Dr Gabrielle Lyon: we've got a lot of questions about healthy aging, aging for women and I know you are an advocate for teaching people about muscle and why muscle is so important. So can you explain why muscle matters just so much?
Dr Rupy: I think it's a really interesting perspective because when we think about aging and even young women moving into adulthood and then beyond, their conversation for the last five decades has been all around adipose tissue and fat. It's been all around body fat, which has set a landscape up for aging to be very counterintuitive. And here's what I mean by that. When we spend decades after decades focused on body fat percentages, we're focused on what we have to lose and we limit what we have to gain and the actual importance of the counterbalance to body fat, which is muscle mass. And skeletal muscle, I have said this a million times, is the organ of longevity. You cannot age well, and aging begins, you know, you have a little boy and I have two little kids, it begins right away. However, skeletal muscle is really the foundation of your metabolic strength. It is the foundation for how you are going to be able to go through your life and ultimately how you're going to age and what you're going to withstand. And so, from a very practical perspective, muscle is that key organ of all things aging and you have to recognise that as early as possible. It's never too late, but it really is the foundation and the most underappreciated organ system that exists.
Dr Gabrielle Lyon: I love that. I love that framing against the idea, particularly for women, that it's about loss and it's just about fat and the appreciation for muscle health has been lost in that journey. Let's talk about some of those key mechanisms behind how muscle actually helps your health because I think there is this idea that muscle is about aesthetics, about the gym, and whilst those all might be important, you know, muscle as the longevity organ, you know, there are a number of mechanisms behind that which explain why it's so important. Let's dive into into that a bit.
Dr Rupy: Yeah, it's a really fascinating and dynamic organ system. So skeletal muscle is an endocrine organ, which means that it releases peptide hormones that affect both the cells and the tissue locally and also systemically. And why does that matter? It's kind of like the thyroid. We've all heard about thyroid, we've all heard about ovaries. We've all heard about organ systems that make hormones. Well, skeletal muscle is not dissimilar to that. And it makes these peptide hormones called myokines that are unique in the way that they interface with everything. They interface with the brain, hence exercises affect on mood and cognitive ability. Exercising skeletal muscle and these myokines affect metabolism and glucose regulation and fat regulation. It affects bone. You know, one of the things that many of my patients worry about is osteoporosis. Well that the first early sign of osteoporosis is low muscle mass. It's not a fracture. You can identify and begin to think in terms of osteoporosis when you look at someone with low muscle mass because that's an early indicator. When we envision skeletal muscle as this organ system, we have to recognise that there is the physical structure, its physicality, which it is the architecture and infrastructure of our body. Activities of daily living, mobility, strength, power, force, all of the things that we think about from a body perspective. And then on the flip side, there is this metabolic perspective. And that is what's gaining more and more attention and what is really intertwining muscle in the conversation of longevity. And from a metabolic perspective, when you think about the diseases that are killing us, we think about heart disease, you think about Alzheimer's, you think about cancer. The list goes on, but these are the real or type two diabetes, obesity. Much of the survivability and root cause begins in skeletal muscle decades earlier. The reason this is that way is because skeletal muscle is your primary metabolic regulator. What do I mean by that? Obesity, diabetes, things that cause or are right along with metabolic syndrome, hypertension, elevated levels of triglycerides, elevated levels of glucose, elevated levels of insulin, we imagine that is purely diet related. And I would argue diet plays a huge role, which you and I are going to discuss. I know we're going to talk about protein and carbohydrates and probably all of it. But the reality is it's a mismatch between nutrients coming in and the health and activity of skeletal muscle.
Dr Gabrielle Lyon: I think what would be really useful for the audience, perhaps who haven't come across your work before, is to talk to us a bit about your experiences as a geriatrician because you trained in this, you've seen people on the ward, you know what it looks like to be under-muscled and for someone to have this higher risk of disease that actually the end point is they're in hospital. Talk us a bit about your training. Like why did you even decide to go into geriatric medicine in the first place? Because, you know, it's not the sexiest specialty, you know, across the board in both the UK and the US. So there would have been some reasoning behind it.
Dr Rupy: Frankly, it wasn't by choice. I trained in nutritional sciences under one of the world leading experts in protein metabolism. His name is Dr Donald Layman. And I began my training with him and mentorship with him 20 years ago. I did my undergraduate in nutritional sciences and then because of my mentorship, my very close mentorship with Don, for those of you who don't know who Dr Don Layman is, there's probably four world leading experts in protein metabolism that have really moved the needle and contributed greatly to both the academic body of literature, but also have made major discoveries. And he is one of those individuals. And after I went through medical school and then I did a residency and then I came to him and I said, well, obviously I need more nutrition training. He said, well, the way to do that is you're going to have to do a fellowship. In order for you to understand research and in order for you as a physician to be highly trained in nutritional sciences, you need to go back. And I'm thinking to myself, okay, I've just spent three years in family medicine, two years in psychiatry, and now I'm going to go continue my training. I'm in, sounds like a great idea. In order for me to get funding, this is the way that it works, that you have to work in a medical department, for example, geriatrics to be able to fund the research. So this is a, I went to WashU, which is considered the Harvard of the Midwest. It is a top tier school and their metabolic training is probably top three. Within their nutritional science division is geriatrics. And they've now since separated it, but in order for me to go get funding, right, for to get a stipend, I needed to partner with a medical fellowship. And the medical fellowship that was available to me was geriatrics. I was fully unprepared for what I saw. And it probably took me three years, if not longer, to really process seeing 30 dying patients a day over two years, seeing people that had regrets about the way that they lived, that fell, broke a hip, never were able to walk again. We also ran a memory and aging clinic and my job as a geriatrician was in dementia. The devastation to the patient and the family, some of the most intense things that I have ever seen. And frankly, I was not prepared for it. But it changed my perspective. It changed my perspective on longevity and aging. You can't truly appreciate aging if you don't know what the end points are. You know, when you're young and you're in your 30s or 40s, everything is great and easy. But it's difficult to appreciate when the tipping point happens and with each increase in decade, and we all have had aging parents, or at least God willing, or grandparents, we see where they are and we could never imagine ourselves at that age. When you're 30 or when you are 40, for the majority of people, you do not, especially culturally, we are not thinking about what that looks like. Yeah. At least I can say for us here in the US, we are not closely integrated into what the end of our life looks like and we're not closely integrated into the real nuts and bolts aging process. It's just something we're not. And I know that that sounds morbid, but it gives you an incredible perspective because when you have perspective, it's kind of like, I don't know, when you have a really tough experience, you now have perspective as to what that experience is.
