A popular paper claimed the longevity benefit of lifting disappears once you train more than an hour a week. It's a real paper, but the claim is a misread. This is the free cut of this month's Direct Line, where Drs. Feigenbaum and Baraki also take on whether GLP-1s affect your mood, the "same calories, more weight loss" protein argument, and what you can actually do in the gym when you have chronic fatigue syndrome.

For education and infotainment, not medical advice.

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Timestamps:

0:00 Intro

0:38 The paper: does lifting stop helping after an hour?

3:19 The newer 147,000-person, 30-year study

13:21 GLP-1s, mood, and motivation

14:50 The FDA reverses the suicide warning

19:29 What happened when they gave people a GLP-1 in a bar

24:54 Is a calorie just a calorie?

28:17 The "same calories, more weight loss" protein study

30:48 Does keto break the laws of physics?

34:56 Lifting with chronic fatigue syndrome

36:14 The identical-twin experiment

37:36 Can lifting in bed do anything?

45:33 Get the full Direct Line

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1. Momma H, Kawakami R, Honda T, Sawada SS. Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies. *Br J Sports Med*. 2022;56(13):755-763. doi:10.1136/bjsports-2021-105061

2. Dankel SJ, Loenneke JP, Loprinzi PD. Dose-dependent association between muscle-strengthening activities and all-cause mortality: prospective cohort study among a national sample of adults in the USA. *Arch Cardiovasc Dis*. 2016;109(11):626-633. doi:10.1016/j.acvd.2016.04.005

3. Zhang Y, Lee DH, Rezende LFM, Ma Y, Giovannucci E. Long-term resistance training with all-cause and cause-specific mortality: assessing dose-response and joint associations with aerobic physical activity. *Br J Sports Med*. Published online June 2, 2026. doi:10.1136/bjsports-2025-110503

4. US Food and Drug Administration. FDA requests removal of suicidal behavior and ideation warning from glucagon-like peptide-1 receptor agonist (GLP-1 RA) medications. Drug Safety Communication. January 13, 2026. Accessed August 12, 2026. https://www.fda.gov/drugs/drug-safety-communications/fda-requests-removal-suicidal-behavior-and-ideation-warning-glucagon-peptide-1-receptor-agonist-glp

5. Hendershot CS, Bremmer MP, Paladino MB, et al. Once-weekly semaglutide in adults with alcohol use disorder: a randomized clinical trial. *JAMA Psychiatry*. 2025;82(4):395-405. doi:10.1001/jamapsychiatry.2024.4789

6. Klausen MK, Justesen SK, Pedersen JN, et al. Once-weekly semaglutide versus placebo in patients with alcohol use disorder and comorbid obesity: a randomised, double-blind, placebo-controlled trial. *Lancet*. 2026;407(10540):1687-1698. doi:10.1016/S0140-6736(26)00305-3

7. Haghighat N, Ashtary-Larky D, Bagheri R, et al. The effect of 12 weeks of euenergetic high-protein diet in regulating appetite and body composition of women with normal-weight obesity: a randomised controlled trial. *Br J Nutr*. 2020;124(10):1044-1051. doi:10.1017/S0007114520002019

8. Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, Board on the Health of Select Populations, Institute of Medicine. *Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness*. National Academies Press; 2015. Accessed August 12, 2026. https://www.ncbi.nlm.nih.gov/books/NBK274235/

9. Giloteaux L, Hanson MR, Keller BA. A pair of identical twins discordant for myalgic encephalomyelitis/chronic fatigue syndrome differ in physiological parameters and gut microbiome composition. *Am J Case Rep*. 2016;17:720-729. doi:10.12659/AJCR.900314

10. Rangan A, Brealey SD, Keding A, et al. Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial. *Lancet*. 2020;396(10256):977-989. doi:10.1016/S0140-6736(20)31965-6

11. Millar NL, Meakins A, Struyf F, et al. Frozen shoulder. *Nat Rev Dis Primers*. 2022;8(1):59. doi:10.1038/s41572-022-00386-2

12. US Department of Agriculture, US Department of Health and Human Services. *Dietary Guidelines for Americans, 2025-2030*. January 2026. Accessed August 12, 2026. https://www.dietaryguidelines.gov/

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An FDA advisory committee just voted to open a legal compounding supply line for six of seven peptides, including BPC-157 and TB-500, over the objection of the FDA's own scientists, who recommended against all seven. Dr. Jordan Feigenbaum walks through what the Pharmacy Compounding Advisory Committee actually voted on, why a vote about ulcerative colitis ends up governing tendon and joint use, what the single human BPC-157 trial does and doesn't show, and why "a pharmacy makes it safe" and "there's no money to study it" don't hold up. Evidence-based, no hype, no nocebo.

Timestamps:

 | 00:00:00 | The FDA voted 8-6. What it actually means

 | 00:01:25 | What I am, and am not, claiming

 | 00:03:21 | How they got here: Category 2 and the paperwork

 | 00:07:17 | Who was in the room: the panel that flipped

 | 00:10:57 | What they voted on: compounding and the bulks list

 | 00:15:37 | "No money in it, you can't patent it"

 | 00:18:24 | The trials already run: Plevna and MK-677

 | 00:22:55 | "I took it and it worked": placebo and fake surgery

 | 00:27:02 | The one human trial: Ruenzi 2005

 | 00:32:28 | Is it natural? Is it even a drug?

 | 00:36:58 | Harm reduction, or follow the money?

 | 00:42:45 | Three times a missing trial went wrong

 | 00:50:58 | Safety: known, unknown, and unknowable

 | 00:55:22 | The other six peptides

 | 00:58:22 | What I'd actually tell you

 | 01:02:08 | What actually works, and what would change my mind

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1. US Food and Drug Administration. FDA Briefing Document: Pharmacy Compounding Advisory Committee Meeting. July 23-24, 2026. Silver Spring, MD: FDA; 2026.

2. US Food and Drug Administration. FDA review of BPC-157-related bulk drug substances. PCAC Briefing Document. July 23-24, 2026. Media 193343. Accessed July 24, 2026. https://www.fda.gov/media/193343/download

3. US Food and Drug Administration. FDA review of TB-500-related bulk drug substances. PCAC Briefing Document. July 23-24, 2026. Media 193349.

4. US Food and Drug Administration. FDA review of KPV-, MOTS-c-, Semax-, Epitalon-, and Emideltide-related bulk drug substances. PCAC Briefing Documents. July 23-24, 2026.

5. US Food and Drug Administration. Questions for the Pharmacy Compounding Advisory Committee. July 23-24, 2026.

6. US Food and Drug Administration. Pharmacy Compounding Advisory Committee meeting roster. July 23-24, 2026. Media 193772.

7. US Food and Drug Administration. Pharmacy Compounding Advisory Committee meeting roster. 2022. Media 159040.

8. openFDA. FAERS adverse event reports for BPC-157. Accessed July 24, 2026. https://open.fda.gov

9. Pharmacy compounding; 503A bulk drug substances. 21 CFR §216.23 (2026).

10. Federal Food, Drug, and Cosmetic Act §503A, 21 USC §353a (pharmacy compounding).

11. Abigail Alliance for Better Access to Developmental Drugs v von Eschenbach, 495 F3d 695 (DC Cir 2007).

12. United States v Rutherford, 442 US 544 (1979).

13. Trickett Wendler, Frank Mongiello, Jordan McLinn, and Matthew Bellina Right to Try Act of 2017, Pub L No. 115-176, 132 Stat 1372 (2018).

14. US Food and Drug Administration. Regulatory considerations for human drug products containing peptides. Guidance for Industry (draft). 2020.

