I am delighted to reconnect with Dr. Gabrielle Lyon today! She is a dear friend and a physician whose work has profoundly impacted my own work, particularly during the past few years. She previously appeared on the podcast in episode 95 about three years ago.
Dr. Gabrielle Lyon is a highly respected functional medicine provider, the founder of the Institute for Muscle-centric Medicine, a nationally recognized speaker and media contributor, and the author of the book Forever Strong.
In our conversation, we dive into areas where confusion often clouds our understanding of protein intake. We explore the distinctions between commodities and consumer packaged goods and the impact of sarcopenia and other muscle-related changes that affect women during perimenopause and menopause. Our discussion also goes into the hallmarks of aging, uncovers the critical importance of a specific protein threshold to initiate muscle protein synthesis, and examines the role of food matrices and Leucine thresholds, misconceptions surrounding carbohydrates, and the most effective methods for tracking muscle mass. Additionally, we explore the connections between poor metabolic health and cognitive decline, making this conversation exceptionally relevant and informative.
I wholeheartedly recommend Dr. Lyon’s forthcoming book coming out in early October. Her work has played a significant role in shaping my personal and professional life and had a profound impact on many of my female patients and clients.
I am confident that you will find today’s show with Dr. Gabrielle Lyon as enlightening and valuable as I do.
“D3 Creatine is the way of the future and it is a way to directly measure skeletal muscle mass.”
– Dr. Gabrielle Lyon
IN THIS EPISODE YOU WILL LEARN:
- Where did the confusion around the proper intake of protein originate?
- Physiological changes that occur in women as they age
- How hormonal changes during midlife lead to muscle loss and insulin resistance, which can contribute to aging
- What is insulin resistance?
- How unhealthy skeletal muscle leads to low energy efficiency and metabolic implications.
- The importance of protein for women’s health
- How carbohydrates impact our metabolic health
- The impact of intermittent fasting on muscle health
- What is skeletal muscle and how does it affect our health?
- The interconnectedness between skeletal muscle, obesity, and cognitive decline
- The benefits of D3 Creatine supplementation
- Follow on Twitter, Instagram & LinkedIn
- Check out Cynthia’s website
- Submit your questions to firstname.lastname@example.org
Connect With Dr. Gabrielle Lyon
- Check out her website
- Connect on Facebook, Instagram, and Twitter
- Her podcast, the Dr. Gabrielle Lyon Show
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I’m your host, Nurse Practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent, is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I had the honor of reconnecting with not only a dear friend, but a physician whose work has heavily influenced my own work, especially over the last several years, Dr. Gabrielle Lyon. She last joined me in Episode 95, actually three years ago. And if you’re not familiar with her work, she is a very well-respected functional medicine provider, she is the founder of the Institute for Muscle-Centric Medicine, a nationally recognized speaker and media contributor, she’s also the author of Forever Strong.
[00:01:03] Today, we dove deep into where does all the confusion lie regarding protein intake, the role of commodities versus consumer-packaged goods, the impact of sarcopenia, as well as other muscle-related changes that occur especially in perimenopause and menopause, the hallmarks of aging, and why a certain threshold of protein is really critically important to trigger muscle protein synthesis, the role of food matrices, leucine thresholds, confusion with carbohydrates, the best way to track muscle mass, and connections between poor metabolic health and a decline in cognition. This is such an important conversation. I highly, highly recommend Dr. Lyon’s book that is coming out in early October. Her work has been really instrumental in not only my life personally as well as professionally and so many of my female patients and clients. I know you will enjoy this conversation as much as I did recording it.
[00:02:04] Welcome back my friend. It is so good to have you back on the podcast. I had to go back and reflect. It was May of 2020, Episode 95, when I first had you on the podcast, and I love watching the trajectory of your impact and cannot wait for your book to get in the hands of Everyday Wellness listeners. So good to have you back today.
Dr. Gabrielle Lyon: [00:02:28] Thank you so much. We have been very close friends for a handful of years now and I have to say one thing that I love about you is that you always have my back and it is 100% mutual. We are very lucky.
Cynthia Thurlow: [00:02:43] Yes, I am incredibly fortunate. Incredibly, incredibly fortunate. So, I love your book. Actually, my monthly group is reading it in the month of October and they are excited about the book. So, I’d love to start the conversation today and I want to be really transparent with listeners and share with them what I said to you recently. I cannot think of another physician’s work that has impacted my own work so substantially. And I say that from my heart because even with the amount of medical training and experience that I have, I did not realize the net impact of muscle health and protein and how critically important it is, especially as we get older. So where do you think the confusion around proper intake of protein really lies? Where did that stem from originally?
Dr. Gabrielle Lyon: [00:03:36] That is a great question. This idea of how could a macronutrient be so confusing, so controversial and really misinterpreted in not just the literature but also for the public. I have spent a lot of time thinking about dietary protein, what has gone right and what has gone wrong and how do we really kind of put together the pieces as to where we are now? And dietary protein if you look at the history around 1940, when were just coming out of the Great Depression and facing World War II, they drafted the first million soldiers. So, they brought the first million “able-bodied individuals in,” and they had to turn away 38% because they were either what they considered malnourished or “had flabby muscles.”
[00:04:33] Around 1943, nutrition became– again, nutrition is a very early science. Nutrition became a national crisis, meaning when our backs were against the wall and we were faced with losing our country, the government stepped in. They had a three-day meeting and said, “Okay, what do we need to do to get nutrition right?” And they issued a series of recommendations and to no surprise, the ultimate goal– We have to always think, when it comes to nutrition and health in general, what is the ultimate outcome? What the US needed was to have strong, capable, resilient and individuals that had vitality. We were in a really bad space. They issued again two kinds of information pamphlets. So, they had one where they showed a strong worker and said, “Are you helping Uncle Sam?” And they had another pamphlet that said, “Are you helping Hitler?” I mean, this is pretty striking, we wouldn’t necessarily see this today. And the recommendations for a strong, able-bodied person in 1943 was to have high quality dietary protein, at least two servings. Included in this was liver, beef, chicken, eggs. They also included butter was its own food category, dairy.
