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A Conversation on Cardiac Rehab with Dr. Abeel Mangi | Starting Strength Radio #12

Mark Rippetoe | July 12, 2019

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Mark Wulfe:
From the global headquarters of The Aasgaard Company in beautiful, downtown, Wichita Falls Texas... From the finest mind in the modern fitness industry... The one true voice in the strength and conditioning profession... The most important podcast on the internet... Ladies and gentlemen... Starting Strength Radio.

Dr Abeel Mangi:
You'd be astonished though, you know I... There's this lady I operated on... probably about two months ago she came in with an aortic dissection or an aneurysm.

Mark Rippetoe:
Oh Goddamn! Where?

Dr Abeel Mangi:
So her ascending aorta.

Mark Rippetoe:
Oh. On the way out. Exactly. Right.

Dr Abeel Mangi:
Dissected both the arteries up to the brain.

Mark Rippetoe:
Up to the carotids?

Dr Abeel Mangi:
Dissected her coronaries. I mean she was

Mark Rippetoe:
How the hell do you save that?

Dr Abeel Mangi:
Well, so we saved her.

Dr Abeel Mangi:
She has a... she's 72, 73 something like that.

Mark Rippetoe:
Goddamn.

Dr Abeel Mangi:
Comes in dead.

Mark Rippetoe:
You guys are good.

Dr Abeel Mangi:
I mean dead. You know, no blood pressure. Blue. The blue as your chair and we operate on her, get her through all of that.

Dr Abeel Mangi:
And she lives in Florida. So she was up visiting her in-laws comes back and her daughter in -aw comes back to see me for a post-op visit. And she says "Look it's been six weeks now, eight weeks. Can I go back to working out?" So I'm like ...!... This is astonishing to me because you know most of my patients don't work out.So well, "What do you do?" So she starts describing you know I spend some time on the treadmill, I do some yoga, but I've been working with this therapist who now wants me to strength train. So I said have you every ever strength trained before? "Yeah I used to do it for years and years." I was like (boom) Starting Strength training.

Mark Rippetoe:
Absolutely.

Dr Abeel Mangi:
And you know... and for her this was like it was a revelation, honestly. You're actually gonna allow me to strength train. And I said Yeah, I mean you have an injured aorta, as long as your blood pressure is fine, you know. you'll be fine.

Dr Abeel Mangi:
And you know she lost like... a tiny woman 130 pounds, but we lost 20 pounds. So that's really the recovery and all that.

Mark Rippetoe:
Needed to gain it back.

Dr Abeel Mangi:
So she's back in Florida under a barbell now. That's fantastic.

Mark Rippetoe:
That's fabulous.

Dr Abeel Mangi:
So I actually told her: watch the podcast.

Mark Rippetoe:
Yes, in fact.

Dr Abeel Mangi:
As a matter of fact...

Mark Rippetoe:
...watch the podcast.

Mark Rippetoe:
Welcome to Starting Strength Radio. We're here this week with our friend Abeel Manji. Abeel is a cardiac surgeon at Yale and has flown all the way down here to sit down and talk to little old me and little you. And we're gonna have a fairly wide ranging discussion today about several topics all of which will be of immense interest.

Mark Rippetoe:
Thank you for coming down, my friend.

Dr Abeel Mangi:
Rip, thank you for having me.

Mark Rippetoe:
Absolutely. So tell us a little about your background. What you're what 45, 46 years old.

Dr Abeel Mangi:
46

Mark Rippetoe:
And how long have you been doing this and where and why and how?

Dr Abeel Mangi:
So Rip it's an interesting story, you know, I... as when I was young, my teens and 20s, I was you know a high school athlete. I grew up overseas, but I had never really you know formally trained. And so we all exercised. You're talking like the late 70s, early 80s. This is when everything was about you know you got to run. You know do aerobic exercise all that type of stuff.

Mark Rippetoe:
Like the military still believes today.

Dr Abeel Mangi:
Exactly right. So I remember distinctly my dad and I, we used to go on five mile long runs. We used to swim together you know and things of that nature, but very little in terms of you know formal strength training right. So there was calisthenics and you know body weight stuff, but that was about it.

Dr Abeel Mangi:
Then I grew older. You know I went to medical school, surgical residency, which you know back in those days we used to work 100 hundred - 120 hours a week, every other night call. And I trained as a heart surgeon, started a family.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
Right, so over time what happened was I gained a bunch of weight. You know I became physically inactive. I hit that magic, you know, 40 year threshold then you know one day I wake up and I'm, you know, close to 300 pounds. I got two little boys I can barely pick them up and get them up the stairs.