15. Ruenzi M, Stolte M, Veljaca M, et al. Efficacy and safety of PL 14736 (BPC 157) in patients with active ulcerative colitis [abstract]. Gastroenterology. 2005. Meeting abstract; full study not published.

16. Staresinic M, Petrovic I, Novinscak T, et al. Effective therapy of transected quadriceps muscle in rat: gastric pentadecapeptide BPC 157. J Orthop Res. 2006;24(5):1109-1117. doi:10.1002/jor.20089

17. Gwyer D, Wragg NM, Wilson SL. Gastric pentadecapeptide body protection compound BPC 157 and its role in accelerating musculoskeletal soft tissue healing. Cell Tissue Res. 2019;377(2):153-159. doi:10.1007/s00441-019-03016-8

18. Sikiric P, Skrtic A, Gojkovic S, et al. Stable gastric pentadecapeptide BPC 157 and hemorrhage/thrombosis. Pharmaceuticals (Basel). 2026;19(3):463. doi:10.3390/ph19030463

19. Stavchansky VV, Filippenkov IB, Dergunova LV, Limborska SA. The role of glyprolines in the regulation of gene expression: focus on Semax. Genes (Basel). 2022;13(12):2380. doi:10.3390/genes13122380

20. Mendias CL, Awan TM. The safety and efficacy of approved and unapproved peptides. Sports Med. 2026. doi:10.1007/s40279-026-02437-0

21. Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347(2):81-88. doi:10.1056/NEJMoa013259

22. Cobb LA, Thomas GI, Dillard DH, Merendino KA, Bruce RA. An evaluation of internal-mammary-artery ligation by a double-blind technic. N Engl J Med. 1959;260(22):1115-1118.

23. Dimond EG, Kittle CF, Crockett JE. Comparison of internal mammary artery ligation and sham operation for angina pectoris. Am J Cardiol. 1960;5:483-486.

24. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360-366. doi:10.1177/03635465980260030301

25. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790-802. doi:10.1111/j.1600-0838.2009.00949.x

26. Langberg H, Skovgaard D, Karamouzis M, Bulow J, Kjaer M. Metabolism and inflammatory mediators in the peritendinous space measured by microdialysis during intermittent isometric exercise in humans. J Physiol. 1999;515(Pt 3):919-927. doi:10.1111/j.1469-7793.1999.919ab.x

27. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-469. doi:10.1001/jama.2013.129

28. Kearney RS, Ji C, Warwick J, et al. Effect of platelet-rich plasma injection vs sham injection on tendon dysfunction in chronic midportion Achilles tendinopathy: a randomized clinical trial. JAMA. 2021;326(2):137-144. doi:10.1001/jama.2021.6986

29. Pavlova AV, Shim JSC, Moss R, et al. Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis. Br J Sports Med. 2023;57(20):1327-1334. doi:10.1136/bjsports-2022-105754

30. Weintraub M, Sundaresan PR, Madan M, et al. Long-term weight control study I (weeks 0 to 34): fenfluramine plus phentermine versus placebo. Clin Pharmacol Ther. 1992;51(5):586-594. doi:10.1038/clpt.1992.69

31. Connolly HM, Crary JL, McGoon MD, et al. Valvular heart disease associated with fenfluramine-phentermine. N Engl J Med. 1997;337(9):581-588. doi:10.1056/NEJM199708283370901

32. Centers for Disease Control and Prevention. Cardiac valvulopathy associated with exposure to fenfluramine or dexfenfluramine: interim public health recommendations, 1997. MMWR Morb Mortal Wkly Rep. 1997;46(45):1061-1066.

33. Bombardier C, Laine L, Reicin A, et al; VIGOR Study Group. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med. 2000;343(21):1520-1528. doi:10.1056/NEJM200011233432103

34. Graham DJ, Campen D, Hui R, et al. Risk of acute myocardial infarction and sudden cardiac death in patients treated with cyclo-oxygenase 2 selective and non-selective non-steroidal anti-inflammatory drugs: nested case-control study. Lancet. 2005;365(9458):475-481. doi:10.1016/S0140-6736(05)17864-7

35. Smith RM, Schaefer MK, Kainer MA, et al; Multistate Fungal Infection Outbreak Response Team. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med. 2013;369(17):1598-1609. doi:10.1056/NEJMoa1213978

36. Adunsky A, Chandler J, Heyden N, et al. MK-0677 (ibutamoren mesylate) for the treatment of patients recovering from hip fracture: a multicenter, randomized, placebo-controlled phase IIb study. Arch Gerontol Geriatr. 2011;53(2):183-189. doi:10.1016/j.archger.2010.10.004 [Trial terminated early for a congestive-heart-failure safety signal.]

37. Nass R, Pezzoli SS, Oliveri MC, et al. Effects of an oral ghrelin mimetic on body composition and clinical outcomes in healthy older adults: a randomized trial. Ann Intern Med. 2008;149(9):601-611. doi:10.7326/0003-4819-149-9-200811040-00003

38. Van Wagoner RM, Eichner A, Bhasin S, Deuster PA, Eichner D. Chemical composition and labeling of substances marketed as selective androgen receptor modulators and sold via the internet. JAMA. 2017;318(20):2004-2010. doi:10.1001/jama.2017.17069

39. ECRI and Institute for Safe Medication Practices. Unapproved peptide products: safety and quality concerns [white paper]. Plymouth Meeting, PA: ECRI; April 2026.

40. Center for Science in the Public Interest. What are injectable peptides, and are they safe? Accessed July 24, 2026. https://www.cspinet.org

41. World Anti-Doping Agency. The 2026 Prohibited List. Montreal, QC: WADA; 2026. Accessed July 24, 2026. https://www.wada-ama.org

42. US Anti-Doping Agency. BPC-157: a prohibited peptide. Accessed July 24, 2026. https://www.usada.org

43. FDA committee votes in favor of compounding several peptides. Time. July 23, 2026. Accessed July 24, 2026. https://time.com

44. FDA advisory committee backs controversial peptides. Regulatory Affairs Professionals Society (RAPS). 2026. Accessed July 24, 2026. https://www.raps.org

45. FDA panel okays peptides for compounding, including BPC-157 and KPV. STAT News. July 23, 2026. Accessed July 24, 2026. https://www.statnews.com

46. FDA panel recommends easing peptide restrictions over agency scientists' objections. NBC News. 2026. Accessed July 24, 2026. https://www.nbcnews.com

47. Associated Press. Financial ties reported among FDA peptide advisory panel members. 2026. Accessed July 24, 2026.

48. Leerink Partners. Equity research note: PCAC peptide vote and the telehealth compounding market. 2026.

49. Examine.com. BPC-157 research breakdown. Accessed July 24, 2026. https://examine.com/supplements/bpc-157/

50. Jarry J. Body protection compound: no proof required. McGill Office for Science and Society. Accessed July 24, 2026. https://www.mcgill.ca/oss

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A previously healthy 21-year-old shows up with seven months of headaches and 30-plus pounds of weight gain he can’t explain. He’s eating the same and training more, and the scale climbs anyway. We hand the case to Dr. Austin Baraki cold and work it in real time: the exam, the labs, the MRI, and two diagnoses that turn a headache workup into the clearest proof we’ve got that body weight is set by the brain, not by character. This is the capstone of our weight series (willpower, calories, protein), and it ends on the drug that, this year, did something for these patients that nothing had done before.