[00:06:06] They recognized that in order to save the country, we needed stronger people talking about muscle health in the 40s, this is insane. [Cynthia laughs] And then the other side, there’re a few other things. For example, eat fruits and vegetables, minimize processed foods. Recommendations that I would say we should take to heart today. The other side where it said helping Hitler was eat more processed foods, don’t eat dietary protein, don’t consume whole foods. And it was kind of shockingly this resurgence of almost the information that we’re seeing today. Where did confusion come in? Where did the landscape change? At the time they made the first RDA of dietary protein, which they became more specific about in 1968, which was 0.8 g/kg, which is around 0.37 g of protein per pound body weight. That was the minimum to prevent deficiencies in able-bodied men.
[00:07:02] Food industry– then politics got involved, food industry got involved, and the narrative began to change because money started to exchange hands. And ultimately, from my perspective, and I talk about this history in the book, it becomes no longer about the individual, what the individual needs and more about who stands to profit. And really, based on that, the idea that the recommendations have not changed since 1968 means one of two things. Number one, we have no new science, which you and I both know that’s not true. Or number two, perhaps protein has been put on the back burner because profit, because of a numerous other things, potentially narratives that really influence our health and wellness. And that’s where I think, I believe things really went wrong.
Cynthia Thurlow: [00:07:54] It’s interesting, when I used to talk to my grandmother, my grandparents were immigrants, and they had this amazing garden and they cooked organ meats and everything was fresh and made at home. And I just recall my grandmother saying, “I think your generation is losing out on the opportunity to really understand what real food is.” And at the time, I was probably a teenager, young adult, as wise as my grandmother was. I probably didn’t really understand that until I became a parent. And as a clinician, just watching hundreds, if not thousands of patients over the years, that their health declined at such a rapid rate that there was clearly something that was contributing to this. And to kind of touch on what you were alluding to I didn’t realize that there were these significant differences between commodities such as basic agricultural products and marketing promotion abilities for packaged consumer processed goods and the tremendous disadvantage that puts whole food sources in when they can’t make the same claims as the processed crap that’s out there.
Dr. Gabrielle Lyon: [00:09:02] I’m so glad that you brought that up. It’s a critical lens that we have to understand. You know Cynthia, I think when we talk about nutrition, often we think that we’re just talking about empirical data. What are the numbers? What is the conversation? How much muscle? How much protein? But in fact, that’s actually not only the conversation that we’re having. We are having a conversation that is political, that is also empirical, that is moral. It’s not a sole conversation of what is the benefit to the human body. And one way in which we have to think about that is to frame the lens at which we are hearing certain things. You brought up this idea of commodities. Commodities are whole foods, like beef, milk, pork, egg, soy, corn. They are whole foods sold as whole foods and they are under the USDA.
[00:10:00] And by the way, collectively, we don’t hear about individual milk farmers. When you see an ad for milk, which is milk does a body good, you don’t see milk and then this farmer and this dairy farm. All of these commodities pool their resources together for an entire marketing budget of 750 million. 750 million for all commodities versus PepsiCo, which is one company that has a marketing budget of almost $2 billion, also under a different jurisdiction, which a processed food can pretty much say whatever they want until they get a fine or a citation or something that makes them say something different. For example, beef can never be disparaging against another food source. Specifically, beef cannot say this is a more bioavailable form of protein than the protein in this bean complex or this fake meat burger. Therefore, impossible burger or these fake meats can make all of these claims. Yet beef cannot come to its own defense. This becomes really important because the things that we’re hearing in the media, for example, fake meat is better for the environment. Well, is that true? And actually, are we even going to eat our way out of climate change in the US? No, we’re not. However, there’s nothing that the commodities can say disparaging against another food product.
Cynthia Thurlow: [00:11:36] Well and it’s almost as if it’s stacked against them that they can’t provide objective information that would be in contrary to what the social narrative is. Because whether or not something is regulated by the USDA, which is what the commodities are, versus the FDC, the processed food industry almost gets a free pass with being able to convince us as a nation, as individuals, that their products are superior to these commodities. And I find that troubling because I think most people just don’t realize that that’s the way things work, that there is a degree of prejudice against commodities, seemingly, from my opinion, based on what I was reading in the book. And I thought, “Oh my gosh, I think most people don’t even realize this.” They don’t realize that it’s stacked against real whole foods for the expense of supporting the processed food industry. And it’s interesting you write in the book that 60% of the American diet is ultra processed foods and more than 12 million Americans have purged all meat from their diets. And I thought that was staggering.
Dr. Gabrielle Lyon: [00:12:43] Yeah. I mean, red meat consumption is down 30%. And listen, do we care about eating red meat? Do I care if you do it? No, you can or cannot. But the reality is there has to be a conversation about what is just transparent and what is good and healthy for the human body. And we know that beef is a highly bioavailable source of dietary protein. And one of the other things that I do think that we should touch upon is that it’s not just protein. It truly is this idea of a food matrix. The food matrix is all the things that come alongside with dietary protein like creatine, carnitine, taurine, anserine, bioavailable iron, zinc, selenium, you name it. Yet when we say that this one food product is bad for us, that is a whole food that we’ve been eating for countless, countless years. That essentially likely helped our evolution, our brain evolution. It’s just the information isn’t accurate. And here’s why we care about it. We care about it because the conversation will make people choose things that are going to affect their health in a negative way. For example, if they purge meat from their diet, this is a real problem. That’s not to say that someone could not eat meat and still be healthy. What it is to say is that if they are removing high quality sources of food, what are they replacing it with and how are we going to age well. What is the equivalent? A fake meat product is not interchangeable with a beef patty.