Dr Abeel Mangi:
So for me this was a moment that you know something is not right here.

Mark Rippetoe:
Light went on.

Mark Rippetoe:
Light went on. Particularly when you think about the fact that... every day you know I'm operating on people who looked at that time just like me. Young guys, overweight...

Mark Rippetoe:
It had to have occurred to you that this was going to be a problem at some point and...

Dr Abeel Mangi:
It's funny right. You don't, you don't think of yourself as...

Mark Rippetoe:
A patient.

Dr Abeel Mangi:
Exactly.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
Until I went to see a doctor. I hadn't seen a doctor in 10 years.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
Who says guess what? You've got high blood pressure. You've got high cholesterol. I need to start you on these meds. So to me and I'm like you know 43, 44 for me this is crazy. I've got four kids. The youngest is three. The oldest is 16. Yeah. If this continues I ain't going to be around.

Mark Rippetoe:
Yeah.

Dr Abeel Mangi:
It's just not going to happen.

Mark Rippetoe:
You won't see them through college.

Dr Abeel Mangi:
It's not gonna happen. Particularly because every male on my father's side had a heart attack by the time they were 55. Every single one of them including my father. My father and his brother were the only two who actually survived them. The rest of them you know never, never... never made it through.

Dr Abeel Mangi:
So for me this was the thing I had to change the way I was living. So one of the nurses in our operating room. So I actually got introduced to this through CrossFit. You know her son owns a CrossFit gym up in Branford Connecticut. And so I started training with one of his brothers who was actually was gonna come here with me too but couldn't get the logistics sorted out.

Dr Abeel Mangi:
So anyhow you know I started training... within four to five months I had dropped 60 pounds.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
As I was telling you guys over lunch today, the first day I showed up there he was like "Show me a squat." I couldn't squat my bodyweight. I couldn't squat to the ground and back up. You know this was... this was scary, you know. He had me ride the bike and I could barely ride the bike for 30 seconds. I was done that day. I was done, I couldn't do anything more.

Dr Abeel Mangi:
So you know, but I said hell you know the first the first day was awful. You know the second day was worse. Said hell with this I gotta get this. I kept going back. And you know here we are two two years later.

Dr Abeel Mangi:
You know I got introduced to your stuff really through the internet first and I bought your books, read all your books. My wife bought me that seminar when I came to you up in Maryland. That's where we met the first time.

Dr Abeel Mangi:
And you know I've been training now, consistently strength training for about 18 months. So I went from not being able to squat you know without a barbell. Now you know last week I squatted 355 for five. So for me this is like...

Mark Rippetoe:
Excellent. That's just excellent.

Dr Abeel Mangi:
And guess what? The... all the meds are gone.

Mark Rippetoe:
Good.

Dr Abeel Mangi:
One... one morning I'm working out with John in the gym and I'm like "Jesus, I'm so light-headed." I'm light headed and he's like "What did you not eat? Did you not sleep?" I'm like, "No, everything's fine.".

Mark Rippetoe:
It's the beta blockers.

Dr Abeel Mangi:
Yeah, exactly. He's like, "You've got no blood pressure." So...

Mark Rippetoe:
You're 80 over 35.

Dr Abeel Mangi:
Exactly. That's exactly what it was. So you know there... I mean I did it for myself.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
You know and today, I mean I feel like a different person.

Mark Rippetoe:
Oh I'm sure you do.

Dr Abeel Mangi:
I actually met somebody who I trained with. So this is about 15 years... I hadn't seen him in 15 years. This is two weeks ago and he says "You know what? You look 10 years younger today than you did then.".

Mark Rippetoe:
15 years ago.

Dr Abeel Mangi:
So that's incredible. Yeah I mean I think and so for me this is... it's a big deal both personally and professionally.

Mark Rippetoe:
Well it... it is a big deal because of the fact that this is an interventional strategy that requires no medication.

Dr Abeel Mangi:
Right.

Mark Rippetoe:
That works every single time it's applied correctly. That is incredibly inexpensive compared to every other single alternative.

Dr Abeel Mangi:
Absolutely.

Mark Rippetoe:
And is more effective. This is probably the most important thing. It's much more effective than any medication combination that could possibly be administered.

Dr Abeel Mangi:
And I agree with you, 100%.

Mark Rippetoe:
With no side effects.