Dr Gabrielle Lyon: Yeah, yeah. I, you know, I don't think even from my experience working as a medical doctor for around 15 years where I did family medicine, I trained in A&E and ITU and stuff. We we see a lot of people at the start of that journey where they where they degrade, you know, because of something like a hip fracture, because of something like a fall where and we'll talk about this a little bit later where you lose muscle very rapidly. I don't think I put the dots together and I think, you know, with your experience and now with that new lens, you can articulate exactly what that tipping point looks like and how people can intervene. So if people are listening to this and they're thinking to themselves, okay, I don't want to be that patient on the geriatric ward. I don't think anyone wants to be that person and they've probably had some first hand experience of that, whether it's parents or grandparents. Can you articulate to folks where that tipping point is likely to occur and how we can at least delay or prevent that further through the lens of muscle health?
Dr Rupy: This is a bit of a nuanced question and answer and I am going to do my best to articulate this because we are in a landscape that we have never been before. I'm going to give you the answer that I would have given you two years ago. Okay. Three years ago before the real boom of GLP-1s. Okay? And for those listening, this is the things like Monjerno or Ozempic. I'm going to give you the answer that I would have given you had these not come onto the market in an accessible way. Aging is inevitable. Strength is a choice. You must train. There is no way around being strong. If you want to age well, your number one asset is to have strength and to have muscle. The greatest influence on that is your physical activity. Period. If I were to say what is the lever, it's 75% training and 25% diet. I'm speaking in absolutes, clearly it is not absolute. You are not going to build muscle, you are not going to be able to be strong if you do not have proper protein ingestion, it's not going to happen because those are the amino acids required to facilitate the repair mechanism of the entire body and then also skeletal muscle. When you are young, as our kids are young, and let's just say young, we decide you no longer are young when you stop growing. Let's say 18 to 25. Sure. You are no longer driven by hormones being highly anabolic. Okay? And I don't mean and again, I am simplifying this greatly and there is a bit of nuance, but for ease of accessibility of the core fundamental principles, you are no longer growing up. You're not getting taller, you're you're not putting down more bone, you're not doing any of these things in essence. You are less, when you are young and you are highly anabolic, like our kids could have two grams of protein and they're fully anabolic. As an adult, that skeletal muscle becomes resistant to stimulus, resistant to protein that is ingested, and I would argue, depending on how you have lived your life, somewhat resistant to exercise. Which is fascinating. Meaning, that tissue, while you can always improve it, there may be some evidence to support that if you are overweight or obese and you have unhealthy skeletal muscle, and I would define unhealthy skeletal muscle as fat infiltration, intermuscular adipose tissue, there may be less of a robust response, which is why potentially we see interpersonal or variability and of one type situation. So I have a girlfriend, she just looks at a weight, she can put on skeletal muscle. Maybe another girlfriend, she it would take her forever to lift and 20 years later she's still not putting on a ton of muscle. So there is a variability between different people. But an overarching theme is when you are young, it is extremely easier, it is much more easy to maintain and build skeletal muscle. It's what I call muscle span. You've heard about lifespan, we've all heard about that, and then health span got this huge boom, but really from an aging perspective and a wellness perspective, it comes down to muscle span. And it's the length of time you live with healthy skeletal muscle and there are very clear differentiating points that the body goes one way or the other. That is in youth, the more active an individual is, the more metabolic healthy, the more metabolic health they will have as they age. Right now, 20% to 28% of kids are getting 60 minutes of activity a day. They're on screen seven hours a day. We are going to have an epidemic of unhealthy skeletal muscle because of this sedentary behavior like we've never seen before. Age is on their side and the ability to come back from that is favourable, right? It's very favourable. As we no longer are growing and we are not driven by hormones that are making us grow taller, and I'm not talking about necessarily hormones of menopause or perimenopause. I am typically, I am speaking about the generation of new tissue. As we no longer are driven by those hormones, we become much more reliant on physical activity and diet. And this is where making sure we make good protein decisions, which that is based on age, physical activity, metabolic health and personal choice. You cannot eat and train the way that you did when you were in high school. You are setting yourself up for poor metabolic outcomes. And there are a number of physiological things that happen. One of them is called anabolic resistance. That would be my answer to you two years ago.
Dr Gabrielle Lyon: Okay, so two years ago, you would have said, okay, diet, training, sounds like the strategy would be ensure during your youth where your tissue is going to be sensitive to protein, sensitive to that exercise stimulus, you build a good foundation, a lovely base of skeletal muscle health, almost like a pension that degrades over time because unfortunately when you're older, like I'm in this situation right now with a nine month old where my training volume has just been completely decimated and there's nothing really I can do about it. I was up at 4am last night because he's teething and all the rest of it. You know the score.
Dr Rupy: I'm still dealing with it. My kids are four and five. I'm just like, I just want to sleep one night. One night. That's it. I'm just, I just want one night.
Dr Gabrielle Lyon: So, so that would have been the strategy two years ago, like do as best you can, build that muscle, make sure you're getting enough protein, which we'll talk about in a bit more detail later. That's the strategy. So what what's happened in the last two years?