Cynthia Thurlow: [00:14:24] So I think that’s an important conversation to have. And I reflect on this quite a bit when I’m in a yoga class or Pilates, because I see a lot of women who are healthy and active, but in very large amounts. Just in conversations, hearing from them their fear of eating animal-based protein, their concerns about the impact on the environment and how they lean into this plant-based diet. And I just listen objectively. I don’t offer an opinion, I just kind of sit back and listen to this. But also, on the other side of that, and something that I certainly have reevaluated my own personal life, is that as we are getting older, our protein needs change. This is a really important aspect of your work, helping people understand that your protein needs don’t go away, they actually increase. And so, let’s pivot and kind of touch on what are some of the physiologic changes that occur in our bodies as women, as we are getting older that impact how we build and maintain muscle, how our insulin sensitivity changes, and how some of those sex hormone changes impact our quality of the muscle that we possess?
Dr. Gabrielle Lyon: [00:15:36] That is a great question. It’s an important point, especially when you think about women as we age, we all go through changes. There are a few different changes, and I’m going to highlight two that I think are very valuable for your listener. Number one, hormone changes. So, I’m going to make note of that. And number two, the physiological change with skeletal muscle. Let’s talk first about hormone changes midlife. Hormone changes midlife typically result in a decrease in estrogen, progesterone, testosterone. Potentially at the time, testosterone may remain a bit higher and you do see some central obesity. There is that potential. But overall, all hormones seem to decline. What happens during that time? Well, it is also the same time we see a rapid rise in loss of skeletal muscle and function, and this could be defined as sarcopenia. Does it have to happen midlife? Arguably it’ll happen a lot earlier if you are younger, but when you’re younger, you still have a robust amount of hormones.
[00:16:46] When you see changes in estrogen, one of the things that happens is there is this natural decline of activity, which is interesting and unusual. We don’t exactly know why that happens. But we do know that when activity decreases, insulin resistance in skeletal muscle increases. What is insulin resistance? Insulin is a hormone released from the pancreas that is necessary to move glucose out of the bloodstream into cells, into tissues like liver, like skeletal muscle. Skeletal muscle is responsible for the majority of glucose disposal. Insulin is required at rest for this. When you become more insulin resistant, you have an increase in blood glucose, which we know that the definition of diabetes over time is elevated levels of blood glucose. You also see an increase in insulin in the bloodstream. You also– oftentimes this coincides with an increase in triglycerides, all of which create a milieu that is unfavorable for the body and especially unfavorable for aging.
[00:17:57] Now, when we think about insulin resistance in skeletal muscle, what are some of the core underlying mechanisms? I would say arguably the most well studied is this idea of decreased flux. Decreased flux skeletal muscle is under voluntary control and it should be an exercise tissue. It should be a tissue that is active, that we exercise, that we move, that we leverage resistance training. And it’s this flux that maintains the health of the tissue. What do I mean by flux? Let’s take the example of a suitcase. I think that most of your listeners are women, right?
Cynthia Thurlow: [00:18:36] Yes.
Dr. Gabrielle Lyon: [00:18:37] So as a woman you are going on a trip and your trip is two days, yet you are packing as if you are going on a trip for 30 days. If your muscle is a suitcase and you are overpacking it with clothes, eventually that glucose has nowhere to go. It has nowhere to go, there’s no more glycogen stores, it will go back into the bloodstream. And over time, skeletal muscle is the site of insulin resistance. When we cannot dispose of insulin and of course I’m simplifying this, the mechanisms– there’re multiple things happening at once, but over time, when you are not training skeletal muscle and you do not have an increase in flux, ultimately fat deposits within skeletal tissue, your tissue ends up looking like a marbled steak rather than a fillet. This contributes to low levels of inflammation, not just systemically, but also in skeletal muscle.
[00:19:32] With low levels of inflammation, skeletal muscle becomes less efficient at utilizing energy. What else is in skeletal muscle? Mitochondria, this is the site of fatty acid oxidation. This is the site of ATP generation, glucose utilization. When you damage or have unhealthy skeletal muscle, as you can see, this becomes the pinpoint and really the pinnacle of where we need to focus as it relates to metabolic health throughout aging. That is just the metabolic implications that does not include, which also happens the changes in strength. If you damage skeletal muscle, if you have unhealthy skeletal muscle, skeletal muscle over time you will see an increase in connective tissue, you will see an increase in fibrotic tissue within skeletal muscle. We used to see this in the older adults that really didn’t exercise. The tissue actually changes and you can see this on an MRI. And this becomes critical to understand that we are focusing on skeletal muscle as this endocrine organ system and really the system that we can do something about. We can’t think our ovaries or exercise our ovaries to produce estrogen, we can’t do any of that stuff. Therefore, skeletal muscle really becomes the focal point.
[00:20:52] The other thing that happens and then there’re two other things. I said that I was just going to tell you one, but let’s also think about some of the other things that happen. There is this thought that as we age, we naturally become more insulin resistant. I do not know if that is true. I used to believe wholeheartedly that that is true. But we don’t have a ton of studies on highly active individuals. We are at the precipice of really seeing what is possible and what is capable through healthy aging. Something that again, this is a new science, things change. This is amazing to see.
[00:21:24] Now, the other aspect that I think that we need to talk about is that skeletal muscle is a nutrient sensing organ. It senses the quality of the diet primarily through dietary protein, particularly leucine. And when you age and are inactive, the efficiency of protein utilization decreases. Let me explain what efficiency is and the way that I’m thinking about it. I am thinking about it through the lens of a muscle protein synthesis. Muscle protein synthesis is a physiological process that involves the incorporation of amino acids into skeletal muscle for the ultimate outcome of muscle accretion. These definitions, I think, are really important to understand. There are two things that really happen and this is kind of the twofold process of aging. Number one, just to recap, hormones decrease. And number two, the efficiency and the capacity of skeletal muscle as a nutrient sensing organ, primarily when you are sedentary increases, there’s a decreased efficiency. This happens as we age and it’s called anabolic resistance.