Dr Abeel Mangi:
Yeah. I was telling you the other day that's why I love this slogan on the T-shirt.

Mark Rippetoe:
From Bill Starr's book.

Dr Abeel Mangi:
Bill Starr. Yes, but it is absolutely correct.

Mark Rippetoe:
Yes.

Dr Abeel Mangi:
And there's data to support it. We can talk about the data.

Mark Rippetoe:
Let's let's talk about strength and longevity.

Dr Abeel Mangi:
Yeah.

Mark Rippetoe:
There's several things we want to talk about today. We want to touch on on the effects... Why would a cardiac surgeon be concerned with strength training and want to talk about conventional... the conventional approach to cardiac rehab and what a hilarious waste of time it is. And then we'll, you know, got a couple of special things we want to talk about.

Mark Rippetoe:
So let's talk about strength and its relationship to... to mortality. And I guess probably the thing to talk about first would be the fact that that cardiovascular disease is neck and neck with cancer right now as the number one cause of mortality in the United States. And for the most part the vast majority of cardiac... of cardiovascular disease is environmental.

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
It's environmental which means it's your fault, not his. It's your fault. And you can fix it if you want to. But what we see is they don't want to fix it bad enough to do anything hard.

Dr Abeel Mangi:
Yeah.

Mark Rippetoe:
Because they have been perhaps told that there's a pill or some combination of pills that will fix this and that is just not true. And it's unfortunate that this is the... this is what everybody believes. Since everybody believes that, it's extremely difficult to penetrate with the message that you have to get up off of your dead, lazy, ass and fix this yourself. It's not a comfortable message for people.

Dr Abeel Mangi:
No, it's not at all.

Dr Abeel Mangi:
I mean, I think as you look at the context of this disease. So cardiovascular disease has been the leading killer of both men and women in America for decades. Since the 50s. It's now neck and neck with cancer depending on who you read. Cancer may be a little bit ahead now, but regardless... The most commonly performed operation that we do - coronary bypass surgery - we do a half million of them a year in this country. Every year.

Mark Rippetoe:
Five hundred thousand bypass operations.

Dr Abeel Mangi:
Bypass operations every year in this country. And just to put that in context you know, there are about 5000 heart surgeons in this country practicing today. There is expected to be a shortfall of about 30 percent of qualified cardiac surgeons in America in the next decade simply because you can't keep up with the demand. The demand is exploding.

Mark Rippetoe:
Because you are creating the demand. Because you will not do what it takes to not have cardiovascular disease.

Dr Abeel Mangi:
I mean let's think about it right. Two thirds of us are overweight. Diabetes is epidemic. Epidemic. And we can talk about the role of the diet, the role of governmental recommendations...

Mark Rippetoe:
The role of the of the promotion of carbs over fat.

Dr Abeel Mangi:
It's based on...

Mark Rippetoe:
Starting 30 years ago.

Dr Abeel Mangi:
Bad science.

Mark Rippetoe:
Yes it's based on Ancell Keys.

Dr Abeel Mangi:
Exactly.

Mark Rippetoe:
Is who it's based on.

Dr Abeel Mangi:
Exactly.

Mark Rippetoe:
Ancell Keys.

Dr Abeel Mangi:
And if you read his famous study, the Seven Countries Study.

Mark Rippetoe:
Yes.

Dr Abeel Mangi:
Right. That study is fatally flawed because it was cherry-picked.

Mark Rippetoe:
It should never have been published.

Dr Abeel Mangi:
It should never have been published.

Mark Rippetoe:
It shouldn't have been published yet. It forms the basis...

Dr Abeel Mangi:
Yes.

Mark Rippetoe:
...to this day as far as I know - unless they've changed it - of the American Dietetic Association's recommendation for a low fat diet they still recommend a low fat diet.

Dr Abeel Mangi:
You look at the American Heart Association, the American Medical Association... every major professional society recommends whole grains and lots of them and low fat low fat. So carbs should account for 70 percent of your caloric intake.

Mark Rippetoe:
That's and that's n... that is a recipe for diabetes.

Dr Abeel Mangi:
Absolutely.

Mark Rippetoe:
And it always has been. And I mean lots and lots of people have made these observations for lots and lots of years. And yet the dogma with professional societies still remains incorrect like this. And it's it's you know I think that everybody that's interested in it at any level already knows this because of the availability of the information.

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
And but nonetheless a large percentage of the population are still under the influence of their doctors...

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
...who have not taken the time...

Dr Abeel Mangi:
And who don't know this...

