212. How Much Cardio Do You Really Need? Zone 2, VO2 Max, HIIT, and the Minimum Effective Dose (Training Series, Part 3)

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Welcome to Medicine Redefined.

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I'm Dr. Ultima Sharajah.

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And I'm Dr. Darsha.

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Let's put the hell back in healthcare.

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If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks, and you want to work with me directly, you can book at refininghealthrx.com.

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All right, let's jump in.

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All right, back here with another module talking about building our holistic exercise program.

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That word is cringe.

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Holistic?

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You know what?

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You don't like it?

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I went into osteopathic school because I used to love that word.

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And I think now it's one of those words that has been really muddied.

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Don't you think?

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It's true.

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It has been muddied.

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I don't know.

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It's funny because one of the nurses just, today, she was like, my whole adult life, I've been seeing DOs because you guys are holistic.

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So it's just one of those things.

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It's appropriate.

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But because it's misused so much.

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And language is such a funny thing that way.

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I mean, maybe it is.

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Okay.

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Maybe we can say all encompassing.

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Comprehensive.

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Comprehensive.

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I like comprehensive.

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No, I'm kidding.

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We'll use holistic.

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It's 80 still.

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We'll use holistic.

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All right.

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Love it.

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All right.

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We're going to do a holistic, comprehensive overview and break out each component.

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So today we're doing cardiology.

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Sorry, guys.

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Sorry.

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Cardio.

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Wow.

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There we go.

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That's where my mind's at right now.

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Just because I sent a text out about cardiology right now.

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Cardio.

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It will be cardiology.

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Yeah.

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It'll be cardiorespiratory fitness.

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I think that's a crucial point.

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So last would be a talk a lot about strength and hypertrophy.

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And when we're looking at some of the key components in the order that we looked at the overview, strength, hypertrophy, and the next question that people are always asking is like, how do I make sure...

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Engine is working with a lot of capacity, right?

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So B02 max is something that people got really excited about looking at the data.

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maybe a little bit more attention has been paid to VO2 max, or at least on my social media feed, I have some theories why people get so excited about VO2 max and don't pay attention to strength.

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But I think really ultimately this comes down to which lens we're looking at this longevity problem from, as I said before.

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So maybe we'll start with the floor, right?

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So this, when I went back and I'm always looking at to see like what the ACSM, what the CDC guidelines are.

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For most things, the guidelines are...

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the floor and say, that's not enough.

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That's not enough when you look at the literature.

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And again, it's kind of the case with this, but it's actually better than when it comes to strength and other things.

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So the CDC recommends at least 150 minutes of moderate aerobic activity per week or 75 minutes of vigorous.

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I think I said last episode I said, or the first episode I said, moderate to vigorous, but really it's 75 minutes of vigorous activity.

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exercise, plus strength training two or more days.

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What they do say is some activity is better than no activity and more brings additional benefit.

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So here's something that I posted about in August.

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And this came...

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Like I think I get this weekly updates on MSK and in 2026, earlier this year, you had Lang and colleagues.

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They followed about 17,000 folks from the UK Biobank study and for nearly eight years.

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And what they did was they measured activity for these folks on a wrist device and they estimated their fitness with baseline fitness was measured on like a bicycle, a cycle ergometer.

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to see where they were at.

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And they wanted to see how many people were meeting that 150-minute guideline and how many people were going well beyond that.

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Some folks were going all the way up to 610 minutes of aerobic activity, moderate to viracid activity per week.

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What they found was that meeting 150 minutes a week gave about 8% to 9% lower cardiovascular risk.

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So that's pretty awesome.

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But they modeled some of that reduction

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of about 30% benefit when you get all the way up to 560 to 610 minutes a week.

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But only about 12% of those people were there.

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Now, what was interesting about this, man, was that your levels of baseline fitness really shifted the dose.

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That 150-minute benefit held at every fitness level, no matter if you're low levels of fitness, high levels of fitness, but the least fit people

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needed 30 to 50 minutes more a week than the fittest to reach the same level of benefit from cardiovascular.

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Say that one more time.

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The people with the least amount of fitness needed 30 to 50 minutes more moderate to a vigorous activity per week to get that same outcome, same cardiovascular risk reduction.

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Any thoughts on to why that might be the case?

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Lower floor, right?

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I mean, if we're looking at like aerobic capacity zone two, I don't know if it's maybe just when you look at that pyramid, right?

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We talked about building that base.

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That would be my hypothesis is they kind of just need a raise that floor a little bit higher, but I don't know.

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Yeah, I think so.

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I think that, yes, what you're trying to say.

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So like, here's what we know.

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It's like a correlation causation or chicken egg situation.

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So what I didn't talk about in this post on social media, and I didn't have space for it.

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It's like they also ran a genetic analysis in this, right?

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And what they wanted to see is like people who had genetically higher fitness levels

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They were the ones who were linked to lower heart failure risk, reduced cardiovascular.

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So it's again, it's cardiorespiratory fitness, whether it's just genetically you're more fit, right?

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You picked your parents wisely, or it's because you've acquired that levels of fitness over time, it's protective against all cause mortality, right?

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Not a shocker for people.

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So unfortunately, not a lot of people have the luxury of picking their parents, but what do we have under control, right?

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Now, here's another one.

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So now we're looking at all cause mortality.

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So we're looking at the most important, right?

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So we're looking at death.

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And this is a 2026 paper that I came across where they looked at nearly 600,000 U.S. adults

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Potter and colleagues is the paper in the show notes.

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And they counted each a vigorous minute as two and found that just five minutes a week was associated with about 13% lower mortality compared with none.