Timestamps

• 00:00:00 Cold open: the man who couldn’t stop gaining weight
• 00:01:49 Meet the case (and the rules of the game)
• 00:02:36 The presentation: 21, headaches, unexplained weight gain
• 00:03:57 Austin’s one-liner and how a clinician builds a differential
• 00:05:10 Secondary headaches: what raises the red flag
• 00:13:12 The exam: vitals, and the eye findings that matter
• 00:14:37 The labs, one number at a time
• 00:16:08 Raised pressure and a visual-field clue (bitemporal hemianopia)
• 00:20:45 The MRI
• 00:21:54 First diagnosis: craniopharyngioma
• 00:25:32 The name: a tumor built from tooth tissue
• 00:25:50 Surgery, and what it costs
• 00:27:43 The new mystery: gaining weight faster than ever
• 00:33:41 Second diagnosis: acquired hypothalamic obesity
• 00:39:17 How your brain sets your weight: the POMC brake and the AgRP accelerator
• 00:42:07 What about leptin?
• 00:45:46 Monogenic vs common obesity
• 00:50:30 Why GLP-1 drugs still worked: the brainstem backdoor
• 00:52:11 Responders and non-responders
• 00:55:40 Setmelanotide: a drug for the broken circuit
• 00:56:53 TRANSCEND, and the new FDA approval
• 00:58:55 What it costs
• 01:01:32 Why we care about body fat at all: the garage
• 01:04:36 Flux: which fat is actually dangerous
• 01:09:15 Close

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1. Brijmohan A, et al. Acquired hypothalamic obesity following craniopharyngioma resection in a young adult [case report]. 2025. PMCID: PMC12268545; PMID: 40677794. 

2. Miller JL, et al; TRANSCEND investigators. Setmelanotide in acquired hypothalamic obesity: a phase 3 randomized trial. N Engl J Med. 2026. 

3. Rhythm Pharmaceuticals. FDA approves IMCIVREE (setmelanotide) for acquired hypothalamic obesity. News release. March 19, 2026.

4. US Food and Drug Administration. FDA approves first treatment for weight management for people with certain rare genetic conditions (setmelanotide). 2020.

5. Montague CT, Farooqi IS, Whitehead JP, et al. Congenital leptin deficiency is associated with severe early-onset obesity in humans. Nature. 1997;387(6636):903-908.

6. Farooqi IS, Jebb SA, Langmack G, et al. Effects of recombinant leptin therapy in a child with congenital leptin deficiency. N Engl J Med. 1999;341(12):879-884.

7. Krude H, Biebermann H, Luck W, et al. Severe early-onset obesity, adrenal insufficiency and red hair pigmentation caused by POMC mutations in humans. Nat Genet. 1998;19(2):155-157.

8. Farooqi IS, Keogh JM, Yeo GS, et al. Clinical spectrum of obesity and mutations in the melanocortin 4 receptor gene. N Engl J Med. 2003;348(12):1085-1095.

9. Clément K, Vaisse C, Lahlou N, et al. A mutation in the human leptin receptor gene causes obesity and pituitary dysfunction. Nature. 1998;392(6674):398-401.

10. Fabbrini E, Tamboli RA, Magkos F, et al. Surgical removal of omental fat does not improve insulin sensitivity and cardiovascular risk factors in obese adults. Gastroenterology. 2010;139(2):448-455.

11. Klein S, Fontana L, Young VL, et al. Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med. 2004;350(25):2549-2557.

12. Guyenet SJ. The Hungry Brain: Outsmarting the Instincts That Make Us Overeat. Flatiron Books; 2017. 

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Every couple of years a new headline warns that the protein you eat is quietly hurting you. This year the target is your kidneys. Before that it was cancer, then your bones, then the claim that your body can only use twenty or thirty grams of protein at a meal. In this episode, Dr. Jordan Feigenbaum goes through the actual studies behind each scare: the kidney trials, the 2014 IGF-1 and cancer paper that started the panic, the acid-ash bone hypothesis, and the per-meal "cap." Each fear starts from a real mechanism, and each one was run straight to a frightening conclusion the clinical outcomes never supported.

The take home is simple. For a healthy adult, protein is not the lever people think it is, and where a real signal exists (processed and red meat, or a kidney that is already diseased) it tracks the whole dietary pattern more than the protein number. The two things that actually decide your health here are whether you eat mostly real food and whether you train.

Timestamps

• 00:00 The protein scare cycle 
• 01:23 The four fears 
• 01:59 Kidneys: healthy kidneys under higher protein 
• 06:22 Kidney disease: does cutting protein help? 
• 09:38 Red meat and the dietary pattern, not protein 
• 12:00 Muscle, aging, and lifting on a restricted diet 
• 13:54 Cancer: IGF-1 and the 2014 study everyone cites 
• 16:22 The age reversal, and what travels with protein 
• 18:48 Bigger data, processed meat, and the IGF-1 tell 
• 22:15 Bones and the acid-ash myth 
• 25:13 The 30-gram cap 
• 27:17 What protein actually does, and how much you need 
• 32:20 The two questions that matter

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Studies

• Levine et al. Cell Metabolism 2014. doi:10.1016/j.cmet.2014.02.006
• Naghshi et al. BMJ 2020. doi:10.1136/bmj.m2412 
• Devries et al. J Nutr 2018. doi:10.1093/jn/nxy197 
• Antonio et al. J Nutr Metab 2016. doi:10.1155/2016/9104792 
• Knight et al. Ann Intern Med 2003. doi:10.7326/0003-4819-138-6-200303180-00009 
• Klahr et al. (MDRD). NEJM 1994. doi:10.1056/NEJM199403313301301
•  Hahn, Hodson & Fouque. Cochrane 2020. doi:10.1002/14651858.CD001892.pub5 
• Obeid, Hiremath & Topf. Kidney360 2022. doi:10.34067/KID.0001002022 
• Lew et al. J Am Soc Nephrol 2017. doi:10.1681/ASN.2016030248
• Castaneda et al. Ann Intern Med 2001. doi:10.7326/0003-4819-135-11-200112040-00008 
• Bauer et al. (PROT-AGE). JAMDA 2013. doi:10.1016/j.jamda.2013.05.021
• Fenton et al. Nutrition Journal 2011. doi:10.1186/1475-2891-10-41
• Shams-White et al. Am J Clin Nutr 2017. doi:10.3945/ajcn.116.145110
• Witard et al. Am J Clin Nutr 2013. doi:10.3945/ajcn.112.055517
•  Macnaughton et al. Physiol Rep 2016. doi:10.14814/phy2.12893
• Trommelen et al. Cell Reports Medicine 2023. doi:10.1016/j.xcrm.2023.101324 
• Wycherley et al. Am J Clin Nutr 2012. doi:10.3945/ajcn.112.044321
•  Moore et al. JAMA Intern Med 2016. doi:10.1001/jamainternmed.2016.1548 
• Larsson et al. Cancer Med 2020. doi:10.1002/cam4.3345 
• Brenner, Meyer & Hostetter. NEJM 1982. doi:10.1056/NEJM198209093071104 
• Chan et al. PLoS One 2011. doi:10.1371/journal.pone.0020456
• Berryman et al. Am J Clin Nutr 2018. doi:10.1093/ajcn/nqy088 
• Morton et al. Br J Sports Med 2018. doi:10.1136/bjsports-2017-097608

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Is weight loss really just Calories in, Calories out? The equation is true, but "just count your Calories" is bad advice for most people, and almost every objection to it is pointing at something real. In part two of our energy balance series, Jordan Feigenbaum takes the biggest "it's not Calories, it's ___" claims (metabolism, thyroid, cortisol, PCOS, insulin, the type of food) and tests each against the best evidence. The verdict: none of them breaks the equation. Every one is a hand on a lever that moves Calories in or Calories out, not a hole in the math.