[00:22:38] Here’s the good news. So, I know that this is a lot of heavy science, but I think that Cynthia is really into the science and I’m sure that the listeners are really into the science to just kind of sum everything up, skeletal muscle is your metabolic sink. It is your site, your primary site for insulin resistance. We care about insulin resistance because it is a risk factor for cardiovascular disease. It is a risk factor for Alzheimer’s disease. It is a risk factor for obesity, type 2 diabetes, you name it. These diseases of Western society are all rooted in skeletal muscle, even PCOS. PCOS could be considered, in my opinion, a skeletal muscle disease. Now, that is skeletal muscle at the high level. The next thing is that we can do something about it. And this is super simple. If we understand how to leverage nutrition and training. We can really move the needle, and it has to be done now. So, this is the time. The time we have a lot of leeway. You and I were talking about your son, who’s super active. You have two very, very athletic kids. Kids, they’re like small adults now.
Cynthia Thurlow: [00:23:48] I know.
Dr. Gabrielle Lyon: [00:23:49] Which is crazy? And they can get away with a lot because they’re athletes. As we age, we all have life and things that are challenges. For example, me, I’m a mom of two very little children. I text Cynthia all the time. I mean, I don’t even know how anybody does it. I have a two-year-old and a four-year-old, and for example, I woke up at 5 to work out, but my kids woke up too. We have to pivot. It’s just not realistic. The workout was some push-ups with my kid on my back and playing ball at 5 in the morning in the garage. Not ideal. Therefore, my nutrition has to really be dialed in to offset the fact that I wasn’t able to hit what was scheduled for my workout today.
Cynthia Thurlow: [00:24:31] But I think that brings up such a good point that predominantly the individuals that listen to this podcast are women, and they’re trying to navigate all these responsibilities to our children, our significant others, our businesses, our occupation, our extended families, and understanding that in each phase of our lives, as an example, as a parent, there’re different challenges. Like now my kids, gosh on the weekends, I’m lucky if they’re up by 10 or 11 o’clock in the morning. The days of them getting up really early are behind me, but now it’s having conversations with them about nutrition. My older son had Chick-fil-A couple of days ago, came home and vomited and was sick and just said, “I don’t know why I eat this stuff. I was out with my friends, I just don’t feel good when I eat this. I do better when I eat at home.”
[00:25:19] And I think it’s part of this. I always say we try our best to invest in our children’s emotional, physical, intellectual growth, and we hope that they make good decisions. And my kids will go out and they’ll come home and tell me, “Okay, that didn’t work well, okay, what are you going to do differently next time?” So, I think for each one of us, it’s so helpful to know that on days when you can’t get that really good workout in, then you’re like, “Okay, this is not the day to blow my diet. This is the day to be even more conscientious about my protein and my other macros.” And this is probably a really good kind of segue into, because I know many listeners are probably thinking when you’re talking about how much protein, what are we aiming for? If we know the RDA is literally just enough to make sure we don’t die, what is the Lyon protocol for adequate protein intake, because I would imagine most listeners are not eating enough.
[00:26:13] And I can tell you that the very first time I met Gabrielle, which was in 2020, one of the first things you said to me was, “I bet you’re not eating enough protein.” And I was so taken aback, I was like, “I’ve never thought about protein like that.” So, if you’re in that position where you’re like, “Whoa, I haven’t ever actually thought about this.” So as women, how much protein should we be aiming for with each one of our meals? And I also want touch on fasting, because obviously that’s kind of the lens that I come at looking at things. But we’re very much in alignment about making sure women are getting sufficient amounts of food into their feeding window, not undereating, which is what I suspect a lot of people are doing.
Dr. Gabrielle Lyon: [00:26:54] This is a very important topic, this idea that how much protein that we’re eating, we’re eating too much. Why do I care so much about protein? Let’s just put this on the table. 100% of people eat. We have to nail food. 50% of Americans exercise. Only 50% and really, 24% of Americans are actually even meeting the exercise requirements. I want to go on record of saying that exercise is probably a much bigger stimulus to muscle, but they go hand in hand. You cannot not train. However, if you do have dietary protein, you will protect lean tissue. Now, I also want to highlight something that lean tissue is everything aside from adipose tissue. Lean tissue is not interchangeable with skeletal muscle. And why am I bringing this up? Because this idea that why do we need dietary protein? Let’s really kind of think about why we need it.
[00:27:50] We need dietary protein for a few reasons. Number one, we need it for protein turnover. Let’s just take muscle out of the equation. We need protein for nearly every portion system thing in our body. It is the most important essential macronutrient. I say essential because we cannot make it. We must eat it. Yes, there are certain amino acids we can make, but overall, it is an essential nutrient you cannot survive without it. You could never eat a dietary carbohydrate in your life and you could still live. You do need some essential fatty acids, but the reality is higher protein is critical. Why does it matter? Well, number one, we have to understand that dietary protein, we talk about it as if it’s one thing, but it is made up of 20 different amino acids. And those 20 different amino acids all have unique, diverse biological roles. And I would argue that each amino acid needs to be considered its own nutrient, which is where I think the future of dietary protein research is going, is identifying each individual amino acid that is typically, I would say, essential and defining that on the label. For example, we should begin to see and I’m hoping this will happen leucine amount, methionine amount, lysine amount, these limiting amino acids, which are all limiting in various conditions, bringing us back to this idea of dietary protein. We eat dietary protein for, again, a number of reasons on a very macro level, we eat it for protein turnover. Your muscles are turning over. Your liver is turning over. Your intestines are turning over.