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So the biggest gap here is going from nothing to something, just five minutes, dude, five minutes of intense activity, right?

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At 115 minutes, which is the CDC guideline that we talked about.

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you're getting to about 19% lower all-cause mortality.

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At 300 minutes, it's about 24%.

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At 600 minutes, it's about 26%.

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So there's this plateau that you continue getting benefits.

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Again, there's going to be a standard deviation of this, right?

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But-

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right, you're continuing getting.

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So the most benefit you're going to get is from nothing to something.

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Like, I think that's the biggest take-home point for this.

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A 2022 paper on my research pretty much came across the same thing.

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Far less people when they looked at that.

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But I thought that's what was the coolest thing about this is like just the amount, the minimum effective dose to get some is so low.

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That bar is so low, yet there's still a lot of people who are just not achieving this.

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How do we define mild, moderate, vigorous exercise that heart rate-based exercise?

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Yeah.

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Yeah.

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Most of the time it's going to be about like where you're getting.

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I know a lot of time people when they're looking at zone two, they're talking about, okay, well, can you have a conversational pace and stuff?

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We're going to come back to zone two, but typically it's going to be heart rate based.

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Like anytime you're above 70%, you're probably in that vigorous 75% or higher, you're going to be in that vigorous.

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Moderate intensity exercise is going to be, again, this is your absolute maximal heart rate.

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which for simplicity reason, there are a lot of different variables out there.

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I would do 220 minus your age.

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That's kind of the simplest way to get that.

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I forget who, I think this is the Phil Maffetone had talked about this.

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They said, if you're on some type of chronic medications, just reduce, you do 220 minus your age, then maybe reduce 10 beats per minute.

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If you're on top of have chronic illness or chronic medications as well.

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So like you can just do that.

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It doesn't always, because you could be on some type of chronic medication from primary prevention standpoint, which is what you and I are at this point, right?

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And I don't know how that comes into that.

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So I haven't gotten a chance to ask him these follow-up questions, but I think that's one way to look at it.

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But I think 220 minus your age, if you've done a VO2 max, you will know what your max heart rate is.

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Also trainable.

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Also, you can, something you can push.

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I think moderate would be somewhere between, I would probably say about 40 to 70% of your max heart rate.

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How do you, when you're tracking, because you do a lot of this steady stuff, you talk about zone two, you're doing your threshold running.

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How do you track where you are, how hard you're pushing?

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I use the Morpheus heart rate strap.

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So I use that for all my strength training and then as well as...

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Which it doesn't.

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So it's good because, you know, it's Joel Jameson's company.

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But when you do the strength training, it doesn't actually record it.

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You're just using it as data so it can affect your HRV the next day.

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But for anything I log as cardio or mixed cardio strength, it will log it for me.

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But that in itself will test out my max heart rate and then based off that, give me the percentages and then tell me what my dose should be for that week.

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Yeah.

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And then, sorry, the percentage, is it the same percentage that we were just talking about in terms of where you are?

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So zone two would be like 60.

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You're talking about the heart rate or you're talking about how much of each getting per week?

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According to your heart rate.

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60% zone two.

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And then it'll be like 61 to probably 80 for like zone three, four.

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And then zone five will probably be like 80, 85 plus.

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Yeah.

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And it goes in different colors, right?

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It's like blue, green, and red.

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And Lunaban will do the same thing.

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Okay, okay, okay.

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Yeah, I haven't used that in a while.

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But I do, yeah, I do like that as well.

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Sometimes when I'm on an Airdyne bike and it's charged, I'll throw that thing on.

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One thing that's worth mentioning is even in...

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Fellowship training, we had talked a lot about this.

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I had the privilege of working with a really awesome sport cardiologist who was a really avid cyclist.

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And so we were talking about a lot of this data that James O'Keefe had talked about.

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This scary J-curve that people would think that we would have is like at higher levels of training, actually, it would be more detrimental.

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Really, in the general population and in most active individuals, it's kind of been debunked, right?

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So for those who don't know, you quickly use J-curve of aerobic exercise.

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It just basically says, so the numbers that I had talked about all the way up to 600 minutes, you're getting benefit.

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For most people, that actually turns up being the case.

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I think what was scary was that in younger athletes below the age of 55, there was a slightly higher incidence of AFib.

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So atrial fibrillation, the initial study was this 2015 flawed paper that looked at 40 athletes and two of them ended up dying.

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But the confidence interval was really low, so it really didn't mean much.

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But a more recent meta-analysis in 2021 where I think Newman and colleagues had looked at that, okay, yes, about 2.5 times higher odds of AFib.

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What was interesting was that

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There's this Venn diagram, right?

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So you have people who are highly fit, who are training at high levels.

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And then most of these are actually men and they're training in sports like soccer more than pure endurance sports.

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But then you also have these folks in the other sides of the Venn diagram, which have some type of coronary artery calcification.

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So they have a significant calcium score.

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And maybe they're not checking.

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And so when that Venn diagram overlaps, if you can think about it, there are going to be people in there who are going to have some calcium, some atherosclerosis, and are also going to be training at really high levels.

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So that's, I think, some of where that comes from, that you want to be aware of that.

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Does that kind of make sense?

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Yeah, because I definitely heard that too.

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Most marathon runners, they've been training their whole life.

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They're going to develop AFib.

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And then that's where that scariness comes from.

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Am I doing too much aerobic training to eventually get that way?

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Yeah.

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Yeah.

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So when it comes to just the biggest things that the concern about the J curve for death that I think that I talked about, really, there's really no J curve in the big data.