In this episode: why your metabolism does not crash at 40, how small real metabolic adaptation actually is after weight loss, why hypothyroid weight is mostly water, what the cortisol and PCOS (now PMOS) data show, how absorption and cooking move Calories only at the edges, why even dietitians miscount their own intake, and why the carbohydrate-insulin model fails three tests, including the GLP-1 drugs that raise insulin and still produce the biggest weight loss we have ever approved.

Part two of three: willpower, Calories in Calories out, then GLP-1 drugs. Next week: are GLP-1s cheating?

Timestamps

• 0:00 Is it really just calories in, calories out?
• 0:18 The willpower episode and the through-line
• 2:10 Thermodynamics: what sets both sides
• 2:41 Your metabolism is three things
• 4:05 Claim 1: my metabolism crashed
• 4:24 No cliff at 40: the doubly labeled water study
• 5:33 Real metabolic adaptation after weight loss
• 6:56 Why your food diary lies
• 7:49 Claim 2: it's my hormones
• 8:07 Thyroid: mostly water
• 9:36 Cortisol: explains about 1 percent
• 11:12 PCOS is now PMOS
• 13:06 Menopause
• 14:18 Claim 3: a calorie isn't a calorie
• 16:48 Absorption: nuts, cooking, eggs
• 19:44 Why calorie counting fails
• 21:12 Claim 4: it's not Calories, it's insulin
• 22:02 Testing the carbohydrate-insulin model
• 25:52 The GLP-1 drugs that should end it
• 28:34 The whole list, claim by claim
• 29:53 What to actually do
• 30:42 Next week: are GLP-1s cheating?

Resources:

Barbell Medicine coaching and templates: https://www.barbellmedicine.com

https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/

https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/

Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/

Pontzer et al., Science 2021. https://doi.org/10.1126/science.abe5017

Muller et al., Am J Clin Nutr 2015. https://doi.org/10.3945/ajcn.115.109173

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Karmisholt et al., J Clin Endocrinol Metab 2011. https://doi.org/10.1210/jc.2010-1521

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van der Valk et al., Obes Rev 2022. https://doi.org/10.1111/obr.13376

Nikokavoura et al., Diabetes Metab Syndr Obes 2015. https://doi.org/10.2147/DMSO.S85134

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Jastreboff et al., N Engl J Med 2022. https://doi.org/10.1056/NEJMoa2206038

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Obesity roughly tripled in about 60 years, and the genes didn't change in that time. So if body weight isn't a willpower problem, what is it? Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through what actually sets your weight: the adoption and twin studies behind the genetics, the "defended range" your biology fights to hold, the food environment that does most of the eating for you, and where GLP-1 medications actually work. Along the way — why diets regain after you white-knuckle them, what The Biggest Loser six-year data show about resting metabolism, and four willpower myths worth retiring. 

Hosted by Dr. Jordan Feigenbaum and Dr. Austin Baraki, co-founders of Barbell Medicine.

Timestamps

• 00:00 Cold open: Danny Cahill and The Biggest Loser
• 01:03 What we mean by "willpower"
• 05:48 Obesity tripled in ~60 years: the one number
• 06:31 Adoption and twin studies: genes vs. household
• 09:37 Set point vs. the defended range
• 10:37 Gene–environment mismatch
• 14:03 In the clinic: a lifelong weight history
• 19:18 Losing weight vs. keeping it off
• 20:26 Appetite doesn't reset (Sumithran)
• 25:52 Metabolic adaptation and the Biggest Loser data
• 34:07 Part 2: eating on autopilot
• 35:10 Portion size runs the meal
• 39:12 What changed in the food supply
• 40:42 Same genes, new environment: Pima and immigrants
• 43:20 Why ultra-processed food is easy to overeat
• 50:28 Processing vs. calories: the Hall ward study
• 52:36 When the brain changes eating: gourmand syndrome
• 1:00:01 Why the willpower story stuck
• 1:01:08 Taft, Churchill, and the intelligence myth
• 1:02:43 Does intelligence predict weight? (sibling study)
• 1:11:16 Are GLP-1s cheating? What they actually do
• 1:15:10 Beyond the scale: muscle, health, nutrition
• 1:24:21 Myth-busting: lightning round
• 1:39:04 Three takeaways: what to actually do
• 1:41:00 Danny Cahill, revisited 

Resources

 

Barbell Medicine coaching and templates: https://www.barbellmedicine.com

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Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/

Coaching, programs & templates: https://www.barbellmedicine.com/

Prevalence of Overweight, Obesity, and Severe Obesity Among Adults Age 20 and Older: United States, 1960-1962 Through August 2021-August 2023. NCHS Health E-Stats. 2024. https://www.cdc.gov/nchs/data/hestat/hestat111.htm

Obesity and Severe Obesity Prevalence in Adults: United States, August 2021-August 2023. NCHS Data Brief No. 508. Hyattsville, MD: National Center for Health Statistics; 2024. https://www.cdc.gov/nchs/products/databriefs/db508.htm

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Morton RW, Murphy KT, McKellar SR, et al. A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults. Br J Sports Med. 2018;52(6):376-384. https://doi.org/10.1136/bjsports-2017-097608

Stunkard AJ, Sorensen TIA, Hanis C, et al. An adoption study of human obesity. N Engl J Med. 1986;314(4):193-198. https://doi.org/10.1056/NEJM198601233140401

Stunkard AJ, Harris JR, Pedersen NL, McClearn GE. The body-mass index of twins who have been reared apart. N Engl J Med. 1990;322(21):1483-1487. https://doi.org/10.1056/NEJM199005243222102

Speakman JR, Levitsky DA, Allison DB, et al. Set points, settling points and some alternative models: theoretical options to understand how genes and environments combine to regulate body adiposity. Dis Model Mech. 2011;4(6):733-745. https://doi.org/10.1242/dmm.008698

Kalm LM, Semba RD. They starved so that others be better fed: remembering Ancel Keys and the Minnesota Experiment. J Nutr. 2005;135(6):1347-1352. https://doi.org/10.1093/jn/135.6.1347

Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. 2011;365(17):1597-1604. https://doi.org/10.1056/NEJMoa1105816

Fothergill E, Guo J, Howard L, et al. Persistent metabolic adaptation 6 years after 'The Biggest Loser' competition. Obesity (Silver Spring). 2016;24(8):1612-1619. https://doi.org/10.1002/oby.21538

Hall KD. Energy compensation and metabolic adaptation: 'The Biggest Loser' study reinterpreted. Obesity (Silver Spring). 2022;30(1):11-13. https://doi.org/10.1002/oby.23308

Cohen DA, Farley TA. Eating as an automatic behavior. Prev Chronic Dis. 2008;5(1):A23. https://www.cdc.gov/pcd/issues/2008/jan/07_0046.htm

Rolls BJ, Morris EL, Roe LS. Portion size of food affects energy intake in normal-weight and overweight men and women. Am J Clin Nutr. 2002;76(6):1207-1213. https://doi.org/10.1093/ajcn/76.6.1207

Diliberti N, Bordi PL, Conklin MT, Roe LS, Rolls BJ. Increased portion size leads to increased energy intake in a restaurant meal. Obes Res. 2004;12(3):562-568. https://doi.org/10.1038/oby.2004.64

Hollands GJ, Shemilt I, Marteau TM, et al. Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco. Cochrane Database Syst Rev. 2015;(9):CD011045. https://doi.org/10.1002/14651858.CD011045.pub2

Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause excess calorie intake and weight gain: an inpatient randomized controlled trial of ad libitum food intake. Cell Metab. 2019;30(1):67-77.e3. https://doi.org/10.1016/j.cmet.2019.05.008

Pontzer H, Raichlen DA, Wood BM, et al. Hunter-gatherer energetics and human obesity. PLoS One. 2012;7(7):e40503. https://doi.org/10.1371/journal.pone.0040503

Careau V, Halsey LG, Pontzer H, et al. Energy compensation and adiposity in humans. Curr Biol. 2021;31(20):4659-4666.e2. https://doi.org/10.1016/j.cub.2021.08.016

Miller WC, Koceja DM, Hamilton EJ. A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention. Int J Obes Relat Metab Disord. 1997;21(10):941-947. https://doi.org/10.1038/sj.ijo.0800499

Gaesser GA, Angadi SS. Obesity treatment: weight loss versus increasing fitness and physical activity for reducing health risks. iScience. 2021;24(10):102995. https://doi.org/10.1016/j.isci.2021.102995

US Department of Agriculture, Economic Research Service. Food Availability (Per Capita) Data System, Loss-Adjusted Food Availability. https://www.ers.usda.gov/data-products/food-availability-per-capita-data-system/

Steele EM, Baraldi LG, Louzada ML, Moubarac JC, Mozaffarian D, Monteiro CA. Ultra-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study. BMJ Open. 2016;6(3):e009892. https://doi.org/10.1136/bmjopen-2015-009892

Wang L, Martinez Steele E, Du M, et al. Trends in consumption of ultraprocessed foods among US youths aged 2-19 years, 1999-2018. JAMA. 2021;326(6):519-530. https://doi.org/10.1001/jama.2021.10238

Schulz LO, Bennett PH, Ravussin E, et al. Effects of traditional and western environments on prevalence of type 2 diabetes in Pima Indians in Mexico and the US. Diabetes Care. 2006;29(8):1866-1871. https://doi.org/10.2337/dc06-0138

Goel MS, McCarthy EP, Phillips RS, Wee CC. Obesity among US immigrant subgroups by duration of residence. JAMA. 2004;292(23):2860-2867. https://doi.org/10.1001/jama.292.23.2860

Papavramidou NS, Papavramidis ST, Christopoulou-Aletra H. Galen on obesity: etiology, effects, and treatment. World J Surg. 2004;28(6):631-635. https://doi.org/10.1007/s00268-004-7458-5

Haslam DW, Haslam F. Fat, Gluttony and Sloth: Obesity in Literature, Art and Medicine. Liverpool: Liverpool University Press; 2009. https://www.liverpooluniversitypress.co.uk/9781846311734/fat-gluttony-and-sloth/

Townend L. The moralizing of obesity: a new name for an old sin? Crit Soc Policy. 2009;29(2):171-190. https://doi.org/10.1177/0261018308101625

Levine DI. Corpulence and correspondence: President William H. Taft and the medical management of obesity. Ann Intern Med. 2013;159(8):565-570. https://doi.org/10.7326/0003-4819-159-8-201310150-00012

Wright L, Davies NM, Bann D. The association between cognitive ability and body mass index: a sibling-comparison analysis in four longitudinal studies. PLoS Med. 2023;20(4):e1004207. https://doi.org/10.1371/journal.pmed.1004207

Mechanisms of GLP-1 receptor agonist-induced weight loss: a review of central and peripheral pathways. Am J Med. 2025 (review of hypothalamic arcuate nucleus and brainstem area postrema action). https://www.sciencedirect.com/science/article/pii/S0002934325000592

Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity (STEP 1). N Engl J Med. 2021;384(11):989-1002. https://doi.org/10.1056/NEJMoa2032183

Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide once weekly for the treatment of obesity (SURMOUNT-1). N Engl J Med. 2022;387(3):205-216. https://doi.org/10.1056/NEJMoa2206038

Grannell A, Fallon F, Al-Najim W, le Roux C. Obesity and responsibility: is it time to rethink agency? Obes Rev. 2021;22(8):e13270. https://doi.org/10.1111/obr.13270

Al Khatib HK, Harding SV, Darzi J, Pot GK. The effects of partial sleep deprivation on energy balance: a systematic review and meta-analysis. Eur J Clin Nutr. 2017;71(5):614-624. https://doi.org/10.1038/ejcn.2016.201

Helms ER, Aragon AA, Fitschen PJ. Evidence-based recommendations for natural bodybuilding contest preparation: nutrition and supplementation. J Int Soc Sports Nutr. 2014;11:20. https://doi.org/10.1186/1550-2783-11-20

Garthe I, Raastad T, Refsnes PE, Koivisto A, Sundgot-Borgen J. Effect of two different weight-loss rates on body composition and strength and power-related performance in elite athletes. Int J Sport Nutr Exerc Metab. 2011;21(2):97-104. https://doi.org/10.1123/ijsnem.21.2.97

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Once a month we answer Barbell Medicine Plus subscribers’ questions on the Direct Line. This is a free look at June’s episode. We start with GLP-1 drugs and muscle: why DEXA overstates the loss, what resistance training actually does, and whether creatine is worth taking. Then whether bulking and cutting does anything the scale can’t already tell you, how to get real benefit from one training hour a week, and what happens to your muscle, strength, tendons, and bone when you take time off, including why muscle memory brings it back faster than you built it.

What we cover:

•   GLP-1s and muscle: the DEXA problem, resistance training, and creatine

•   Bulking vs cutting vs just maintaining, and a health-first way to choose

•   Training on one hour a week: the least that still moves the needle

•   How fast you lose muscle when you stop, and why it comes back fast

The full two-hour episode and every back episode are on Barbell Medicine Plus, which can bundled with Premium. Resources and full references below.

Timestamps

0:00 Intro + GLP-1 and the DEXA muscle-loss myth

3:00 Do GLP-1s spare or waste muscle?

8:03 Does creatine help on a GLP-1?

10:45 Does bulking and cutting do anything?

13:18 Health first: when to lose fat before gaining

22:30 Training on one hour a week

36:22 How fast you lose muscle when you stop

43:19 Muscle memory: why it comes back

48:25 The full episode on Plus

Resources

• Barbell Medicine coaching and templates: https://www.barbellmedicine.com
• https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/
• https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/
• Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/
• 
  

https://www.barbellmedicine.com/blog/glp-1-muscle-loss/

https://www.barbellmedicine.com/blog/creatine-on-ozempic-does-it-prevent-muscle-loss/

https://www.barbellmedicine.com/blog/novice-intermediate-advanced-strength-training/

Lundgren JR, et al. Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined (S-LITE). N Engl J Med 2021;384:1719-1730. nejm.org · NEJMoa2028198

T-REX trial: tirzepatide with or without resistance training (Univ. of Western Australia). Preliminary. ANZCTR ACTRN12623001236684

Creatine + GLP-1 pilot (Univ. of Saskatchewan). Ongoing, results expected 2027. ClinicalTrials.gov NCT07625202

Momma H, et al. Muscle-strengthening activities and lower risk/mortality in major non-communicable diseases. Br J Sports Med 2022. PubMed 35228201

Wall BT, et al. 2014. Immobilization and disuse muscle atrophy (quadriceps −3.5% at 5 days, −8% at 14 days). PubMed 24168489

Gaffney CJ, et al. 2021. Grip strength loss with short-term arm immobilization. PMC8107283

Farthing JP, et al. 2009. Cross-education and preservation of the immobilized limb. PubMed 19150859

Marusic U, et al. 2021. Bed rest: strength loss outpaces size loss. PMC8325614

Yoshihara, et al. 2023. Sepsis-associated muscle wasting (−26% in a week). PMC10003568