Dr Rupy: And it was very simple back then. Okay. In fact then, with the use and introduction of GLP-1s, which I must say, I think absolutely are valuable. And for those that are not familiar with GLP-1s, they are agonists, they're glucagon-like agonists that affect appetite amongst other things. They they affect a lot of things, but let's for the sake of keeping this on track with skeletal muscle, let's talk about appetite. We now have agents that allow people to suppress their hunger to a degree that we have never seen before. We have never had an effective medication that is potentially more effective than bariatric surgery. It trumps any other medication that we have ever had in magnitude. And I did obesity medicine, so my fellowship was in obesity medicine. Now the caveat here is that over 70% of adults do not meet baseline physical activity in both domains, cardiovascular activity and resistance training. Okay. The majority of our youth are also not meeting physical activity baseline guidelines. We recognise that the only way to have healthy skeletal muscle is you must exercise. There is no free lunch, it doesn't happen otherwise. You have to exercise. We now have an agent, so we have a sedentary population, we've now added on an agent that allows people to essentially enter into a level of starvation or food restriction that they lose both, could be 50% fat, but it's also 40 to 50% muscle, depending on the rate at which they utilize these agents. You add that onto sedentary behavior, we are now trading an obesity epidemic for an epidemic of sarcopenia in proportions that no physician alive has ever seen. We will be entering a new landscape that nobody is prepared to manage. And this is where we are going. So, now the question becomes, how do we really begin to think about this new integration and what does it mean for the health of aging? Because if our youth then choose these medications, they now spend a lifetime cycling through muscle loss. And muscle becomes much more precious as you age. And the individuals that are now taking GLP-1s, which again, we prescribe them in our practice all the time, but without understanding the focal point of skeletal muscle, we are trading one epidemic for another, and I would argue that the sarcopenic epidemic is more dangerous than obesity.
Dr Gabrielle Lyon: That's really, really interesting. So in this scenario, and I I gather just from the ubiquity and the accessibility of these new drugs, I completely see where you're coming from in terms of the trade for obesity versus sarcopenia, given what we know about the need for skeletal muscle, the need for activity, and the and the way people are. The question becomes, if you can't stop people erroneously taking a drug like the the the number of different GLP-1 agonists that we have available, how do you do it in a safe way aside from ensuring that the appropriate patient population is on the drug in the first place?
Dr Rupy: Yeah, it's a great question and I think that when you reduce overall food intake, then you have to prioritise protein. It becomes a non-negotiable and we have to get really clear. There should not be an argument between what is a high quality protein and what is not. And the reason that all of this becomes irrelevant is because if you and me and health influencers and health doctors really care about the people, then we have to become unified in the fact that dietary protein is important and it is one way to stimulate muscle. And in the landscape of those individuals that are not training, we already know, it's wonderful because you and I are, we like to exercise. Well, we did before we had kids. We don't have a problem. Or our friend Drew, you know, we all like to train. But in my mind, that's very selfish. You and I, we already like this. But if our goal is to really help the rest of the world, then we have to recognise that people that are consuming this might be eating healthy or doing certain things, but they might not be training. Because listen, if you don't grow up in a household where there are habits that are instilled where physicality is the culture, it's very difficult to go out and change those habits. It is much easier to establish good baselines when you are young than spend a lifetime trying to undo poor habits.
Dr Gabrielle Lyon: Yeah, yeah.
Dr Rupy: You and I are both, we have both practiced in medicine for 15 plus years. You and I both know this to be true. And so I I suppose I frame this up because I you know, I've been a, I've been seeing patients for gosh, I graduated med school in 2006. I've been seeing patients for a really long time. And with the use of social media, I think it's amazing. And then I also, I also think it's our responsibility to to really frame it up for people that there are the nuances that matter and then there are the core fundamental principles that in order to protect this new epidemic, which is which is coming, it is coming, we should no longer be arguing about plant protein, animal protein, processed foods. You know, we have to really refocus and re-establish what is our baseline. And our baseline must be on and in the foundation of dietary protein plus resistance training. The way that I see it, it is non-negotiable, even if someone who is going through menopause is on hormone replacement or a man who is experiencing low testosterone, you still require the necessary inputs, which is dietary protein and resistance training.
Dr Gabrielle Lyon: Yeah. So talk me through a a hypothetical individual in your clinic who is on a GLP-1 drug now. How would you navigate the conversation around the dose of protein that this individual should be on? What characteristics of that patient would determine what their dose is and how you would instigate healthy resistance training habits for someone who is perhaps new to training or is fairly up to date, but they they play tennis more than they lift a dumbbell.
Dr Rupy: I would say tennis is probably sounds like a lot more fun if you enjoy it. And the first thing that I would do is to recognise, so in our clinic, and we have a telehealth clinic, in our clinic, the first thing is, there are the standard dosing for disease treatment and then there is a capacity when you use say a compounding pharmacy that you trust, you know, here in the US and actually globally, we use empower. You guys actually have access to empower. And we microdose GLP-1s. We recognise where the person is and an individual, and I also believe in body autonomy. Let's say an individual has been struggling with the same, we have a 50 year old woman who is postmenopausal on hormone replacement, but has been struggling with the same 10 pounds for the last 10 years. But it's only 10 pounds. I would have no problem initiating a GLP-1 for her. We would typically use Terzepatide, a compounded Terzepatide because the side effect profile seems to be better. Because someone would say, but that's only 10 pounds overweight. And I would say, listen, this 10 pounds has consumed this person for 10 years and they have done diet and exercise and tried all of these things. They should have the freedom of choice to use an agent that could potentially really help them. Because again, it's not, we think about it in terms of weight, but the effect of GLP-1 on intermuscular adipose tissue, and this is something that I haven't really shared much about, that I think is much more relevant to the conversation. I don't think body fat matters. I think it's just a, you know, biomarker that's somewhat outdated. The real influence on metabolic health is intermuscular adipose tissue. It is the fat within the muscle. It is not the percent body fat. You have a female, a largely female audience. The number one cause of female infertility is PCOS. There is the brain connection PCOS and then there's the metabolic PCOS. The individuals that improve with metabolic PCOS, so there's the lean type and then this metabolic, this metabolic phenotype. I interviewed the world leading expert, her name is Melanie Cree, on this. So she's a world leading expert on PCOS. And the use of GLP-1s. I asked her, I said, what percent body fat is the cutoff marker for those that get better versus those that don't? And she looked at me, she goes, Gabrielle, it actually has nothing to do with body fat, it's irrelevant. It's the percentage