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But for AFib, there's a real signal at the far end.

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So I think that those are two things that people want to look at from an arrhythmia perspective.

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Yes, I'm concerned about, but I think just globally, most people who are choosing most actually most people aren't choosing between training three to 600 minutes.

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I don't think that's a problem that we're seeing, even at the high level.

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you're training for really high levels.

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You might be, it might be 300 minutes and stuff if you include all your high rocks training.

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So I think this is really elite athletes who are maybe some more marathon runners.

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We can talk about that.

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And so you really have to kind of figure out what the dose is yours.

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But I think the take-home point is there.

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It's like going from nothing to something is you're going to have the biggest effect, the biggest positive effect anyway.

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All right, which brings me to zone two because you had sent this message as well.

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I have a question for you.

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Why do you do a zone two?

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So I wonder, for me, I guess it's twofold.

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One, if I'm looking to improve that BO2 max and just...

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my stability and stamina throughout, that would be one reason too, right?

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When you're looking at that floor, being able to sustain a heart rate for that long, whether it's 20 minutes plus.

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The second, if you're looking at it physiologically, when it comes to mitochondrial density, biologically speaking, when you look at longevity, people talk about how zone two helps with that type of system efficiency from a fat burning, right?

221
00:12:55.866 --> 00:13:01.950
Metabolism perspective compared to when you're at zone three and above where you're using more of those carbohydrates as fuel.

222
00:13:02.578 --> 00:13:04.879
That's kind of why.

223
00:13:04.899 --> 00:13:06.039
I have heard the same.

224
00:13:06.779 --> 00:13:14.421
And this is the part that when my reading of literature and when I talk to my exercise physiology colleagues on this, I'm not really sure that's actually the case.

225
00:13:15.061 --> 00:13:15.201
Right.

226
00:13:15.221 --> 00:13:19.782
So while researching this, right, there's a 20-25 paper by Storch-Schirke and colleagues.

227
00:13:20.363 --> 00:13:25.644
We talked about the current evidence that did not support zone 2 as the optimal intensity for improving mitochondrial or fat burning capacity.

228
00:13:26.324 --> 00:13:29.045
Higher intensities produce larger improvements in VO2 max.

229
00:13:29.305 --> 00:13:37.487
And the authors tell us that people who skip hard work in favor of zone two, they're actually probably limiting their benefits of exercise.

230
00:13:37.947 --> 00:13:42.229
I think this is one of those things that has been said on enough podcasts and social media.

231
00:13:42.309 --> 00:13:44.569
And we've talked about how to measure zone two.

232
00:13:44.689 --> 00:13:45.990
And look, zone two is important.

233
00:13:47.962 --> 00:13:48.462
I like it.

234
00:13:48.803 --> 00:13:58.550
I think probably from a performance-based standpoint and when it comes to athletes, it's probably more of a recovery-based tool and probably more for something, again, when you're building it hours and hours.

235
00:13:58.590 --> 00:14:01.372
So you already are training seven, eight, nine, ten hours a week.

236
00:14:01.953 --> 00:14:04.335
And you're thinking about, well, where else am I going to add volume?

237
00:14:04.955 --> 00:14:10.358
Instead of adding junk volume, you're going to add in zone two because it's going to be helping build recovery.

238
00:14:10.638 --> 00:14:10.818
Right.

239
00:14:10.979 --> 00:14:18.403
If you again, we know this when we look at the literature of how exercise helps from a mental health perspective, helps improve your sleep quality.

240
00:14:18.863 --> 00:14:20.844
Well, yes, all exercise is going to do that.

241
00:14:20.884 --> 00:14:26.588
But if you're already training 10 hours of high intensity and you need to add in more of that aerobic efficiency.

242
00:14:27.492 --> 00:14:32.537
Zone two may be a good place to do that without exceeding that recovery capacity like we talked about the last episode.

243
00:14:32.577 --> 00:14:32.757
Right.

244
00:14:32.817 --> 00:14:34.639
And so that's a good place to add it.

245
00:14:35.340 --> 00:14:36.361
This is not most people.

246
00:14:36.601 --> 00:14:38.343
These are not the people you're seeing in clinic, dude.

247
00:14:38.563 --> 00:14:39.624
It's not the people that I'm seeing.

248
00:14:39.764 --> 00:14:40.425
Absolutely not.

249
00:14:40.485 --> 00:14:44.509
And so I think this infatuation of zone two has probably gotten a little bit out of hand.

250
00:14:44.849 --> 00:14:50.715
And if you think about it, you actually pay attention to those who are talking a lot about zone two, the importance zone two.

251
00:14:51.901 --> 00:14:58.286
They have a really strong background from being aerobic athletes and endurance athletes.

252
00:14:58.346 --> 00:15:00.548
I don't think Usain Bolt is doing a lot of zone two training.

253
00:15:00.568 --> 00:15:02.369
And I'm pretty sure his VO2 max is pretty darn good.

254
00:15:02.670 --> 00:15:05.012
Maybe not today, but at least when he was.

255
00:15:05.472 --> 00:15:08.374
Johan Blake is probably fine with his VO2 max.

256
00:15:08.474 --> 00:15:10.256
And I don't think he's doing a lot of zone two stuff.

257
00:15:10.816 --> 00:15:12.538
And so that's the other thing.

258
00:15:12.558 --> 00:15:15.040
I heard John Barty talk about this a long time ago.

259
00:15:15.720 --> 00:15:17.662
When you look at the literature, you dig into that.

260
00:15:18.904 --> 00:15:25.628
high intensity interval training, or probably longer intervals is just as good, if not a better way to do that.