Warren GL, et al. 2017. Strength loss and recovery after muscle injury (meta-analysis). PMC5214801

Hortobágyi T, et al. 1993. Short-term detraining in strength athletes. PubMed 8371654

Gavanda S, et al. 2020. Training cessation in previously untrained adolescents. PMC7241623

Lovell DI, et al. 2010. Detraining strength loss in older adults. PubMed 20140683

Mujika I, Padilla S. 2001. Physiology of detraining (review). PubMed 11474330

Smith K, et al. 2003. Two years of training, then detraining, in older adults. PubMed 12955872

Staron RS, et al. 1991. Detraining and muscle cross-sectional area in women. PubMed 1827108

Ivey FM, et al. 2000. Detraining across age and sex. PubMed 10795719

Taaffe DR, et al. 2009. Training and detraining in older adults. PMC2756799

Grgic J, et al. 2022. Muscle size loss with detraining (meta-analysis). PubMed 36360927

Bosquet L, et al. 2013. Detraining effects on strength and power. PubMed 23347054

Bruusgaard JC, et al. 2010. Myonuclei acquired by overload persist after detraining (muscle memory). PMC2930527

Weakley J, et al. 2017. Day-to-day variation in strength performance. PubMed 28277425

McGuigan MR, et al. 2004. Strength performance variability. PubMed 15320651

Andreoli A, et al. 2009. DEXA precision and assumptions. PMC9263164

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Is there really a “menopause-specific” way to train, eat, and supplement — or is most of it marketing? In the finale of our 4-part menopause series, Drs. Jordan Feigenbaum and Austin Baraki go straight to the evidence on building muscle and bone before, during, and after the transition.

We cover whether menopause blunts your response to lifting (the Isenmann 2023 head-to-head trial and the 2026 meta-analysis of ~4,000 women say it doesn’t), the one-index-card prescription that actually works. Then we work through the loudest claims in the space — cortisol “wrecking” your fat loss, anabolic resistance, the protein and creatine hype, hormone therapy as a cure-all, and “you need a different paradigm” — steelmanning each before we push back. We close with the strongest case in the whole space: heavy lifting for bone density (the LIFTMOR trial), the pelvic-floor evidence, your three biggest fears answered, and how to tell a good coach or clinician from a bad one.

Claims discussed are associated with Stacey Sims, Mary Claire Haver, Mindy Pelz, and the broader functional-medicine space. We push back on the claims, not the people.

Timestamps:

• 0:00 The 90-year-olds who tripled their strength
•  1:10 Why this matters: heart disease and falls, not vanity
•  2:28 Can women still build muscle after menopause? (Isenmann 2023)
•  7:31 Does menopause blunt your gains? The 2026 meta-analysis
•  8:49 Is it menopause, or just individual variation?
•  14:42 The estrogen "shield" and the mechanical override
•  18:31 Does hormone therapy replace training? (the 2021 estradiol trial)
•  22:44 What actually works: the whole prescription
•  24:18 Program details: frequency, volume & insulin sensitivity
•  30:22 Nutrition: protein and the 2026 review
•  35:06 Creatine, vitamin D & calcium
•  43:29 Anabolic resistance: mostly overstated
•  47:22 Clinical case: the supplement-stack patient
•  52:23 A short history of wrong advice for women
•  53:38 Claim 1: "Lift heavy or lose your bones" (Stacey Sims)
•  1:01:09 Claim 2: the cortisol myth
•  1:15:18 Clinical case: the cortisol-anxious patient
•  1:18:20 Claim 3: "It's all hormonal, HRT fixes it" (Mary Claire Haver)
•  1:20:45 Testosterone in women: what it does and doesn't do
•  1:21:51 Claim 4: "Menopause needs its own paradigm" & the SWAN data
•  1:24:48 Bone density done right: the LIFTMORE trial
•  1:33:07 Does heavy lifting wreck your pelvic floor?
•  1:38:59 Your three biggest fears, answered
•  1:40:44 Green flags & red flags 

Resources:

• Menopause Series Part 1 : https://www.youtube.com/watch?v=yzk0IkTy0WM
• Menopause Series Part 2 — https://www.youtube.com/watch?v=YKAlamIOiwU
•  Menopause Series Part 3 — https://www.youtube.com/watch?v=jzoNMQaBAcI 
• Hypercortisolism episode - https://open.spotify.com/episode/7tDdUi8dDFWjMYx0fRJdOz 

Barbell Medicine coaching and templates: https://www.barbellmedicine.com

Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/

Isenmann (2023) https://doi.org/10.1186/s12905-023-02671-y

Isenmann (2026) https://doi.org/10.1016/j.jsams.2026.01.004

Fiatarone (1990) https://doi.org/10.1001/jama.1990.03440220053029

Fiatarone (1994) https://doi.org/10.1056/NEJM199406233302501

Dam (2021) https://doi.org/10.3389/fphys.2020.596130

Markofski (2015) https://doi.org/10.1016/j.exger.2015.02.015

Orsatti (2022) https://doi.org/10.1016/j.exger.2022.111904

Walter (2026) https://doi.org/10.1186/s40798-025-00954-2

dos Santos (2021) https://doi.org/10.3390/nu13113757

Myung (2021) https://doi.org/10.3390/nu13020368

Dote-Montero (2021) https://doi.org/10.1111/sms.13999

Ravussin (2015) https://doi.org/10.1093/gerona/glv057

Cadegiani (2016) https://doi.org/10.1186/s12902-016-0128-4

Greising (2009) https://doi.org/10.1093/gerona/glp082

Islam (2019) https://doi.org/10.1016/S2213-8587(19)30189-5

Testosterone in women review (2026) https://doi.org/10.1080/09513590.2025.2592402

NAMS nonhormone position statement (2023) https://doi.org/10.1097/GME.0000000000002200

Vasomotor exercise meta-analysis (2022) https://doi.org/10.1080/13697137.2022.2097865

Greendale (2019) https://doi.org/10.1172/jci.insight.124865

Watson, LIFTMOR (2018) https://doi.org/10.1002/jbmr.3284

Skaug (2024) https://doi.org/10.1249/MSS.0000000000003278

Skaug (2021) https://doi.org/10.1007/s00192-021-04739-5

Dumoulin (2018) https://doi.org/10.1002/14651858.CD005654.pub4

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Most women in 2026 are told menopause affects everything, the weight, the belly fat, the bones, the heart, the brain, and that the fix is hormones, supplements, and a proprietary protocol. The data tell a different story. Menopause does some of it, but not all of it.

In this episode, Dr. Jordan Feigenbaum and Dr. Austin Baraki, with OB-GYN Dr. Loraine Baraki at the clinical handoffs, put real numbers on what menopause actually changes, e.g. body composition, the cardiometabolic shift around the final menstrual period, bone, cognition and sleep — and on the single biggest modifiable lever against what actually kills postmenopausal women.

This is Episode 3 of Barbell Medicine's four-part menopause series.