of fat within the muscle that determines the positive outcome for these patients. Body fat is an outdated biomarker. It is important, but it's I don't think that it's nearly as important as that fat within skeletal muscle. So that was a long-winded way of saying, is it just the amount of weight that someone has to lose that should direct our decision-making capacity? I I would say no. I would say that there's a lot that we are unaware and that we don't know in terms of intermuscular adipose tissue. Also, the personal experience of a patient. It's not necessarily for us to determine her amount of suffering. So we put her on a microdose. She starts with a very beginner dose and she does well and she starts losing weight. Right away, the first thing that we would do is the goal is to not decrease their protein and for anybody less than 100 grams a day. I strongly believe that we should not and my reasoning is thus. We turn over 250 to 300 grams of protein a day. The body must replace this. We are not eating 250 to 300 grams a day. The max growth requirement might be 5 grams. Repair and replacement for all tissues and all enzymes and the liver is 250 grams a day. The body is extremely efficient and can maintain many of its own amino acid stores and it can pull from muscle and it can recycle. But if you are on board and you agree with me that muscle is the organ of longevity, every time you go into an overnight fast, your body is maintained in part by skeletal muscle. When you wake up, you are in a catabolic state, meaning the body is pulling from these quote protein stores, which would be skeletal muscle, which we already know most people are under-muscled. That the minimum target that I would pick would be 100 grams a day. Period. You can titrate up, but I would argue I wouldn't titrate anybody down. So now the next question from a protein decision is how are you going to do that? And how are you going to dose that? And for those that are on a GLP-1 or those that are, so our 50 year old patient who is postmenopausal, who has always been on a higher carb diet, that's going to feel a little overwhelming. And so what you do is you just really simplify it. And this can come from a protein shake, whether it is a whey protein shake, a soy protein shake, a rice pea blend protein shake, I don't care. And that's why we have to really refocus our conversation about processed foods are bad. Processed foods are, you know, it's very black and white, but it's not because a whey protein shake is a processed food. And so really the way that we think about it is, again, are whole foods, does that win? Are they nutrient dense? Yes, absolutely. But my goal is what is the practical aspect of what we need to do to maintain healthy aging? And this is a practical aspect and some of the things that I'm talking about, I put in my new playbook, which is not out yet, it doesn't come out till January, but it is a way in which we make protein decisions. Age, physical activity, metabolic health and personal choice. The younger you are, the less protein you need. You don't need 100 grams of protein. The older you are, the more protein you need. And the worst case scenario is a sedentary person on a GLP-1 who is more mature. The protein need for these individuals is arguably higher because there's only two ways to really stimulate skeletal muscle and that is the amino acid input through dietary protein or the training input. And so for our 50 year old, we'll call her Sarah, if she is sedentary and 50 and metabolically unhealthy, meaning she has high glucose, high insulin, high triglycerides because she doesn't have enough muscle, then our choice would be, we start with 100 grams, maybe she's not that hungry, we dose it twice a day, we give her 50 and 50, super easy, and we say this is where you're going to start. Sarah, this is where you're going to start. And you're going to walk when you can, you're going to resistance train and it can be body weight. It can be body weight. We start there and then we progress to bands and then we progress to weights so that there is a progressive stimulus. She doesn't have to go lift heavy to get a stimulus. She doesn't have to crush herself in the gym. You know, some of us like to do that. It's like my favorite pastime. You know, I'm married to a SEAL. So for us it's a it's a, you know, I'm married to a tier one operator. Their idea of a good time is pretending like we're in boot camp. Right? But that is completely off putting for a lot of other people and it doesn't have to be that way. You don't have to, there's a million different ways to create a stimulus. It's not progressive overload because a lot of women who have never lifted weights don't want to do that. They like their 10 pound weights. Okay. So lift your 10 pound weights more frequently with more reps, increase the volume, change the tempo. There's a million different ways to do it and one way to do it wrong, which is simply don't do it.
Dr Gabrielle Lyon: Yeah, yeah, yeah. So with the dietary protein, if you're over 50, you're looking for a ballpark 100 grams. That's around 30 to 40 grams in a typical three meal a day eating pattern. And I guess it corresponds depending on weight to anywhere between 1.2 and 1.6 grams of protein per kilogram per 24 hours, roughly.
Dr Rupy: Yeah, so yeah, so, um, we, that's right. Um, it's for us, it's yes, 1.2 I would say would be the minimum up to 2.2, but that would, that seems very overwhelming for people. And I would argue that if we were going to get really clear on the data, the data will say that 1.1 will typically always be better than 0.8, which is the minimum. Yeah. 0.8 grams of protein per kg is set at the minimum amount. And we have often times thought of that as the maximum, but it's not. It's a minimum to prevent deficiencies. And I just want to liken this to vitamin C. If you get sick, no one goes, you know what? The RDA says 60 milligrams of vitamin C is what I need. When you're sick, you're like, I'm going to get 100 milligrams, give me a thousand. I need this because I need more vitamin C. I'm not feeling well. Sure. But we fail to translate that over to protein. But we look at a lot of other things similarly. And I'm going to throw out one more thing, which I think your audience is probably very astute to, is that we're not eating for protein. And protein is not one thing. Protein is 20 different amino acids that all have very unique biological properties. For example, leucine, my favourite amino acid, if I had a dog, I'd probably name it leucine, is essential for muscle health and muscle protein synthesis. Threonine is another amino acid that is necessary for mucin production in the gut. Phenylalanine is another amino acid that is important for neurotransmitter production. Methionine is another amino acid that is important for glutathione production, which is the master antioxidant, which seems to diminish as we age. While you and I, my friend, are talking about protein as if it is one thing, we do have to recognise that it's not. And by meeting the baseline needs for skeletal muscle, we're ensuring that we're getting all of these other amino acids that do other things in the body. When you are eating a lower level of amino acids, the body doesn't care about muscle. The body cares about protecting your liver and your kidney and your other organ systems and muscle is disposable because it's a privilege. It's like this thing that you have to work so hard to maintain. And when we think about it and zoom out from that perspective, the the conversation, I think becomes much more clear and it's not about is red meat bad for you? Is plant protein okay? It's not about all these other smoke screen arguments. If our unified goal and the people watching and listening to this and their goal is to age well, then we have to recognise that we make protein accessible, we do not overcomplicate it. I mean, you wrote a whole cookbook on this. I would say you were here, I would love to see you cook in my kitchen. I would love to see you make protein meals in my kitchen. I would be so thrilled. And then we normalise physical activity and then we no longer have to worry about how we're aging. We can then worry about what we're going to do with all the time that we have to get and dedicate to the things and the people that we love.