261
00:15:26.208 --> 00:15:28.910
Which brings me to the other thing that people get really excited about.

262
00:15:29.270 --> 00:15:30.991
The Norwegian 4x4.

263
00:15:31.392 --> 00:15:33.153
Is this something that you've gotten excited about?

264
00:15:33.213 --> 00:15:34.173
You've tried to do?

265
00:15:36.595 --> 00:15:37.075
I've done it.

266
00:15:37.475 --> 00:15:37.936
I've done it.

267
00:15:38.036 --> 00:15:39.957
I'm not like the biggest fan of it.

268
00:15:40.497 --> 00:15:41.298
And nor am I of Zone 2.

269
00:15:41.318 --> 00:15:42.698
So what you just said is kind of music to it.

270
00:15:42.718 --> 00:15:43.879
Why are you not a good fan of it?

271
00:15:44.600 --> 00:15:45.680
It's just not my type of training.

272
00:15:45.880 --> 00:15:46.601
Like, I...

273
00:15:48.291 --> 00:15:50.835
Maybe I'll do it, but in terms of running and sprints, right?

274
00:15:50.875 --> 00:15:53.579
But then my fatigue is different compared to an airdy bike.

275
00:15:54.341 --> 00:15:56.544
If I were to do like sprints, I was just sprinting.

276
00:15:57.025 --> 00:15:59.609
How, what would be the interval or the length of the sprint?

277
00:15:59.873 --> 00:16:03.814
I'd probably go 30 seconds on, two minutes off, but I'm, yeah.

278
00:16:04.854 --> 00:16:06.175
So I think that's the good news.

279
00:16:06.255 --> 00:16:07.735
I think there's one takeaway for you.

280
00:16:07.755 --> 00:16:08.835
Like this is the good news for you.

281
00:16:08.955 --> 00:16:09.676
I'm the same way.

282
00:16:09.976 --> 00:16:12.296
I think that growing up, played sports.

283
00:16:12.696 --> 00:16:13.977
I think it sounds like we played similar.

284
00:16:13.997 --> 00:16:14.897
We both ran track, right?

285
00:16:14.937 --> 00:16:16.917
And so we were both sprinters in track.

286
00:16:16.977 --> 00:16:24.979
And yeah, when we ran 200s, run a bunch of 200s with a one to three work ratio and tell me your VO2 max doesn't improve it.

287
00:16:25.019 --> 00:16:27.100
Or run 400s and tell me your VO2 max doesn't improve it.

288
00:16:27.200 --> 00:16:30.382
But a 400 meter at 60 seconds is pretty slow, right?

289
00:16:30.442 --> 00:16:30.862
Yeah, sure.

290
00:16:31.042 --> 00:16:35.204
Like even if you run it like 80% or whatever, like you're going to run 65, 70 seconds.

291
00:16:35.664 --> 00:16:38.305
Yeah, run three 400s and tell me your VO2 max doesn't improve after that.

292
00:16:38.945 --> 00:16:42.287
So I think that when we look at that, the Norwegian 4x4, what is it?

293
00:16:42.427 --> 00:16:48.350
So this, again, it's a lot of the group out of the same lab where you do four hard minutes.

294
00:16:49.331 --> 00:16:52.752
You're getting anywhere between 85 to 95% of your max heart rate.

295
00:16:53.292 --> 00:16:55.113
And then you have three easy minutes of a cool down.

296
00:16:55.633 --> 00:16:56.913
And then you go for another four intervals.

297
00:16:56.933 --> 00:17:00.455
So it's four by four, not four minutes of work, four minutes of rest.

298
00:17:00.595 --> 00:17:02.435
It's four minutes of work, three minutes of rest.

299
00:17:02.455 --> 00:17:04.096
And you're doing four total intervals.

300
00:17:05.056 --> 00:17:15.563
And there are a bunch of trials on this, again, pretty much out of the same group where they looked at that, hey, this has been really beneficial, but it's not the only thing that looked at this, right?

301
00:17:15.623 --> 00:17:24.349
And so, or when we look at, again, like I talked about, so my aerodynamic sprints are actually 30 minutes, 30 seconds, excuse me, on, and I'll do 60 seconds off.

302
00:17:24.369 --> 00:17:26.810
So it's a one to two work to rest ratio.

303
00:17:27.351 --> 00:17:29.832
Now I'm doing a two minutes warmup.

304
00:17:30.293 --> 00:17:33.295
I'll do maybe six to eight sessions of really hard on that.

305
00:17:34.915 --> 00:17:36.075
And then I'll do a two-minute cool down.

306
00:17:36.216 --> 00:17:39.816
The entire workout takes me about 15 minutes on and off the bike, right?

307
00:17:39.836 --> 00:17:40.857
And I can do that pretty quickly.

308
00:17:40.877 --> 00:17:43.297
I don't have to have an extended warm-up because I'm done bike.

309
00:17:43.857 --> 00:17:46.898
I can really go hard with low risk of injury.

310
00:17:47.118 --> 00:17:49.579
If you're on a treadmill or something, you might need to do a little bit more time.

311
00:17:49.679 --> 00:17:51.619
Stuff that you're doing, you might need to spend a little bit more time.

312
00:17:52.540 --> 00:17:53.640
So you really have to think about that.

313
00:17:54.441 --> 00:17:57.163
Now, in an ideal world, I would probably want to stress that out.

314
00:17:57.443 --> 00:18:12.652
When I was digging into my program and your program against this, it turns out probably what we could if we were thinking about ideal for us, turns out that probably work or at least the intervals for work.