[00:29:41] The protein turnover in the body is between roughly 250 to 350 g a day. The average American eats, a woman might eat 70 g of protein, man might eat 100 g. That is challenging to keep up with, and especially as we age. And that does not mean you need to eat 250 g of protein. It’s understanding that as we age, the body becomes less efficient at this protein turnover, which is one reason why we see these changes. And this is kind of one of the hallmarks of aging, this change in protein turnover. Now, when we eat for skeletal muscle, I’ll say effectively then we hit these individual amino acid needs, for example, threonine. Threonine is an amino acid that is essential for mucin production in the gut. Phenylalanine is an amino acid that is essential for dopamine production. Tryptophan is an essential amino acid for serotonin. Arginine is an amino acid that is essential for nitric oxide production.
[00:30:46] As you can see, these diverse biological roles make dietary protein critical. When we eat for skeletal muscle health, and we get the right amount for skeletal muscle health, everything else falls into place. Because dietary protein is high enough where we can address skeletal muscle and then everything else falls into place. The current recommendation is 0.37 g/kg. Now, that equates to if you are 115 pounds, 45 g of dietary protein, that is abysmal at best. And the other thing to think about is that we have to understand that these amino acids, and specifically leucine, are required in a certain amount to stimulate muscle tissue. And that would be about 30 to 50 g of dietary protein at a meal. The current RDA, again, which is the minimum to prevent deficiencies, is between 2 and 3 g of dietary leucine.
[00:31:49] The aging data and the data for more optimal health put the leucine need at around 8 to 9 g per day. Again, how do we want to age? The current evidence indicates that a more effective range would be double the RDA. And we’ve seen that. There’re multiple studies that will compare body composition with 0.8 g/kg to 1.6 g, which is around 0.7 g/lb body weight versus even triple the RDA. And maybe there is no benefit, at least from a muscle perspective, to go three times the RDA. But there’s no downside. I personally recommend 1 g/lb ideal body weight. You could go 0.7 to 1 g/lb ideal body weight. This would be a target. It’s okay if you’re a little less. But this is really the target.
Cynthia Thurlow: [00:32:38] Well, and I find that for a lot of patients and clients, they’re surprised when they start consuming more protein because they’re so satiated. Finally, they’re not thinking about snacking in the afternoon or the evening because they eat that steak or they eat that large portion of fish or they’re eating that chicken or that duck or whatever it is that they’re consuming bison, elk, whatever, that they’re so satiated that they have no digestive issues. Because I find that higher protein diets for most of my patient population, they tolerate really well. If they do that and they do some vegetables, I think the elephant in the room is there– We’ve gone so far off base with carbohydrates where we know that I think most Americans, 50% of their diet is comprised of carbohydrates and not the unprocessed variety. We’re talking about the processed stuff. How do we make sense of what is an aim of carbohydrate with a meal? Because I think that there are definitely individuals that do better with a ketogenic, very low-carb diet. There’s no question. But do I think, in my clinical opinion, that’s what everyone needs to do? No. But when you’re working with your patients, how do you help them clear up the confusion around carbohydrates? Because I think in many ways they’ve been bastardized. Everyone’s assuming, like, all carbohydrates are bad. That’s not what we’re saying. But how do we find out what our tolerance for carbohydrates are? How much should we be consuming in a meal? What is a reasonable expectation?
Dr. Gabrielle Lyon: [00:34:09] Another very important question and very practical. The first step, I would say, is are you metabolically healthy? What is your insulin? What is your fasting blood glucose? What are your triglyceride levels? What is your waist to height ratio? How much adiposity do you have? Number one, so first, determine where you’re at. Second, determine how many carbohydrates that you’re eating. The average American is consuming according to the Anaheim’s data, which is the largest data set that we have, 300 g of dietary carbohydrates a day. Now, that’s a lot for someone who is metabolically unhealthy and inactive. If you reduce your dietary carbohydrates to 130 g/day, we have seen and this is some of the earlier research out of Don Layman’s lab when he reduced dietary carbohydrates to 130 g within two weeks, he saw improved insulin, improved glucose, lower triglyceride levels, and again, 130 g is that too much for an individual. Well, you’ll have to see. You would have to see what the response is to your body.
[00:35:21] The next thing that we have to consider is how are we going to dose the carbohydrates? This idea that it’s all about the 24-hour consumption doesn’t make total sense to me. And I’m going to share with you, why? We have to be very careful about how we leverage insulin. Insulin secretion from a robust amount of carbohydrates typically, we see anything over 50 g of dietary carbohydrates creates a robust insulin response. Insulin while is important for managing blood glucose. The question is, should it be leveraged and utilized the way that it is? I think of insulin as more of a fail-safe mechanism. When carbohydrates are too high, then you are releasing a robust amount of insulin. This is not something that from my perspective should be utilized on a daily basis. How do we minimize robust insulin responses over time? And the way to do that is to dose your carbohydrates 40 g to 50 g of carbohydrates per meal depending on what your carbohydrate tolerance is. I totally cover this in the book, which is, I’m sure why you brought it up because where did that number come from? That number came from the rate of disposal.
[00:36:37] When we make a recommendation, at least when I make a recommendation, I have to be able to back it up as to why I’m making that recommendation. From a perspective of glucose disposal, how much is the liver using, how much is the brain using? How much is skeletal muscle using and how long does it take over time? We know that if in a two-hour period you should be able to dispose of that just simply from the kinetics of how we are leveraging the disposal mechanism. Now, if you are metabolically unhealthy, I would say that a way to think about it is doing a potentially one to one ratio of protein to carbohydrates for a number of reasons. Number one, we have to manage your hunger. Likely, if someone is metabolically unhealthy or they’ve been eating a high-carbohydrate diet, we are going to see swings in blood sugar, high ebbs and flows in blood sugar which release cortisol. There is a subsequent release in insulin and then your blood sugar drops and then you are chasing blood sugar all day long.