Timestamps:

• 01:23 Intro 
• 02:45 Body composition & the SWAN study 
• 04:16 How much weight gain is really menopause?
•  06:55 The answer: about 1.5 kg 08:14 Subcutaneous vs visceral fat
•  11:08 Why waist beats weight (and body-fat %) 
• 17:21 Does menopause crash your metabolism? 19:02 Clinic: MHT for body composition 
• 23:51 Dr. Loraine Baraki — MHT, weight & testosterone 
• 27:29 The cardiometabolic shift: cholesterol at the FMP 
• 30:18 Insulin resistance & metabolic syndrome 
• 33:12 Blood pressure & 10-year heart risk 
• 34:54 Clinic: the "estrogen crisis" lipid panic 
• 39:13 Bone: the advice vs the data 40:34 Why DXA misses most fractures 
• 41:24 LIFTMOR: lifting heavy with low bone density 
• 44:47 The LIFTMOR results 
• 46:53 Lifting vs Pilates, and falls 
• 52:17 Clinic: "Should I be deadlifting?" 
• 56:14 Cognition & brain fog 
• 57:50 Why brain fog is mostly a sleep problem 
• 59:17 Clinic: brain fog, night sweats, broken sleep 
• 1:03:06 Depression & dementia in midlife 
• 1:05:43 Does hormone therapy protect the brain? 
• 1:08:53 Clinic: "Am I getting early dementia?" 
• 1:13:19 Dr. Loraine Baraki — the timing hypothesis & the brain
• 1:16:15 What actually kills postmenopausal women 
• 1:17:31 Fitness: the biggest mortality lever 
• 1:20:21 Strength, power & grip 
• 1:25:15 Clinic: where to start when you're overwhelmed 
• 1:30:41 The detraining problem 
• 1:32:38 Trained vs untrained: what's recoverable 
• 1:34:53 The actual plan 
• 1:39:48 Takeaways

Resources:

Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/

Barbell Medicine coaching and templates: https://www.barbellmedicine.com/

Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/

Body composition & metabolism

 Greendale et al., SWAN body composition, JCI Insight 2019: https://doi.org/10.1172/jci.insight.124865

 Lovejoy et al., visceral fat across the transition, Int J Obes 2008: https://doi.org/10.1038/ijo.2008.25

 Pontzer et al., daily energy expenditure across life, Science 2021: https://doi.org/10.1126/science.abe5017

 Karppinen et al., metabolism in midlife women, Eur J Prev Cardiol 2023: https://doi.org/10.1093/eurjpc/zwad177

Cardiometabolic

Matthews et al., lipid changes & the menopause transition, JACC 2009: https://doi.org/10.1016/j.jacc.2009.10.009

Janssen et al., menopause & metabolic syndrome (SWAN), Arch Intern Med 2008: https://doi.org/10.1001/archinte.168.14.1568

 El Khoudary et al., AHA Scientific Statement on midlife women, Circulation 2020: https://doi.org/10.1161/CIR.0000000000000912

Bone

Greendale et al., SWAN bone loss across the FMP, JBMR 2012: https://doi.org/10.1002/jbmr.534

 Siris et al., undiagnosed low BMD & fractures (NORA), JAMA 2001: https://doi.org/10.1001/jama.286.22.2815

 Watson et al., LIFTMOR, JBMR 2018: https://doi.org/10.1002/jbmr.3284

Kemmler et al., EFOPS 16-year, Menopause 2017: https://doi.org/10.1097/GME.0000000000000720

Kistler-Fischbacher et al., MEDEX-OP, JBMR 2021: https://doi.org/10.1002/jbmr.4334

 Sherrington et al., exercise for preventing falls, Cochrane 2019: https://doi.org/10.1002/14651858.CD012424.pub2

ACSM Position Stand: Osteoporosis and Exercise, Med Sci Sports Exerc 1995;27(4):i–vii (no DOI)

Cognition & mood

Greendale et al., SWAN cognition, Neurology 2009: https://doi.org/10.1212/WNL.0b013e3181a71193

Kravitz et al., sleep in midlife women, Obstet Gynecol Clin North Am 2018: https://doi.org/10.1016/j.ogc.2018.07.008

Cohen et al., Harvard Study of Moods and Cycles, Arch Gen Psychiatry 2006: https://doi.org/10.1001/archpsyc.63.4.385

Bromberger & Kravitz, mood and menopause (SWAN), Obstet Gynecol Clin North Am 2011: https://doi.org/10.1016/j.ogc.2011.05.011

Livingston et al., Lancet Commission on dementia 2024: https://doi.org/10.1016/S0140-6736(24)01296-0

Shumaker et al., WHIMS (estrogen+progestin & dementia), JAMA 2003: https://doi.org/10.1001/jama.289.20.2651

 Espeland et al., WHIMS (estrogen-alone & cognition), JAMA 2004: https://doi.org/10.1001/jama.291.24.2959

Gleason et al., KEEPS-Cog, PLoS Med 2015: https://doi.org/10.1371/journal.pmed.1001833

 Henderson et al., ELITE (timing hypothesis & cognition), Neurology 2016: https://doi.org/10.1212/WNL.0000000000002980

USPSTF, hormone therapy for primary prevention, JAMA 2022: https://doi.org/10.1001/jama.2022.18625

Fitness & mortality

 Mandsager et al., cardiorespiratory fitness & mortality, JAMA Netw Open 2018: https://doi.org/10.1001/jamanetworkopen.2018.3605

Kodama et al., fitness & mortality meta-analysis, JAMA 2009: https://doi.org/10.1001/jama.2009.681

Sui et al., fitness & adiposity in older adults, JAMA 2007: https://doi.org/10.1001/jama.298.21.2507

Momma et al., muscle-strengthening activity & mortality, Br J Sports Med 2022: https://doi.org/10.1136/bjsports-2021-105061

Araújo et al., muscle power vs strength & mortality (CLINIMEX), Mayo Clin Proc 2025: https://doi.org/10.1016/j.mayocp.2025.02.015

Leong et al., grip strength & mortality (PURE), Lancet 2015: https://doi.org/10.1016/S0140-6736(14)62000-6

Detraining & trained-vs-untrained

Troiano et al., accelerometer-measured activity, Med Sci Sports Exerc 2008: https://doi.org/10.1249/mss.0b013e31815a51b3

Fleg et al., aerobic-capacity decline (BLSA), Circulation 2005: https://doi.org/10.1161/CIRCULATIONAHA.105.545459

Ratley et al. aerobic-capacity changes during menopause, 2025

https://pmc.ncbi.nlm.nih.gov/articles/PMC12358808/

Janssen et al., skeletal muscle mass across adulthood, J Appl Physiol 2000: https://doi.org/10.1152/jappl.2000.89.1.81

 Pollock et al., master athletes & aerobic capacity, J Appl Physiol 1987: https://doi.org/10.1152/jappl.1987.62.2.725

Latella et al., strength across ages in powerlifters, Sports Med 2024: https://doi.org/10.1007/s40279-023-01962-6

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The story goes that hard exercise is risky for women, and that the idea is ancient. Both halves fall apart on contact. In this solo episode, Dr. Jordan Feigenbaum follows the claim that physical effort harms the female body across twenty centuries, and shows that almost every version of it arrived as a verdict first, with the science bolted on afterward.

It runs from antiquity to the present: what Galen actually wrote, why Sparta trained its women on purpose, the Victorian “vital force” panic and Edward Clarke’s claim that studying would sterilize girls, the doctor who prescribed bed rest to women and the wilderness to men, and the 1928 Olympic 800m that was erased for 32 years over a collapse that never happened. Then the correction: the research that finally tested heavy training in older women and women with low bone mass, and what it found. The episode closes on 2026, where the guidelines say lift and the menopause market often says don’t.

What we cover

•    Why the “ancient Greeks” origin story for the no-hard-exercise rule doesn’t hold up.

•    How a Victorian energy-budget idea became a medical case against women lifting and studying.

•    The real story of the 1928 Olympic women’s 800m and the 32-year ban.

•    The strong women who were relabeled as freaks or exceptions instead of counted.

•    What Fiatarone’s nonagenarians and LIFTMOR actually showed about lifting heavy later in life.