315
00:18:13.560 --> 00:18:22.385
two minutes or maybe a little bit longer than two minutes seems to be probably better if stretching out the view to max is your main goal.

316
00:18:23.165 --> 00:18:29.229
But yeah, the four by four, again, it's another thing that's really pushing you towards that mile and mile repeats.

317
00:18:30.129 --> 00:18:32.190
And I'm not sure that's the best way to do that.

318
00:18:32.230 --> 00:18:34.031
But from an efficiency standpoint, it's really hard.

319
00:18:34.432 --> 00:18:34.932
And not to mention

320
00:18:37.553 --> 00:18:41.457
85% or 90% sustained at four minutes.

321
00:18:42.377 --> 00:18:42.858
I don't know.

322
00:18:43.098 --> 00:18:44.399
Like this is one of those things.

323
00:18:44.479 --> 00:18:49.743
Like if you love getting into the cold bath in the morning, by all means, go to the Norwegian four by four.

324
00:18:49.883 --> 00:18:51.805
Like you are the person to do that.

325
00:18:51.905 --> 00:18:52.125
Right.

326
00:18:52.245 --> 00:18:56.287
But like sitting in a cold bath for four minutes on, four minutes off like type of situation.

327
00:18:56.447 --> 00:18:56.847
Yeah.

328
00:18:56.867 --> 00:18:58.007
Then this, you're the type of person.

329
00:18:58.267 --> 00:19:06.511
But most people that I'm seeing in clinic that I think we're just working across, even elite level athletes, that's a level of intensity that they just, they're not able to sustain.

330
00:19:07.011 --> 00:19:08.852
Your elite cyclists, yeah.

331
00:19:09.092 --> 00:19:13.033
When you have that much lactate buildup, that's something that they like.

332
00:19:13.134 --> 00:19:18.696
But most people don't, especially if you're a power anaerobic type athlete, like somebody like you, somebody like me.

333
00:19:19.755 --> 00:19:27.237
I think that's my issue with it is that when you're going four minutes, it's hard to gauge like how much you should push in that first 30 seconds and then minute and then do you back off.

334
00:19:27.257 --> 00:19:32.678
But the way my heart rate's dropping into it, but like it's hard to actually gauge in those four minutes how much intensity you need.

335
00:19:33.018 --> 00:19:39.800
And then again, you add in, let's say those allostatic load of the next time you're training for it and you're like, wait, why is my heart rate so high when I'm not?

336
00:19:40.180 --> 00:19:46.021
So I just feel like there's too much variability within the four minutes, which is why I like to condense it because it's 30 seconds treadmill or not.

337
00:19:46.081 --> 00:19:47.501
I can, I know what I have to do in that.

338
00:19:47.822 --> 00:19:49.342
I know what miles per hour I can run at.

339
00:19:50.082 --> 00:19:52.643
and just get after it that way and still get my heart rate jacked up.

340
00:19:53.304 --> 00:19:53.544
Yeah.

341
00:19:54.164 --> 00:20:01.648
The other thing is like with these specific protocols, when they actually looked at that, a lot of these studies, they actually had multiple sessions per week.

342
00:20:02.408 --> 00:20:11.573
So this, I think, paper that I came to the small 2007 trial with Helger Ed and colleagues, they had three sessions a week for eight weeks, which raised VO2 max by 7%.

343
00:20:12.753 --> 00:20:17.682
in that group, but then the other control group, but I think that it may be 15 seconds on, 15 seconds off.

344
00:20:18.203 --> 00:20:19.446
It was like 5.9%, right?

345
00:20:19.466 --> 00:20:23.773
So it's not that significant in the interval group that they had, if I'm remembering the data correctly.

346
00:20:24.154 --> 00:20:24.695
Not all we'll plug.

347
00:20:25.728 --> 00:20:28.111
So again, it's not that impressive of protocols.

348
00:20:28.131 --> 00:20:31.875
So really, again, it comes back to anything is going to be better than nothing.

349
00:20:31.895 --> 00:20:33.036
That's going to be your biggest leap.

350
00:20:33.056 --> 00:20:36.640
And then find something that allows you to be consistent and come back to that.

351
00:20:36.760 --> 00:20:38.442
And you're going to build towards that.

352
00:20:39.102 --> 00:20:40.764
So I think that was like the biggest takeaway.

353
00:20:40.784 --> 00:20:42.866
Because I used to think, I'm like, oh, man, how do I?

354
00:20:43.006 --> 00:20:44.528
I've been hearing a lot about this 4x4.

355
00:20:44.548 --> 00:20:45.489
I got to do this 4x4.

356
00:20:45.549 --> 00:20:46.850
And then now after...

357
00:20:47.611 --> 00:20:52.635
doing a little bit of studying for this in preparation for these episodes, I'm really not interested in that at all.

358
00:20:53.096 --> 00:21:01.142
It's something that, again, to go back to James Clear, like in the last episode you had talked about is, what do we say?

359
00:21:01.302 --> 00:21:02.723
Yeah, what gets rewarded, gets repeated.

360
00:21:03.364 --> 00:21:09.289
And I guess the inverse of that is the more friction you create, the less likely you are to do that, right?

361
00:21:09.309 --> 00:21:11.030
So if you absolutely hate the four by four, it's

362
00:21:12.711 --> 00:21:20.278
I guess my message for my PSA for people would be is like, if you're listening to a lot of podcasts like us and you're reading and you're watching social media and people are telling you, you got to do this.

363
00:21:20.318 --> 00:21:21.419
This is the ideal way to do it.

364
00:21:21.459 --> 00:21:22.700
That is absolutely false.