[00:37:43] That is why potentially an even distribution would be a great first strategy. An even distribution of protein and an even distribution of carbohydrates. You could start with– I typically don’t go under 100 g of carbohydrates for patients because you do want some insulin response. And also, what about fiber and the phytonutrients and the other potential benefits that ride alongside of carbohydrates? Just like we talked about, red meat has all these other benefits within this food matrix. What about the benefits of dietary carbohydrates? They exist. Again, phytonutrients, prebiotics a whole host of reasons that would be very beneficial to the body. That would be a great place to start.
[00:38:25] Now, before I go into the evidence, the evidence by the way, on dietary protein, I don’t want to confuse people, but really all the evidence is based on that first meal. If you get nothing out of this interview, get your first meal right. The first meal of the day when you are coming out of an overnight fast should be robust in dietary protein. I am happy to push that number up. 30 g of high-quality dietary protein is a minimum, but probably closer to 40 g would be more beneficial for an aging individual, a woman going through menopause, and really getting a robust tissue response. And if you wanted to have carbohydrates in that first meal, make it a lower amount, make it 30 g of dietary carbohydrates.
Cynthia Thurlow: [00:39:10] Yeah. And I think that the thing for me that I’ve found really interesting. I always say intermittent fasting picked me. That was never the intention when I did that second talk. And over the course of the last four years in particular, a lot of questions about how do I eat, what do I make recommendations of? And I agree with you wholeheartedly that that first meal for blood sugar stabilization, for satiety, really should be protein centric. And we know that as middle-aged women or perimenopausal, menopausal women, we’re more insulin sensitive during the day and that can be very beneficial. Now, the big elephant in the room that I’ve been really looking forward to having a conversation with you about is intermittent fasting I think is a strategy that can be utilized successfully in the context of can you get enough protein in your feeding window?
[00:40:01] I think that’s very important because I see a lot of women that are engaging in probably more food restriction than they should. I see a lot of women doing OMAD not just because it’s around a holiday or a vacation or they overeat, but doing it sustained and consistently. And so, I would love for us to talk about in the context of aging and what’s happening and changing in our muscles and this process of catabolism that’s ongoing in a lower estrogen state. What are your thoughts on what are your concerns around OMAD as a sustained strategy?
Dr. Gabrielle Lyon: [00:40:36] Yeah. OMAD is probably my least favorite strategy, this one meal a day unless you are jacked like Shawn Baker [Cynthia laughs] eating like a beast and could potentially eat one meal a day, I don’t think that it is a good strategy. And here is why, because we’ve already done that experiment and there is plenty of data to support during the time of the food guide pyramid where individuals would consume and also some of the earlier French data, this protein pulsing. Essentially what they did was, and this is kind of like the standard American diet is you’ll have a little bit of cereal or some kind of carbohydrate, a low protein breakfast. Again, this isn’t one meal a day, but let’s just walk through some of the way in which we can think about this. One meal a day or one protein meal a day, let’s start there.
[00:41:22] First meal is mostly carbohydrates with maybe 10 g of protein, maybe 12, second meal is the same, then that last meal is typically for Americans, it’s their largest meal with a huge steak dinner or a huge protein bolus. We have already seen what that does to body composition, it does not support healthy aging. Again, you are stimulating muscle protein synthesis one time a day. This is not ideal. Again, the evidence doesn’t look at the middle and the last meal when it comes from a molecular mechanism standpoint. But we know that there is data out there and information out there that at least two meals a day is more beneficial, especially from an aging perspective.
Cynthia Thurlow: [00:42:08] I think it’s just important. I mean, even I’ve gotten to the point now if I do, the focus is two to three days of strength training. But on those days, and my family has been able to witness this, I’ve been eating three protein meals in my feeding window. And I’ve opened up my feeding window to make sure that I’m really focusing and leaning into that protein piece. Because as a middle-aged person that’s in menopause, even with hormone replacement therapy, it is much harder to maintain than it used to be. I think that these are things that for me, I wanted to make sure that we touched on so that listeners could hear it from someone other than myself talking about. OMAD, I think is fine in the context of you went to a party, you overeat, you’re on vacation. Maybe you had one big meal because you just ate way too much. But as a sustained strategy for most individuals, it is not going to allow you to maintain metabolic health.
Dr. Gabrielle Lyon: [00:43:01] You’re stimulating skeletal muscle once a day through dietary mechanisms. A much better strategy would be at least twice a day to optimize that and maintain skeletal muscle health. Doug Paddon-Jones did a series of papers around this idea of a catabolic crisis. And this catabolic crisis is this idea that aging is not linear. It’s not that we have a slow decline. It’s typically something major happens and we are on bed rest or we are sick in bed for a week. The loss of skeletal muscle can be two pounds of skeletal muscle in one week, closer to five days. This is how we have to think. How do we optimize skeletal muscle mass before there is impact engagement with the enemy? If the enemy is the external world in some capacity, optimizing skeletal muscle moving away from one meal a day is critical for aging. It’s just critical. It’s critical from the idea of how do we support muscle mass and I would say for your listeners, try it. Try increasing dietary protein to at least two meals and see what happens to body composition. Use a DEXA or an InBody. I’m not super fans of those, but that’s what we have and see how tissue changes.
Cynthia Thurlow: [00:44:12] That was actually my lead in next question. What are the best ways to track muscle mass? So, it’s interesting, my trainer likes BOD POD. Are you familiar with BOD POD? It looks like an egg.
Dr. Gabrielle Lyon: [00:44:22] Yeah.