Dr Gabrielle Lyon: Yeah, yeah. I I I completely agree. I want to unpack the intramuscular fat a little bit more because I think that's a really important part of the conversation that doesn't get as much airtime. So a couple of the reasons why people might have more intramuscular fat is excess glucose in the bloodstream, liver packages it into the energy storage molecule of choice, fat, that ends up in the muscle. There's also just the excess amount of calories as well that we consume, which I mean, the majority of people unfortunately are because of just the ubiquity of ultra-processed hyper-palatable foods that leads to an energy imbalance. And with regards to GLP-1s, whether we're using the current recommended doses, which are which are different depending on whether we're talking about semaglutide or terzepatide, whether we're using those standard doses or the microdose, do you think the mechanism of action for those drugs is because of just reducing calories or is there something else funky going on in the in the muscle?
Dr Rupy: So when we think about intramuscular adipose tissue, we should clarify. So there's there's IMAT, which is what I'm talking about, and that's inter with an E. And this is a fat that accumulates between muscle groups. This is unhealthy fat that is very difficult to use for energy. This is not something called, for example, intermyocellular lipids, which are used for fuel utilization close to mitochondria that athletes have to use for energy source. This is different than subcutaneous fat, which is the fat that we've all focused on. And I think the reason that we've focused on it is because it's super easy to see. It's like, have you ever heard of the lamppost effect? Have you ever heard of that?
Dr Gabrielle Lyon: No, what's that?
Dr Rupy: The lamppost effect is there's this drunk guy, you've been to New York City, you've been to Central Park. Yeah, yeah. Okay. So you go to Central Park, there's this drunk guy, it's two in the morning and he's on his hands and knees and he's looking for his keys. He's just over here, he's looking for his keys. And a cop comes over and he's like, yo, can I help you? You've been out here looking for your keys. And the the drunk guy goes, oh gosh, yeah, I'd totally be so grateful. So then the cop gets on his hands and knees and he's looking for his keys. And then after 20 minutes, the cop goes, are you sure you dropped your keys? It's pitch black, there's this just area that's lit up. He's like, are you sure you dropped your keys here? And the guy goes, no, I dropped my keys over there, but it's so dark, I can't see. The moral of the story is this is what we've been doing in health and wellness. Because subcutaneous fat is so easy to see, then that must be the answer and that must be the problem when in fact it's not. But it is just the most obvious. So I think that that becomes important to understand because we are really behind the times. The way in which we have hyper focused on body fat has been unbelievable. We get a DEXA and people will say, so a DEXA is this dual X-ray, machine, absorptometry, whatever it is, machine that is really good for bone and fat and then extrapolates everything else, lean tissue. It does not directly measure skeletal muscle, nor does it tell us the quality of that muscle. And we are not good at measuring the health and the quality of skeletal muscle. The ways in which we do that are CT and MRI and for you listening, if you do not need a CT, you do not want one. And an MRI is loud and expensive to look at skeletal muscle. Could you look at it under ultrasound and see these fatty streaks? You could, but again, we don't have good technology yet that is accessible to the public to understand what their percent of intermuscular adipose tissue is. And why do I say that? I say that because part of this conversation, my desire is to shift the understanding and the framework and the paradigm for understanding how we have been processing and thinking about body fat and really shifting to the critical role of muscle and actually the components of muscle and understanding that when you have myosteatosis or fat infiltration into muscle, like when you're eating a marbled steak, this is the problem. And this is largely driven by inactivity. It's a primary driver with fuel and food consumption that is mismatched for muscle health.
Dr Gabrielle Lyon: Okay, gotcha. So protein is definitely part of that equation for that reason. Over consumption of calories, would you say that as well? Or would you say it's more about the milieu of the protein carb fat ratio?
Dr Rupy: No, I think that it is a it is a overall calorie consumption problem with an over consumption of carbohydrates because carbohydrates really distort metabolism. We think that when we eat carbohydrate, the body should release insulin. And I think that that is more of a fail safe mechanism, not something that we should rely on. When you walk and move, skeletal muscle can utilize glucose and increase insulin sensitivity and increase the use of glucose without insulin. You don't, it is, it is an extremely effective way. So you eat and then you go for a walk. You eat and you exercise. Exercising skeletal muscle is not solely dependent on insulin. Insulin, spiking insulin, you know, the average individual eats double the RDA, it's 300 grams of carbohydrates.
Dr Gabrielle Lyon: 300 grams of carbs. So
Dr Rupy: And the baseline is 100, you know, is 130 grams.
Dr Gabrielle Lyon: So we
Dr Rupy: which if you're metabolically unhealthy, shouldn't even be using.
Dr Gabrielle Lyon: So we only need around 130 grams of carbs per day? Is that is that
Dr Rupy: You probably only need 80.
Dr Gabrielle Lyon: 80. And so what does 80 look like? So we're talking about carbs, the macronutrient. So what does 80 grams of carbs look like from the perspective of someone, you know, who eats bread or pasta or whatever it might be?
Dr Rupy: Yeah, I think that we have to to kind of shape this out a little bit. The body has no requirement for carbohydrates. The body can generate its own carbohydrates through, for example, something called gluconeogenesis. 60, if you eat 100 grams of protein, roughly 60% will get converted to carbohydrates through the utilization, the process of gluconeogenesis. It's not efficient, it is not like eating carbohydrates, it doesn't spike insulin in the same way. It is a very different metabolic process. The carbohydrate need, if you were to calculate how much does the brain need, how much does the organ systems need, it probably comes out, what about red blood, like it probably comes out to about 80 grams a day. The body can generate that, but it's not a dietary quote need, right? If you know people that have totally stopped eating carbohydrates and they're they're still alive, they're okay. There is not a need. And I would argue that what's happened is you have to earn your carbohydrates through exercise. That at the baseline, again, and in our clinic, we don't put people below 100 grams. We typically would do a one to one ratio because you still want to get phytonutrients, you still want to get fiber, it's important. So we don't totally take out carbohydrates, nor do you need to. But I do think that need and desire are two separate things. You need dietary protein. You cannot age well without it. You need a handful of essential fatty acids. These are required for life. Carbohydrates does not carry that same need. And if someone were listening to this and saying, okay, so what do I need for practical takeaway? What what should I eat and how should I do it? I would, number one, say resting skeletal muscle does not primarily burn carbohydrates at rest. Your muscle does nothing for you at rest. It burns primarily fatty acids. You do not want it burning glucose. People will say, oh, muscle is so metabolically active. No, it is not very metabolically active at all. But when you train it and when you are involved and engaged in the activity of exercise, now you are talking about 40% of your body being highly active and advantageous. And arguably, it's the only, it's one of the only things that we have a voluntary choice over. You can choose to do activity. Typically, how we do it is we do not recommend over 40 grams of carbohydrates at a meal. Anything outside of that, you have to earn through activity because once you start eating over 40 grams of carbohydrates, you distort metabolism. You start with a robust insulin response. These are things that you do not want your body dependent on the ebbs and flows of insulin.