365
00:21:23.461 --> 00:21:26.924
And please don't get caught into the trap that I did as recently as a couple of months ago.

366
00:21:28.042 --> 00:21:33.607
Have you looked into the 12-minute run test for VO2 max?

367
00:21:33.627 --> 00:21:40.452
Like you just run the farthest distance you can for 12 minutes and then use that as a proxy to predict your VO2 max if you're not actually getting it officially done?

368
00:21:41.733 --> 00:21:43.375
We did that in high school track.

369
00:21:43.395 --> 00:21:43.995
I remember that.

370
00:21:45.376 --> 00:21:46.537
Yes, we did that.

371
00:21:46.778 --> 00:21:50.260
I don't know if you had any thoughts on it because for me, running 12 minutes for this distance, like...

372
00:21:50.981 --> 00:21:57.202
Again, I mean, is it true then that the best VO2 or the people with the highest VO2 max are these people who run 800 meters, right?

373
00:21:57.282 --> 00:22:05.404
Or a mile and are trushing it versus a sprinter who, again, will not have the type of muscle density or even that type of cardio respiration.

374
00:22:05.544 --> 00:22:11.005
I don't want to say cardio respiration or fitness, but that type of mechanism or advantage to run two miles in 12 minutes.

375
00:22:11.445 --> 00:22:13.565
Like I know I can't run two miles in 12 minutes anymore.

376
00:22:13.905 --> 00:22:15.926
But you can run a mile under six minutes, right?

377
00:22:15.946 --> 00:22:16.526
Exactly.

378
00:22:16.806 --> 00:22:18.066
I haven't in a while, but I probably can.

379
00:22:18.086 --> 00:22:20.707
Yeah, but I remember at some point you could run a five something mile, right?

380
00:22:20.727 --> 00:22:21.768
So yeah, no, I agree.

381
00:22:22.008 --> 00:22:32.831
Look, the reality is, yes, people who are running miles and two miles or distance runners are probably likely to have a better view to max on average than your sprinters.

382
00:22:32.891 --> 00:22:36.152
Like that's just because you're training a different system like we talked about.

383
00:22:37.702 --> 00:22:38.982
Again, it's like, what game are we playing?

384
00:22:39.062 --> 00:22:41.803
Are we playing the game that's get your VO2 maxes high?

385
00:22:42.203 --> 00:22:44.263
Because if that's the case, then let's get your VO2 maxes high.

386
00:22:44.283 --> 00:22:46.084
This is to go back to my proxy point, right?

387
00:22:46.344 --> 00:22:46.564
Right.

388
00:22:46.904 --> 00:23:01.987
If we're going, if we're in the game of, I want to be a great high rocks athlete, or I want to be a good tennis player, or I want to be a healthy person who is getting a deep life, as Cal Newport would say at 80 years old, then VO2 max is just a, it's a surging.

389
00:23:02.347 --> 00:23:02.567
Yeah.

390
00:23:03.108 --> 00:23:04.868
So I think that's like the really important point about this.

391
00:23:05.390 --> 00:23:05.550
Yeah.

392
00:23:05.570 --> 00:23:11.954
I think what's interesting too, when we talk about wearables, a lot of these wearables are now starting to predict VO2 max, which is interesting.

393
00:23:12.454 --> 00:23:15.656
Again, not super accurate, but again, just like anything else, if you see a trend.

394
00:23:16.612 --> 00:23:18.193
That's probably the most important thing.

395
00:23:18.233 --> 00:23:18.553
Yeah.

396
00:23:18.693 --> 00:23:23.175
On that note, I actually came across this 2025 validation study by Lam and colleagues where they found the Apple Watch.

397
00:23:23.275 --> 00:23:23.816
I'll bring that up.

398
00:23:23.856 --> 00:23:30.799
It caught my attention because I was wondering if I'm going to upgrade from my Series 8 to my Series 12, which I could get with Verizon, but decided not to.

399
00:23:31.360 --> 00:23:37.383
It actually underestimated VO2 max by about six points on average in mostly fit people with errors around 13%.

400
00:23:37.823 --> 00:23:39.324
Now, probably whoop.

401
00:23:40.124 --> 00:23:41.125
Morpheus and stuff.

402
00:23:41.206 --> 00:23:42.707
I don't know what the data around that shows.

403
00:23:43.268 --> 00:23:49.035
I know that I think with heart rate straps, probably you're going to get better data than you are going to get with the wrist straps, right?

404
00:23:49.055 --> 00:23:53.100
Because wrist straps, it gets a little bit tricky as you're moving your arms and stuff.

405
00:23:53.120 --> 00:23:56.204
And that's looking at like just activity and how that's behaving.

406
00:23:56.224 --> 00:23:56.905
Yeah.

407
00:23:57.145 --> 00:24:01.326
And so probably the closer you can get to your actual heart, you're probably going to get better data in that regard.

408
00:24:01.946 --> 00:24:05.226
Well, the way it does it, Apple Watch, they use GPS tracking too.

409
00:24:05.246 --> 00:24:10.847
So they're looking at the distance you're traveling and whether there's like elevation and stuff, and then your heart rate during that.

410
00:24:11.507 --> 00:24:14.768
And then it'll trend it over time based off similar activities.

411
00:24:15.108 --> 00:24:21.389
So yeah, that's what I read too, is that in fitter people, it'll underestimate, but in low fitness people, it'll overestimate.

412
00:24:21.409 --> 00:24:25.170
So if you're kind of in that middle sweep, but again, I'll use it as a trend if anything.

413
00:24:25.590 --> 00:24:26.570
So yeah.