Cynthia Thurlow: [00:44:23] Are you a fan of that?
Dr. Gabrielle Lyon: [00:44:24] I think they’re all okay. But the reality is none of them are directly measuring skeletal muscle mass. [crosstalk]
Cynthia Thurlow: [00:44:31] Yeah. So, it’s indirect measurement. So, when you’re working with your patients, do you have other preferred ways?
Dr. Gabrielle Lyon: [00:44:37] Hoping will happen is that we will begin to have access to something called a D 3-creatine. D 3-creatine is the way of the future and it’s a way to directly measure skeletal muscle mass. This, my friend, is going to change the way in which we actually think about the importance of skeletal muscle. Here is why. There is this long-standing belief that it is only strength that matters and not the amount of skeletal muscle mass. You’ll hear this all the time. Doesn’t really matter as long as you are not cachectic or your appendicular lean mass is not two standard deviations below what would be considered average. The reality is we have not been directly measuring skeletal muscle mass. All the information out there is not based on direct measures of skeletal muscle mass. How can we make these statements about skeletal muscle without looking directly at the tissue? This is a problem.
[00:45:32] This is a problem because we have based decades of research on a modality that is not a direct measurement. Therefore, we’ve come to largely what I would consider inappropriate conclusions with this idea that it is all about strength, because there, “isn’t a correlation between mass,” but the reason that there isn’t a correlation between mass is because we haven’t been directly measuring it. And there is a great paper I recommend you read, I recommend everybody read. And there’s a D 3-creatine paper, let me see if I can pull it up, with William Evans has just really done a fantastic job at distilling down the importance of what has happened and the importance that actual skeletal muscle mass plays and the necessity of directly measuring it. And what they’re going to find is that skeletal muscle mass is indicative of strength and is indicative of these processes of aging. And we see it indirectly.
[00:46:30] I’m going to kind of paint the picture in this way. In Galveston– So, the Galveston group, formerly Doug Paddon-Jones’ group, now Emily Lance’s group, they show that with the loss of skeletal muscle mass that there is an increase in insulin resistance. They say they see an increase in triglyceride levels, they see an increase in glucose again, and they see an increase insulin. This is directly related to the loss of skeletal muscle. Yet in the literature, we are still hearing that it’s strength that matters, not muscle. But when you account for skeletal muscle mass directly, you see that it is the mass that is important. And the loss of skeletal muscle mass is probably more important than the gain of body fat when it comes to health outcomes.
Cynthia Thurlow: [00:47:15] That’s really interesting. And how far out do you think the D 3- creatine is?
Dr. Gabrielle Lyon: [00:47:20] I don’t know. I spoke with him. It’s still a couple of years out, but it is going to change the face of everything. And it’s simply a pill that someone takes, creatine is tagged, it’s deuterated. Creatine is found in skeletal muscle and then they measure it in urine.
Cynthia Thurlow: [00:47:33] That’s really interesting. Of course, I’m a huge fan of creatine, and we’ll definitely touch on that. One of the things that I think is particularly important when we’re talking about metabolic health, muscle health, skeletal muscle is the interrelationship between the loss of skeletal muscle, sarcopenic obesity and the impact on cognition. I think a lot of people don’t understand that the brains that we have in our 60s and 70s are made in our 40s and 50s.
Dr. Gabrielle Lyon: [00:48:02] Crazy, right?
Cynthia Thurlow: [00:48:04] It is.
Dr. Gabrielle Lyon: [00:48:04] This is actually where Muscle-Centric Medicine was born. This is why I created Muscle-Centric Medicine. I was doing my fellowship at WashU in Nutritional Sciences, Geriatrics and I was doing Obesity Medicine research. I haven’t really talked so much about this, but I actually didn’t want to do anything on aging. I found it way too depressing, end of life was brutal. I didn’t want to work in nursing homes. I didn’t want to work in end-of-life care in the hospitals. You know, me, I love and when I love, I love hard, I really, really care. And it was just so depressing that I didn’t want to do it. But the deal was, in order for me to do two years of nutritional training in a fellowship, I had to work as a geriatrician. And I, in the evenings, ran an obesity clinic a few times a week. And we were working on a project where we were looking at body composition and brain volume and cognitive testing. We did clamps and VO2 max testing, the whole nine yards. And I really fell in love with this one patient. And she was a participant. You can name her Betty, whatever you want to call her. She was a mom of three, short brown hair. I will never forget her, big brown eyes, curly hair, mom of three, super boisterous, and had always put herself last.
[00:49:18] And I imaged her brain and her brain looked like an Alzheimer’s brain, the beginning of an Alzheimer’s brain. And I felt like we just completely missed the mark. We completely failed her. And I felt responsible. The recommendations for managing body composition are or were move more, eat less, do cardiovascular activity, follow a 50% carbohydrate diet, maybe get some protein and some fat and eat whatever whole foods, maybe not even whole foods. And don’t worry about skeletal muscle, don’t prioritize protein with none of that. And we ruined her metabolism, her muscle. And I can only imagine what the impact of her health it was going to be. And that’s on us. It was at that moment that, you know, when you have that flash of insight and I had this flash of insight. I was going from the nursing home to the obesity clinic to the hospital. I was like, “How is this all related and where is the continuum?” It wasn’t that they were all obese, it was that they all had unhealthy skeletal muscle. And this is when I coined the term Muscle-Centric Medicine. And this is where I realized that we had completely missed the mark and we had been trying to solve the wrong problem of obesity, which begins partially and obviously it’s a very complex disease, but begins in skeletal muscle decades before we’re even seeing these issues. When you think about Alzheimer’s, again, I am a geriatrician by training. These are largely metabolic diseases. Where does that begin? It doesn’t begin in fat tissue, it begins in skeletal muscle.