Dr Gabrielle Lyon: Okay. So if I'm looking at, I don't know, whether it's brown rice or potatoes or sweet potato, choose your carbohydrate of choice. What does 40 grams look like on a plate if we're thinking about it per meal?
Dr Rupy: So, um, let's let's visualize that. Let me see if I can, um, look that up. You know, I could tell you, for example, a half a cup of dry oatmeal, you cook it, that comes out to like two thirds of a cup or even looks like a cup. That's about 30 grams of carbohydrates.
Dr Gabrielle Lyon: Okay, okay. So
Dr Rupy: That's that seems like a lot.
Dr Gabrielle Lyon: Yeah.
Dr Rupy: Um, that's a lot. That's a reasonable.
Dr Gabrielle Lyon: In terms of volume, that that's that's quite satisfying. Because when when someone hears 40 grams, they're like, oh my gosh, like that that's just like that's nothing. I can't eat that or whatever. But actually, when you look at the macronutrient carbs in what is deemed a carb, it's not 100% carb. There's a degree of other nutrients in there, a bit of protein, there might be phytonutrients, all the rest of it. So it's not pure carb. It's not like sugar, but it it will be converted into sugar eventually, but there there is like a discrepancy between the amount of carbs in that and the physical volume of the food.
Dr Rupy: Yes. Yeah, and then when you think about carbs and you think about berries, you know, you just want to make good choices that are high in fiber and have more nutrients in them. And it's it's very easy to make good choices. And when you start, and I I did this in my playbook for a reason. We've never done this before, but we didn't focus on calories. We focused on teaching people how to look at their plate and how to divide their plate so that they could understand the amounts of foods that they were eating to take out that cognitive load to be able to go, I'm going to minimize my nutritional chaos. I'm going to start with dietary protein. I know that I should have roughly 40 to 50 grams, maybe call it 40. Okay, 40 grams at a meal. And then I'm not going to visually on my plate eat more in volume if it's a, um, you know, white source of carbohydrates like oats or rice, then visually what I'm looking at from my protein. It is that simple.
Dr Gabrielle Lyon: Yeah, yeah. I love that word, nutritional chaos. Because I think a lot of people find themselves in the chaos of the supermarket or the kitchen, wondering what to eat. And, you know, the the book that I just wrote, Healthy High Protein, there's so many things that you're saying that really align. I mean, I I remember writing in the book, even though I'm talking so much about protein and anti-inflammatory foods, the biggest lever to your health is actually exercise. And I think we have to be really respectful of that. Even though I'm writing a cookbook and I want people to think about protein, like exercise is probably the one thing I would say, you know, you would prioritize if it had to be a choice between the two, even though it pains me to say that as someone who's just a food lover.
Dr Rupy: It pains me too. And listen, but I and I'll and I'll say that to to make you feel better, the one thing that we all do is eat. We have to learn how to do that. And people can argue and you're absolutely right, is exercise more important? When it comes to a muscle health perspective, yes, nothing moves the needle. But we already know 70% of adults aren't meeting that requirement. Yet we know 100% of people are eating. I love that you wrote a cookbook because actually that is what is going to inspire people to do better, not by choosing something esoteric and hey, you don't do pushups, you are not mandated to do pushups. I literally could sit in my office right here, which by the way, this is not what my studio typically looks like. You caught me on a day I just came back into town, my kids are going crazy, the bath is going, I survived it. I I survived this morning. But we have to recognise that if we fail to meet people where they are at and what is normal and course correct the things that they do, then we are not going to make change. Collectively, as a group, as a unified front of physicians that care about wellness, it's never going to happen. But if we go, you know what? I can tell you there's two things that you do. You breathe and you eat. I could sit in my office and never leave this place and I could order DoorDash, Amazon, I could do everything. And the most amount of steps I would have to take is probably 100 going back and forth to the bathroom. That's it. And that's actually where we are set up for. There's going to be a huge divergence within the population, those that recognise how important this is and those that don't. And the earlier that we can get to people, the better. And listen, perimenopause, menopause, not a death sentence at all. You can always improve. And you know, I I think a lot about this because I actually do research in hormones. I have collaborators here at Baylor. We just published a paper on sexual function and muscle mass and strength. We just presented that at the Androgen Society. We're just publishing another paper on women and the use of pellets and safety. And I will tell you, hormone replacement is really great for people. However, will it, you know, somehow change body composition to a miraculous level where people are all of a sudden, I'm happy with how I look now that I went on hormone replacement? 0% chance.
Dr Gabrielle Lyon: Yeah, yeah. I'm I'm really glad you said that. We've had a number of different women's health experts on here talking about hormone replacement therapy in combination with lifestyle and dietary change. And I think it's it's the same conversation that we should be having with GLP-1s as well. So, yeah, I I I completely agree. And as I was saying in my book, I want people to be good guesstimators of protein on their plate. So they're not necessarily measuring out every single piece of chicken or tempeh or whatever they choose as their core protein source, but they can look at a plate of food and be like, that's around 30 grams. I might need to top it up with I don't know, some nuts or maybe a little bit more of the core protein or a plant-based partner, whatever it might be, because that's the way you get change rather than being super rigid about calories and the weights of food and all the rest of it, because we eat the, you know, the majority of our meals in a rush and you just want to be a good sort of mini calculator in your head rather than someone that's that's super rigid.