•    The cortisol panic, the fasting scare, and cycle syncing, examined against the data.

•    Why the cautious messaging now comes from the market, not the medical guidelines.

Timestamps

• 00:00 The 1928 Olympic “massacre” that never happened
• 03:37 Antiquity: what the Greeks actually said
• 06:50 The Victorians and “vital force”
• 10:02 Mary Putnam Jacobi tests the claim, and is ignored
• 11:53 1928 in full: who killed the women’s 800m
• 13:53 The double standard, and Alice Milliat
• 15:39 The strong women history relabeled
• 20:26 The correction: what the evidence shows
• 22:27 LIFTMOR: lifting heavy with low bone mass
• 24:35 2026: guidelines, the market, and cortisol
• 28:34 Cycle syncing, and naming the pattern
• 30:40 What to take away

Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/

Barbell Medicine coaching and templates: https://www.barbellmedicine.com/

Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/

References

Cahn S. Coming on Strong: Gender and Sexuality in Twentieth-Century Women's Sport. Harvard University Press; 1994.

Clarke EH. Sex in Education; or, A Fair Chance for the Girls. Boston: James R. Osgood and Company; 1873.

Colenso-Semple LM, McKendry J, Lim C, et al. Menstrual cycle phase does not influence muscle protein synthesis or whole-body myofibrillar proteolysis in response to resistance exercise. J Physiol. 2025. PMID: 39630025.

Daly W, Hackney AC. Is exercise cortisol response of endurance athletes similar to levels of Cushing's syndrome? J Sports Med Phys Fitness. 2019. PMID: 31371847.

Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. PMID: 30907953.

Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans WJ. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA. 1990;263(22):3029-3034. PMID: 2342214.

Fiatarone MA, O'Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med. 1994;330(25):1769-1775.

Galen. On the Preservation of Health (De Sanitate Tuenda). 2nd century CE. Various translations.

Jacobi MP. The Question of Rest for Women During Menstruation. New York: G.P. Putnam's Sons; 1877. (Awarded the Harvard Boylston Prize.)

Latella C, Teo WP, Spathis J, et al. Using powerlifting athletes to determine strength adaptations across ages in males and females: a longitudinal growth modelling approach. Sports Med. 2024;54(3):753-774.

Maudsley H. Sex in mind and in education. Fortnightly Review. 1874;15:466-483.

Plutarch. Life of Lycurgus. Approx. 75 CE. Various translations.

Schultz J. Qualifying Times: Points of Change in U.S. Women's Sport. Urbana: University of Illinois Press; 2014.

Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984;65(10):593-596. PMID: 6487063.

Soranus of Ephesus. Gynecology. Approx. 2nd century CE. Translated by Temkin O. Baltimore: Johns Hopkins University Press; 1991.

Switzer K. Marathon Woman: Running the Race to Revolutionize Women's Sports. Cambridge, MA: Da Capo Press; 2007.

Todd J. Various publications. Iron Game History. Stark Center for Physical Culture and Sports, University of Texas at Austin.

Tunis JR. Women and the Olympic Games. Harper's Magazine. July 1929. (And contemporaneous press coverage.)

Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018;33(2):211-220. PMID: 30861219.

Xenophon. Constitution of the Lacedaemonians. Approx. 4th century BCE. Various translations.

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In 1889 a French physiologist injected himself with guinea pig and dog testicle extract and published a claim of self-rejuvenation in The Lancet. That announcement kicked off a 200-year medicalization of menopause that ran through leeches and bromides, Premarin, the 2002 Women's Health Initiative, and the contemporary menopause-content space. 

In Episode 1 of our three-part menopause series, Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through what menopause actually is at the hormonal level, which midlife symptoms are menopause-driven and which are not, the KNDy neuron mechanism behind hot flashes (and the new medication that blocks it), and the 24-year follow-up on the WHI that substantially revised the original conclusions. OB-GYN Dr. Loraine Baraki walks the clinical workup, the lab panel she actually orders, and how she handles patients arriving with DUTCH panels and compounded hormone protocols.

If you have heard contradictory things about menopause hormone therapy from your primary care, your menopause coach, and your sister, that is not your fault. The evidence base has been revised in significant ways since the 2002 publication, and most patient-facing summaries are out of date.

Timestamps

• 00:00 Cold open: 200 years of menopause medicine
• 03:23 Welcome and roadmap
• 04:20 The HPG axis, follicles, and the FSH lag
• 09:11 STRAW+10 staging and the timing of perimenopause
• 13:47 Austin: the 49-year-old with a hormone panel
• 20:00 Loraine: the OB-GYN workup
• 28:00 Symptom attribution: what menopause actually causes
• 33:46 Austin: the all-estrogen patient
• 37:58 VMS duration and the KNDy mechanism (Avis, SKYLIGHT)
• 43:53 Austin: who actually gets fezolinetant
• 47:22 The WHI 24-year correction (Manson, Chlebowski, Boardman)
• 01:00:15 Modern prescribing today
• 01:06:52 Where the menopause-content space gets it right and wrong
• 01:11:50 Testosterone, compounded bioidenticals, and DUTCH panels
• 01:24:13 Takeaways

What we cover

• The HPG axis and the estrogen shield: what is happening across the 35-year reproductive era and what changes at perimenopause.
• STRAW+10 staging: how long perimenopause actually lasts and where most women fall in the timeline.
•  Symptom attribution: hot flashes and genitourinary syndrome are menopause. Weight gain, sleep, and joint pain are mostly other things.
• The KNDy neuron mechanism behind hot flashes and the new pharmacology that blocks it (fezolinetant, elinzanetant).
• The Women's Health Initiative: what the trial actually tested, what the 2002 result said, and what 24 years of follow-up have shown since then. The estrogen-alone arm reduced breast cancer incidence by 22% and mortality by 40% over 20 years.
• The timing hypothesis: hormone therapy started within 10 years of the final menstrual period vs more than 10 years out.
• Modern prescribing today: transdermal estradiol plus micronized progesterone, and why the formulations matter.
• Where the contemporary menopause-content space gets it right and wrong: the undertreatment problem, the zone-of-chaos framing, and the testosterone-for-everything marketing.
• Testosterone in women: one guideline-supported indication.
• Compounded bioidenticals and DUTCH panels.

Resources

• Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/
• Barbell Medicine coaching and templates: https://www.barbellmedicine.com/
• Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal
• Manson JE et al. 18-year mortality from the WHI. JAMA, 2017. https://pubmed.ncbi.nlm.nih.gov/28898378/
• Chlebowski RT et al. WHI estrogen-alone arm at 20 years. JAMA, 2020. https://pubmed.ncbi.nlm.nih.gov/32706854/
•  Boardman HMP et al. Hormone therapy for cardiovascular prevention. Cochrane, 2015. https://pubmed.ncbi.nlm.nih.gov/25754617/
• Avis NE et al. Duration of VMS in the SWAN cohort. JAMA Intern Med, 2015. https://pubmed.ncbi.nlm.nih.gov/25686030/
• Lederman S et al. SKYLIGHT 1, fezolinetant. The Lancet, 2023. https://pubmed.ncbi.nlm.nih.gov/36924778/
• Johnson KA et al. SKYLIGHT 2, fezolinetant. JCEM, 2023. https://pubmed.ncbi.nlm.nih.gov/37410020/
• USPSTF. Hormone therapy for primary prevention. JAMA, 2022. https://pubmed.ncbi.nlm.nih.gov/36318127/
• Davis SR et al. Global Consensus on testosterone in women. JCEM, 2019. https://pubmed.ncbi.nlm.nih.gov/31498871/

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