Cynthia Thurlow: [00:50:57] I think that’s such an important distinction and such a paradigm shift so different than what I learned in the information that we used to convey in cardiology. And it’s interesting, in the book you talk about, there was a meta-analysis involving 1.3 million people revealed that higher BMI or body mass index due to excess fat is associated with increased dementia risk. Role of precursors begin 20 years before symptoms appear. So, this is why I understand you are so passionate about helping people understand at a younger age when we can intervene to ensure that we never get to a point where we are developing executive function, dysfunction or cognitive decline, significant cognitive decline.
Dr. Gabrielle Lyon: [00:51:42] Cynthia, here’s what I care about most. What I mostly care about is that people have the opportunity to be the best version of themselves. What I care about is for them to cut through the confusion while they still have the opportunity to do it. And that’s really why I do what I do, not because it’s easy. The first female physician going through the gates always gets a little bloody, not because it’s easy. And you can attest to this. It’s because if I don’t step up and say something and help reframe this conversation, what kind of outcomes are we going to have? The goal is physical strength. With physical strength comes mental strength. Allows you to show up better as a wife, as a mother, as a friend, as an aunt, you name it. And the reason I did this is because I started seeing all of this stuff.
[00:52:31] I have been in this for 20 years. And it wasn’t until this big, huge boom of social media that information overload happened. It didn’t happen when I started my training. I’m not talking about the fellowship. I did an undergraduate in Nutritional Sciences being trained by Dr. Donald Layman, who really put the connection between leucine and mTOR together in skeletal muscle. They knew that leucine stimulated muscle protein synthesis, but they didn’t know how. They didn’t [unintelligible 00:53:00]; they didn’t know why. And I remember when you had to go to the card catalog and then sit in the journal section, and now information is so freely available and so unvetted. And that is why I feel responsibility to step in because I know with right information, people will have a chance to step up into the best version of themselves.
Cynthia Thurlow: [00:53:25] Well, I’m so grateful for your work. As I said at the beginning of our conversation, and I say as often as I can, I can’t think of a physician that’s had a greater impact on my work and my knowledge than you. And so, I’d love to end the conversation today, talking about a supplement that you and I both embrace and love. Talk about creatine and obviously you got it on my radar several years ago. But let’s talk about how you use creatine in your given patient population. What are the results that you’re seeing? Why are you such a fan of it?
Dr. Gabrielle Lyon: [00:54:00] Well, creatine is interesting. It’s probably the most well-studied supplement out there. As you know, creatine has been around for an extremely long time and very, very, very safe. When you think about creatine, you have to think, where does it come from? Creatine comes from meat and it comes from red meat. In layman’s terms, it’s this amino acid stored in your muscle. It’s in your brain, it’s in your gut. Well, it’s not actually stored in your gut. It’s mostly stored in skeletal muscle. And what has been found is that it’s very valuable for not just skeletal muscle, for energy production in skeletal muscle, but it’s also very important for brain function. And that is something that I think that we’re going to start to see way more of. It’s not just beneficial for a high-intensity interval training, but it is going to be more and more important for cognitive maintenance.
[00:55:02] And also, I actually was thinking about this for individuals, it’s probably difficult to get a more optimal dose of creatine just from eating red meat or from eating foods. I think that is going to be challenging. And it’s challenging especially for women who are going through menopause. The reality is, if you are not training like a beast, you will probably have to reduce your calorie intake. It’s been shown that women will show an increase in performance when you add creatine. Simply, I mean, it could supplement for 10 weeks and there’s evidence to support that it improves performance. There’s no downside. There’s absolutely no downside.
Cynthia Thurlow: [00:55:37] Yeah, it’s interesting. I’ve seen improvement in sleep architecture, jet lag, brain cognition. I mean, obviously there’s research on traumatic brain injuries, but to me it’s one of those supplements that is safe for– my teenagers take it. I’ve got my mother now taking it, who’s in her 70s. I think it’s one of those supplements that the potential of benefits are really endless.
[00:56:02] Well, Dr. Lyon, I’ve loved our conversation. I’ll definitely have to have you back, not within three years, but certainly sooner than that. Please let my listeners know how to get Forever Strong, how to connect with you on social media, how to connect with you about your amazing podcast. And let me be really clear, I’m very selective about which podcasts I listen to, but Dr. Lyon’s always brings on people that are not on my radar. They’re the researchers. They’re the people doing the hard science and making it translatable for the lay public, I think is a huge benefit. So, thank you for all that you do.
Dr. Gabrielle Lyon: [00:56:35] Well, I appreciate you so much. People can order Forever Strong, you can order it off of Amazon. You can order it off of my website drgabriellelyon.com. I am very active on Instagram, Twitter, Facebook. I have a great podcast. Again, as Cynthia said, I typically bring on absolute unknowns for the most part, those that have and are doing research, whether they have a university affiliation, but they typically have some kind of lab. The other guests I bring on are experts in their field in typically life, whether it is a military operator or that kind of individual. And I have a great newsletter. In fact, your book has been in the newsletter more than once.
Cynthia Thurlow: [00:57:16] Thank you.
Dr. Gabrielle Lyon: [00:57:17] Sign up for free. I always put some kind of scientific study or a new podcast or a book that I’m reading and we include that. I did not tell you this, but we will be launching a provider program.
Cynthia Thurlow: [00:57:29] Oh, I love to know that.
Medicine Provider Program. Maybe you would even join. You could come beta test it with us. And that will be launched in January. Yes. And also, I will announce this, which I have not announced, is I have an event in Austin January 13th and 14th, which I will be sending you an invitation to.
Cynthia Thurlow: [00:57:49] Oh, I will be attending. That’s exciting.
Dr. Gabrielle Lyon: [00:57:52] There’s where you can find me.
Cynthia Thurlow: [00:57:53] Awesome. Thank you so much.
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