414
00:24:27.518 --> 00:24:27.958
That's awesome.

415
00:24:28.759 --> 00:24:32.863
The last thing I think it's worth mentioning because this was actually something new to me.

416
00:24:33.023 --> 00:24:36.005
This was something that was testable concept on our sports medicine board.

417
00:24:36.025 --> 00:24:45.053
So it was like, how do you, as you get people back to running, well, one return to running program from an injury, but also if you are building on your running, right?

418
00:24:45.113 --> 00:24:47.675
So we talked about run clubs a couple episodes ago.

419
00:24:48.396 --> 00:24:52.399
Maybe you could apply to your high rocks training or maybe the next games that you end up doing.

420
00:24:53.220 --> 00:24:58.424
The rule that we used to tell people is as you're building volume, you don't want to exceed the 10% threshold.

421
00:24:58.805 --> 00:25:01.687
So the classic rule was 10% on total amount of miles.

422
00:25:01.707 --> 00:25:02.328
You've heard this too?

423
00:25:03.721 --> 00:25:06.843
Well, it turns out the case, that's probably not as important.

424
00:25:06.863 --> 00:25:07.984
The newer data points somewhere else.

425
00:25:08.424 --> 00:25:13.027
So this 20.5 paper that we came across, friends and colleagues, they looked at 5,200 runners for 18 months.

426
00:25:13.728 --> 00:25:16.029
And really what they were looking at is overuse injury, right?

427
00:25:16.089 --> 00:25:18.251
That's the number that we're cautioning people against.

428
00:25:18.631 --> 00:25:26.497
The overuse injury rates in this study, there rose when a single run was more than 10% longer than the longest run in the previous 30 days.

429
00:25:27.257 --> 00:25:29.299
So if you had a small spike, right?

430
00:25:29.319 --> 00:25:41.267
So what that means is just to make it more tangible for people, if you went for a five mile run and then the next week you end up going for a eight mile run on your longest run, that's more than that 10% threshold.

431
00:25:41.307 --> 00:25:45.990
So if you have a small spike, it's about a 64% higher risk for injury.

432
00:25:46.551 --> 00:25:50.934
If you double that, go from five to 10 the next week, just because you're like, oh, I'm going to catch up.

433
00:25:51.514 --> 00:25:54.036
because I'm going to be able to run less because I'm traveling.

434
00:25:54.056 --> 00:26:01.400
So I'm going to do a 10 mile run as opposed to the five mile run, which has been the longest in the last 30 days on my marathon training session or half marathon.

435
00:26:01.920 --> 00:26:03.561
Your injury risk goes by about 128%.

436
00:26:03.722 --> 00:26:05.222
Interesting.

437
00:26:05.243 --> 00:26:05.383
Wow.

438
00:26:05.403 --> 00:26:10.886
But last 30 days, no more than 10% of the most miles you've ran.

439
00:26:11.306 --> 00:26:12.007
In one single mile.

440
00:26:12.027 --> 00:26:12.727
In one session.

441
00:26:13.087 --> 00:26:13.928
Yeah, one single session.

442
00:26:14.208 --> 00:26:14.388
Yeah.

443
00:26:14.408 --> 00:26:21.591
So, I mean, again, this is one study that I came across, but I think this was different than what we had historically thought because we would think, oh, just look at your weekly mileage.

444
00:26:21.691 --> 00:26:21.891
Yeah.

445
00:26:21.991 --> 00:26:22.291
Yeah.

446
00:26:22.351 --> 00:26:22.811
And increase that.

447
00:26:22.831 --> 00:26:24.992
I think there's probably something to that.

448
00:26:25.052 --> 00:26:27.413
We don't completely pivot our practice based off of one thing.

449
00:26:27.854 --> 00:26:28.094
I do.

450
00:26:28.234 --> 00:26:29.254
I did think that this was injury.

451
00:26:29.274 --> 00:26:31.735
This is more of an acute to chronic type of ideas.

452
00:26:31.875 --> 00:26:41.259
As you're doing this progressive overload, you need to be aware of not just the cumulative weekly dose, but also just in that one session, how much can your body actually handle?

453
00:26:41.819 --> 00:26:46.921
So I think that for me, look, it's cross country season now.

454
00:26:47.281 --> 00:26:49.421
We're seeing more injuries and people getting back to that.

455
00:26:49.581 --> 00:26:52.862
Seen already a couple of stress injuries as I'm guiding them back to a return to run program.

456
00:26:53.383 --> 00:27:02.805
I'm actually hopeful that I'm going to send this to a couple of the physical therapists that we work with, but their return to run program that we're also going to caution to not have that one single bout to exceed too much.

457
00:27:03.526 --> 00:27:07.647
So yeah, I think that's the biggest takeaway for me from this, the return to running example.

458
00:27:08.151 --> 00:27:08.852
No, it's good, man.

459
00:27:08.872 --> 00:27:12.815
Because again, down here in Tampa, man, I'll see Strava's of 16 miles on a long run.

460
00:27:12.975 --> 00:27:15.096
And then the other days will be like two, three miles, right?

461
00:27:15.116 --> 00:27:15.937
Of like short runs.

462
00:27:15.977 --> 00:27:19.520
So everyone here, for some reason, has one day of just an extra long run.

463
00:27:19.940 --> 00:27:21.081
But no, it's interesting for me too.

464
00:27:21.101 --> 00:27:23.823
I mean, again, we have different mechanics.

465
00:27:23.863 --> 00:27:25.945
I'm sure you've done long distance.

466
00:27:25.965 --> 00:27:26.985
I don't know if you do anything for it.