Dr Rupy: Totally agree with you. And and that's the way that we then, you know, implement change. And then we say, okay, you want to live great and be amazing when you're 60, you got to start training. And I think that there's a lot of information out there that men and women are different and they are. However, as from my perspective and what I've seen in the literature, good foundation principles are good foundation principles. Yeah. That because I'm a woman doesn't mean I have to do, you know, let's just make this up, long distance running versus my husband who can, you know, just lift weights. It's good foundation principles are good foundation principles, principles of of progressive stimulus, of getting better at increasing volume, of changing these variables and continuously challenging the muscle. That's what I have seen in the data. And that it is an interpersonal variability, not necessarily a sex variability. I think that when we begin to add layers of complexity, it really takes away and becomes confusing and the path forward becomes clouded. This might change, but at this point on August 5th as we are talking about this podcast, I am not seeing the difference between males and females training. I think good principles are good principles and when there's a variation, it's really about the person.
Dr Gabrielle Lyon: Yeah, yeah. I
Dr Rupy: Some people might respond better to high intensity interval training from a metabolic outcome. Some people might respond better to lifting, you know, I am personally someone who needs a higher volume. But again, it is is complex, but if we start with good principles, then that individual can progress and make changes in a way that's meaningful to them. And I think that that's important.
Dr Gabrielle Lyon: Yeah, yeah. I think personalizing that exercise prescription is is super important. So we're going to hit you with some quick fire questions to to round off this conversation. So just to summarize, you know, if I'm thinking about the from the listener's perspective, muscle is the organ of longevity. It is an endocrine organ, so it it secretes hormones, myokines are super important. We've got these receptors in our brain all over the body that muscle has an important impact on. It's also a store of energy, obviously a store of protein that we want to try and preserve as we get older. We talked about GLP-1s and why it's important to have this conversation around protein and exercise stimulus, particularly when these drugs are becoming so ubiquitous in their use, whether that's microdosing or the the regular dosing. Let's talk quickly about exercise, which is something that I perhaps know a lot less about, even though I am someone who exercises. How important is this idea of progression? And and perhaps just unpack very quickly what what we mean by progression as well.
Dr Rupy: Skeletal muscle is a live, dynamic tissue that requires input and it is very malleable to the stimulus and the environment. When you go to space and you have no external input, the body falls apart, right? You accelerate aging, you lose muscle, you lose bone. We are designed to do movements and activity and lift things. That is now optional. People think it's optional because it is become quote optional, but the body is designed to do that. And often times the wives tales or those sayings, which I always think are so cheesy, use it or lose it, it's actually true. And I'm embarrassed to say that. I hope I hope I never watch this and say that to myself, you know, like my mom's like, if you don't ever use it, you lose it. But it's true. The same is for muscle and progressive stimulus, you know, movement is as fundamental as breathing and one of the biggest things and I'm sure that you've heard this a million times is that it is about consistency. And I would argue that one of the greatest diseases or the greatest challenges that we have is the domestication of our environment. We no longer have to do anything. And, you know, training, I think about it in a handful of ways. I think about strength, I think about flexibility, I think about, you know, power and force. There's all different ways to think about it. But if we were to simplify it all, you must be strong. You must be able to put a bag in an overhead bin. You must be able to pick up your toddler. In case of emergency, you must be able to do those things and you should not have to rely on stress hormones to do it. You should physically be able to do that. And I know that the the question was, you know, is progressive stimulus or overload necessary? And it is. But it is not in the way that we think. It doesn't mean that you only have to make things heavier. You can increase volume, increase days, change up tempo. You must be stimulating this tissue in different ways, just like your brain and just like in anything that we do, if we want to improve it in any area of life, we must continue to push it. Period, end of story.
Dr Gabrielle Lyon: Okay, let's talk about me because I want to be selfish here. So I am someone who used to have at least six to seven hours of training opportunity available to me. I now have two at a push. If I've got two hours just to do my resistance training, a week. A week. I'm not a week. What is the most effective way for me to train? What kind of exercises should I be prioritizing to make sure that I'm aging as best as I can?
Dr Rupy: This is a great question and I've asked this question. So, you know, so I have a podcast in case anyone's interested. I think that people like to listen to both our our shows. It's called the Dr. Gabrielle Lion show, shocker. I just did that so people go find it. And I have interviewed the majority of the people that I have on the show are world class at what they do. They're the best in class at what they do. They are academics. And I've interviewed Martin Gabala, who is the Godfather of high intensity interval training. I've interviewed the head of the, you know, American sports, you know, consortium and I will tell you that the majority of them all agree that if you have limited time, that it is a full body intensive workout that collapses time. It is not long, slow, steady state. It is full body, whether plyometrics or something that you are capable of doing, that engages everything and engages it intensely with not a ton of rest in a condensed period and that could be 20 minutes.
Dr Gabrielle Lyon: Okay, so 20 minutes.
Dr Rupy: 20 minutes and I can be, I can get you to have an effective workout.
Dr Gabrielle Lyon: Okay, so within that 20 minutes, give me a couple of exercises that I could, I'm going to do this later on this week. So what what are the exercises that you think are going to give me the most bang for buck?
Dr Rupy: Well, what I would love to do is I would love to introduce something with weight. So for example, when I was pregnant for both pregnancies, I used a kettlebell. You can go on Amazon, you can purchase a kettlebell. You've got your one kettlebell, maybe you do two weights and you do full body movements, something like a kettlebell swing or a goblet squat or a press or a renegade row where you're in a push up position and you're rowing back. This engages full body. And again, start where you are if you are new to training, then it's not going to take much to begin to improve your baseline. But that's what I would do. And I would pick, again, a kettlebell swing is great. A goblet squat is great. A jump rope is great. It is something that is intense that uses your entire body in a short period of time and really putting in effortful training, I think is extremely valuable. And then if you can choose to walk and add in extra stuff, great. But if you are working hard enough doing a full body, and again, I I don't think it's fair to give 100 different exercises. Why? I could give you a kettlebell swing, a farmer's carry, which is where you're you're standing and walking, and a push up to a renegade row. I guarantee, I guarantee you, you're going to be smoked. And you're going to have a full body workout and you're going to be smoked.
Dr Gabrielle Lyon: Absolutely.
Dr Rupy: And you're going to have hit every muscle group. You've going to you're going to have stimulated your muscle. And listen, this is not a what what you and I are talking about, my friend, is not some well-designed strength progressive program. We are like, Gabrielle, I need to train. I have 20 minutes. I have two hours a week. I want to maintain my VO2 max. I want to maintain my strength, if not get stronger. I want to improve my mitochondrial efficiency and frankly, I want to be able to do whatever I want to do physically. That's what I would do.
