinner meal to get the protein intake. So we're having to turn, you know, um, work with industry partners to think creatively about how you can how you can support.

Dr Rupy: Yeah. Um, on the subject of supplements, are there any supplements that you think are potentially useful for folks that actually have an evidence base um behind them?

Professor Lee Breen: GLP-1 or just in general?

Dr Rupy: Oh, sorry, outside of GLP-1, in general, yeah, to support uh exercise in in older adults uh if they start, you know, going to the gym and all the rest of it.

Professor Lee Breen: Yeah, it's it's a very small list with with, you know, really strong empirical evidence to to back the claims. I mean, it's if we talk about muscle health and adaptations to resistance exercise in the older adult, protein front and center. I mean, and it doesn't it doesn't need to be a supplement. I think um, you know, we would always encourage a whole food approach where possible. Um, supplements are convenient, easy way to deliver everything you need. They can be a great way to to as I say, to get the protein intake of a given a given meal up as well. If it's if it's that grain cereal based breakfast, hey, the protein supplement might work really well in that in that scenario to to to deliver the that stimulus the muscle needs. Yeah. So protein, you know, front and center, essential amino acid rich, you know, especially with in amino acid called leucine, which seems to be important um, supporting muscle remodeling and adaptation in older adults. Leucine seems to be really key. Again, most, you know, high quality protein sources from animal and even plant sources do contain good levels of leucine. So you can get there. Beyond that, in terms of optimizing, you know, adaptations, there's there's a suggestion that um, omega-3s, omega-3 fish oils can um, you know, augment or enhance your muscle building response to exercise. But there's an idea that that you know, a kind of a level of the the lipids contained within these within these supplements, there's a there's a suggestion that individuals might require certain levels of these lipids and and um to be incorporated into the membranes that surround muscle in order to achieve sort of effective communication, recognition of that signal that's coming from exercise. So these lipids are um, yeah, they can make their way into into the layers of of, you know, structures that um, that control our organs and our tissues. And so there's there's some idea that, you know, having adequate levels of of EPA and DHA contained in our omega-3s is important. Again, you know, people can get that through through their fish intake, seafood intake. Um, a supplements may be a convenient easy way. I would say there that the evidence, you know, omega-3s as a muscle building supplement is is not there. Sure. But perhaps as something that to to support um, you know, to support the exercise and and protein remodeling response, perhaps. If we talk about increasing the amount of volume somebody can train with and and strength and power output, creatine is still very, very effective. Um, even in older age, creatine's great. I mean, I I think it has connotations again around, you know, serious bodybuilding supplement. But there's there's increasing evidence to show that creatine supplementation um, can enhance the adaptive response to a training intervention. So if you trained alone without creatine over the age of 60, yeah, you get a great response. If you train with creatine, there's there's some evidence to suggest that you get an added an added benefit there as well. So you can get that that little bump. Creatine as well. I mean, thinking beyond muscle, there's there's now some really interesting research, you know, on creatine and brain health. So thinking beyond muscle and benefits to other tissues and organs, creatine supplementation might might play a really important role there. So I think those are the three generally speaking that I would I think are a really useful starting point. Um, you know, I think with the exception of creatine, it's possible to get, you know, the protein and the omega-3s through a um, you know, a diverse um, diverse diet diet choices. Creatine, yeah, yeah, generally it's it's hard to get those levels through the intake of red meat. You would need to supplement.

Dr Rupy: Yeah, yeah. And that that supplement um, dose is that is that still around 3.5 to 5 grams daily? Is that?

Professor Lee Breen: Generally for a a good kind of creatine monohydrate, um, you're talking about, yeah, three to five grams. I mean, the servings on these things are usually quite um, clearly communicated. Um, you know, there's there's some evidence that initially if you in order to, you know, to increase creatine concentrations in the body that you you might need to start with a higher dose near 10 grams in the first week or two. Um, to yeah, increase its absorption and and its availability for tissues. Um, but yeah, generally three to five grams, which is is a relatively small serving. Most of these things you can mix into a standard kind of, you know, glass of water or a drink now as well, quite tasty. Um, that would be the guidance. A little bit of evidence suggesting that, you know, we we thinking about the brain health that, you know, creatine intakes up and around 10 grams seems to have some some cognitive health benefits when we think about the brain. Again, that that's that work is in its really in its early infancy. I don't know that there are any huge health harms of creatine supplementation at the doses we've spoken about today. Now, of course, super high levels of creatine supplementation, I don't you don't get any added benefit and there's potentially a there's potentially a health risk there to um, you know, something like kidney function, for example, if you're going extremely high. Kidney and liver metabolism, you know, some of the scores, the readouts you get with your GP may be may look strange if you take creatine at very high levels. Ah, okay. That's outside the ranges we've discussed here today and the ranges that would be on any on any kind of standard, you know, supplement.

Dr Rupy: Yeah. Um, your moving position quite soon, aren't you? You're going to Leicester, you're going to be working with the endocrinology department and type two diabetic patients in particular.

Professor Lee Breen: Yeah, well, I'm yeah, I'm I'm uh, yeah, moving away from University of Birmingham to, yeah, University of Leicester. I'll be based in the diabetes research center, which is in Leicester General Hospital. Um, yeah, taking my my research in in aging and um, muscle metabolism and and the development of measures to support healthy muscle aging into into that scenario as well. So, you know, working with predominantly with patients who are um, not only advanced in terms of their age, but um, you know, they also have the presence of obesity and and type two diabetes. So exploring about how that when you overlay obesity and type two diabetes into aging, what that does to muscles and and understanding at the molecular level why this deterioration occurs, what are the other effects across the across different tissues and organs and then what we can do to to support that. Again, exercise, nutrition and um pharmacological interventions as well. They'll they'll we hope to do a lot of work in the GLP-1 space as well. You know, so Leicester is a, you know, again, one of the largest diabetes research centers in in Europe. Um, and some great work on GLP-1s in randomized control trials running through the unit already, hundreds of patients um, participating in these trials on GLP-1s. And there's a really fantastic opportunity to to tap into that platform and actually understand things from a muscle-centric view as well. So that's where I'll be I'll be going in the next few years.

Dr Rupy: Yeah, that's awesome. And I think that muscle-centric view as we age, I think is so important, which is why I wanted to have this conversation today because I think traditionally it's something that A, I wasn't taught about at medical school over 20 years ago. But B, I think it's uh it hasn't been as much on my radar as it perhaps should have been. And like leaning into nutritional medicine is is obviously my bias, but I think that combination, that sort of king, queen, kingdom analogy that you've come back to a couple of times, I think is really important for other people to understand as well. Um, and if we can get that that lovely marriage between the two, aging, healthy aging, I think is possible for a lot more people. So I appreciate your your insights. This is awesome. We even get to talk about synolytics and some other muscle targeting drugs, but um, maybe we'll we'll save that for uh a podcast on uh couch to compound.

Professor Lee Breen: Couch to compound. Yeah, happy to happy to come back.

Dr Rupy: Thanks so much for listening to this episode of the Doctor's Kitchen podcast. Remember, you can support the pod by rating on Apple, follow along by hitting the subscribe button on Spotify, and you can catch all of our podcasts on YouTube if you enjoy seeing our smiley faces. Review show notes on the doctorskitchen.com website and sign up to our free weekly newsletters where we do deep dives into ingredients, the latest nutrition news, and of course, lots of recipes by subscribing to the Eat, Listen, Read newsletter by going to the doctorskitchen.com/newsletter. And if you're looking to take your health further, why not download the Doctor's Kitchen app for free from the App Store. I will see you here next time.