467
00:27:27.466 --> 00:27:31.009
But being a sprinter to running long distance, it's just a whole different ball game.

468
00:27:31.029 --> 00:27:32.410
And so me being used to...

469
00:27:33.010 --> 00:27:37.434
running, let's say, two, three miles at a zone three, zone four, kind of has the same mechanics to a sprinter.

470
00:27:37.794 --> 00:27:48.823
Whereas now if I'm going to go do a 15K, yeah, I'm going to, like, my stride lane is going to be very different once I cross that three-mile mark until now I'm feeling it in different places, trying to compensate and whatnot.

471
00:27:48.923 --> 00:27:50.484
So, yeah, it's definitely a real thing.

472
00:27:51.665 --> 00:27:51.826
Yeah.

473
00:27:52.266 --> 00:27:55.849
And it's not even to account for just pre-existing injuries that people have.

474
00:27:56.269 --> 00:28:00.192
Most people, certainly in our age cohort, you got some aches and pains.

475
00:28:00.393 --> 00:28:01.013
It just happens.

476
00:28:01.333 --> 00:28:01.614
And it was...

477
00:28:02.447 --> 00:28:04.930
Laughing with my residents the other day, I was like, yeah, I was 37.

478
00:28:04.950 --> 00:28:08.173
I was scanning my own medial elbow and he was like, oh, you got some stuff going on.

479
00:28:08.254 --> 00:28:09.275
I was like, oh, how old are you?

480
00:28:09.315 --> 00:28:09.735
He's like 30.

481
00:28:09.775 --> 00:28:10.716
I was like, yeah, wait, seven years.

482
00:28:10.736 --> 00:28:11.617
You'll have it.

483
00:28:12.078 --> 00:28:13.219
You know, it just happens.

484
00:28:13.319 --> 00:28:15.261
It's just, it's just, it's part of life.

485
00:28:15.301 --> 00:28:20.627
And especially if you have a lot of mileage that, no pun intended, built up throughout decades of training and running and.

486
00:28:21.508 --> 00:28:24.749
just being a crazy person in the gym, you're going to have some aches and pains.

487
00:28:24.770 --> 00:28:26.270
So you have to account for these things.

488
00:28:26.290 --> 00:28:31.733
So I hope that is digestible for people and we're actually given some actionable data.

489
00:28:31.953 --> 00:28:36.195
But yeah, I think this one was probably one of my more enjoyable ones because I learned a lot.

490
00:28:36.655 --> 00:28:41.597
It's not an area that I consider myself to be really well-versed in the literature, nor do I enjoy doing it.

491
00:28:41.637 --> 00:28:44.358
So some validating stuff, some reassuring stuff.

492
00:28:44.838 --> 00:28:45.639
The one thing I'll say about

493
00:28:46.620 --> 00:28:48.622
to come back to the shorter intervals that we had talked about.

494
00:28:49.062 --> 00:28:57.930
Another reason it gets a little bit harder on the things like Morpheus that we use is that heart rate lags much more when you're doing shorter intervals.

495
00:28:58.530 --> 00:29:02.494
So for instance, like we both like doing 30 second sprints, right?

496
00:29:02.534 --> 00:29:07.378
Or if I'm doing like 20 second absolute airdyne or doing a 20 second treadmill,

497
00:29:07.938 --> 00:29:13.962
by the time your heart rate catches up, it's much longer, which is why another, another reason like this is a little bit hard to pick that up.

498
00:29:14.222 --> 00:29:18.625
And actually when you look at the studies, they actually commented on that caveat as well.

499
00:29:18.645 --> 00:29:22.308
So sense makes sense.

500
00:29:22.348 --> 00:29:24.629
All right, man, we're chipping away.

501
00:29:24.810 --> 00:29:28.612
So Anton, if you're listening, hopefully you are listening to all these episodes one by one.

502
00:29:28.632 --> 00:29:29.793
If you're not, I don't know.

503
00:29:31.820 --> 00:29:32.660
At least I learned, man.

504
00:29:32.680 --> 00:29:34.261
Now I'm like good with vote too.

505
00:29:34.381 --> 00:29:38.863
So we'll come back up and we'll pick up speed and power next week.

506
00:29:39.304 --> 00:29:39.924
Sounds good, man.

507
00:29:40.604 --> 00:29:41.084
Thank you.

508
00:29:43.646 --> 00:29:45.947
Thanks for listening to another episode of Medicine Redefined.

509
00:29:46.547 --> 00:29:50.309
If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes.

510
00:29:51.049 --> 00:29:55.351
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511
00:29:55.992 --> 00:30:00.154
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512
00:30:00.994 --> 00:30:09.961
We also want to thank our team for the production of this podcast, specifically Ethan Ju on video, Harita Yaporian on social media, Zanab Lugmani on research, and Saira Khan for newsletter.

513
00:30:10.501 --> 00:30:16.746
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514
00:30:17.547 --> 00:30:23.291
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515
00:30:24.272 --> 00:30:26.854
Now, time for the ever-so-important disclaimer.

516
00:30:26.874 --> 00:30:27.374
We'll see you next time.

517
00:30:28.106 --> 00:30:32.108
This podcast is intended for general public use and is for educational purposes only.

518
00:30:32.788 --> 00:30:36.070
It does not constitute the practice of medicine, nor should be construed as medical advice.

519
00:30:36.650 --> 00:30:42.073
No physician-patient relationship is formed, and anything discussed in this podcast does not represent the views of our employers.

520
00:30:42.693 --> 00:30:47.476
We recommend that you seek the guidance of your personal physician regarding any specific health-related issues.