Dr Gabrielle Lyon: Absolutely. Uh, quick hot take on bands. I have some some bands. What do you think? Yeah? Okay.
Dr Rupy: I love them. Because again, it's not the tool, it's how you use the modality.
Dr Gabrielle Lyon: Okay.
Dr Rupy: You give me something, I guarantee you I can make it hard for you.
Dr Gabrielle Lyon: Okay, great. That's good to know.
Dr Rupy: It's all about I travel with bands.
Dr Gabrielle Lyon: Yeah, because I I I was short on time when I was in LA as as I was talking to you about before for a month and I I took some bands with me and I was I was using those quite a bit. So that's good. Um, okay, so we know your thoughts on protein. We know your thoughts on protein powders. Um, what are your views on creatine?
Dr Rupy: So the data is great. There's my personal view and I think that there's a, you know, what the evidence would say. I would say personally, I think it's been around for a really long time and it has a good safety profile. 5 grams of creatine, three to five for women has been studied for muscle pretty robustly. And then 10 to 15 plus for brain function. I think it's very difficult to get that naturally. You could not eat enough red meat or foods that have creatine in it. This is the area where supplementation can be extremely valuable. Am I personally taking it right now? I'm not. I mean, I'm still looking for my socks, right? I I am not at this moment taking it, but do I go in cycles of taking it? I do.
Dr Gabrielle Lyon: Interesting.
Dr Rupy: It is very safe and I think that we're going to see more cognitive data come out, especially for people that are over 65. I think that again, it's going to be more and more impactful.
Dr Gabrielle Lyon: Okay, hot take on collagen.
Dr Rupy: I love collagen for hair, skin and nails. I've been using collagen for years. For years. For muscle, it does nothing. I think that the evidence is unclear if it affects tendons or joints. But the way that I think about collagen is the amino acid profile. It's just amino acids. Now it has a protein score of zero. It is an incomplete protein. You do not count collagen as a protein, but when it comes to something that is good for hair, skin and nails, potentially gut health, I love it. Again, I've been using it in my coffee for years. Years and years and years.
Dr Gabrielle Lyon: Okay, that's good to know. Any other nutrients you recommend paying attention to?
Dr Rupy: Yes. I think that there is a compound called Urolithin A and you can see randomized control trials on Urolithin A. I work with a company called Timeline. I think that they have hands down the only Urolithin A that I trust on the market because again, it's very evidence-based. And that's important to me just from a scientific integrity standpoint. I think that there is very interesting data on Urolithin A and it's a postbiotic and roughly 30 to 40% of people will never make this compound and it is a good mitochondrial gut interface, right? And it's just really cool. So that's one. Um, creatine, give or take, I don't personally always take it. I think it's great, but again, I'm I'm now just being selfish and and transparent about what I'm taking right now. Collagen, all day, every day, love collagen. And again, I I have it in my coffee and you know, I drink something called strong coffee. You can laugh, but it is so good and I wish I had known you had been in the US because I don't know where they ship to, but it's amazing. Caffeine is wonderful if you need a little boost. I think omega-3 fatty acids are great. These are all the things that I take regularly. What else am I taking right now? Right now I'm taking
Dr Gabrielle Lyon: What dose of omega-3 do you take?
Dr Rupy: I take a minimum of two grams. So I take a pack that I use and it has magnesium, vitamin D, it's like this one pack. And then if I'm feeling crazy, I leave this stuff on my counter, I'll just grab another two or three omega-3 pills, but a minimum of two grams. I'm probably closer to to four a day. Um, let's see what else am I taking. And then I play with methylene blue. You know, there's certain things that I, again, but I'm not saying, oh, you guys got to that that's the thing. But, um, that is, oh, and the other big thing that I'm really into lately is beta-hydroxybutyrate.
Dr Gabrielle Lyon: Ah, interesting. Is that, do you take that before you train?
Dr Rupy: I take it all the time. Let me see the, um, let me see. So beta-hydroxybutyrate is, from memory, a ketone.
Dr Rupy: I'm obsessed with this and I've been using it for a long, I have, I really, you know, it's it's really tart, the one that I use. So the source that I use, I use the ketones from a particular company and I, I mean, I'm obsessed and there's different isomers. So there's, I don't know if it's like D and L. I mean, I have to look. I honestly can't remember because I'm just, I use it all the time.
Dr Gabrielle Lyon: That's super interesting. Okay, I'm going to do some research on that. And the last one that I want your hot take on is a funky one, colostrum. When I was in LA, colostrum was everywhere. What's your take on that?
Dr Rupy: I think colostrum is amazing. That's the the first thing before mother's milk. And there is a company that, um, it's called Amra. And they make an incredible colostrum. I don't know if you want to know the brands or whatever, but these are brands that I use. And here's why, because it's freeze-dried. And I was looking into making my own product and not colostrum, but protein because listen, I've been talking about protein forever. I would love to make something that I want. And when I went to go look and talk to the manufacturer, they were like, oh, have you ever heard of this company called Amra? I'm like, yeah, I love it. And they're like, oh my gosh, it has everything that is on the label because the these companies they test it. They test to make sure that whatever the companies are saying that it actually exists because for whatever reason, I don't actually know why they do that, but they do. And I think it is great and I think it is really good for gut health.
Dr Gabrielle Lyon: Interesting.
Dr Rupy: Yeah, I think it's great. I don't know if we know the dosing per se, um, because there's always things coming out and it probably is also dependent on the the delivery system, but yes, I am all, I am all about colostrum too.
Dr Gabrielle Lyon: Amazing. Okay, great. Well, Dr. Gabrielle, you're awesome. This is this is such a good education in all things healthy aging. You've convinced me about muscle for sure. I'm a big fan of your show. I know people can go and listen to it. Um, and it's, yeah, it's a great resource. And you you cover a wide variety of topics as well. I think I remember you speaking to a plastic surgeon friend of yours as well and and so you go down beauty, you go down nutrition, you go down muscle, exercise. I think it's it's great what you're up to and uh, yeah, I really appreciate you making time for us over here in the UK.
Dr Rupy: Well, thank you so much. Um, I really appreciate it and uh, this is a lot of fun. Thanks for letting me talk about muscle and intermuscular adipose tissue and all that other stuff. So, thank you.