Mark Rippetoe:
Who don't know this.

Dr Abeel Mangi:
People don't know this. This is not taught in medical school.

Mark Rippetoe:
No.

Dr Abeel Mangi:
OK. So when you you know when you get food out of a box that says "healthy" on it that should make you pay attention.

Mark Rippetoe:
Yes.

Dr Abeel Mangi:
Well you know it's not food if it's coming out of a box.

Mark Rippetoe:
No food does not come from boxes.

Dr Abeel Mangi:
Food does not come from boxes. Food comes out of the ground or of an animal or something like that.

Mark Rippetoe:
Something like that but not out of a box. Chances are anything out of a box is extremely high in carbohydrate.

Dr Abeel Mangi:
And it's processed, heavily processed.

Mark Rippetoe:
Heavily.

Dr Abeel Mangi:
So that's all the stuff. So that... you got cholesterol right, hypertension, cigarette smoking. These are all things that we can do something about by exercise.

Mark Rippetoe:
Yes.

Dr Abeel Mangi:
All right.

Mark Rippetoe:
I wonder, just as an aside, I wonder what percentage of cancer versus what percentage of cardiovascular disease is environmental. I get the impression that essentially all cardiovascular disease with very few exceptions are environmental. In other words YOU cause that. And a quite a bit lower percentage of cancers are environmental although the majority of cancers are... remain environmental.

Dr Abeel Mangi:
You know I think it gets it gets hard to tease this out. You know I think for most conditions I think one could... reasonable people could agree that there is a component that is you were born with, there's nothing you can do about that, but there is a significant component that you do have control over, right, by the things that we're going to talk about.

Mark Rippetoe:
Yes. Type 2 diabetes.

Dr Abeel Mangi:
And essentially cardiovascular disease.

Mark Rippetoe:
You give yourself type 2 diabetes.

Dr Abeel Mangi:
And it's the same for cancer.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
Right. So if you smoke, if you choose to smoke, odds are you know you're escalating your risk for many different cancer right. Similarly with this good data is emerging that consuming processed food can also lead to the metabolic derrangements that lead to cancer. So that... there's you know there's good data again to your point that a considerable amount of it is environmental.

Dr Abeel Mangi:
But with cancer I think is you know it's probably more complex...

Mark Rippetoe:
Probably more complicated than the typical scenario of metabolic syndrome that you find that leads to cardiovascular disease. I think probably the vast majority of of cardiovascular disease especially that which is responsible... which is the responsibility of metabolic syndrome is your fault. Once again is your fault.

Dr Abeel Mangi:
And it's tough, Rip. Right. I mean... I mean the thing is I get it. You know we as human beings I think are conditioned to seek out short term gain as opposed to long term gain. We will often sacrifice long term gain for something that we can take advantage of in the short term. So to your point, it's not easy to get up and train three days a week. It's a hell of a lot easier to take a couple of pills because...what the hell.

Mark Rippetoe:
And to a large extent a normal human behavior mitigates against strenuous activity. Now if you think thirty thousand years ago when life was tough physically just inherently, the smartest thing you could've done is not kill yourself. Not not work real hard because that puts you in a at an extreme disadvantage in terms of the use of your own physical resources, this sort of thing.

Mark Rippetoe:
The advent of modern society has changed that equation to the point that if you behave in what would in a simpler time be a self-destructive way - you're you're running - now why would a thirty thousand years ago. Why would a guy go out and run for no particular reason? He has to run every day anyway. Why would he lift heavy things for no particular reason? That's part of the day. All his life it's part of the day, but now it's important that you place yourself into a set of physical conditions that more closely mimic what we're what we're adapted genetically and and what we had evolved to do. So that if you if you obey your natural proclivity to do things the easy way now, tt's detrimental.

Dr Abeel Mangi:
Yes that's right.

Mark Rippetoe:
And you have to.... And so it's it's kind of counterintuitive. And I understand that. I understand why people would rather have a pil.l Because it's easier and easier is what we've evolved to head in the direction of, but we don't have that luxury anymore.

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
We have to understand that a strenuous lifestyle must be voluntarily undertaken or we suffer the consequences that come with the fact that we are not genetically adapted to a leisurely lifestyle.

Dr Abeel Mangi:
And I think as human beings you know I think that we should be putting ourselves in uncomfortable situations, you know, whether it's intellectually or you know physically you that's the only way we grow.

Mark Rippetoe:
Stress is stress is normal.

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
Stress is a normal component of physical existence.

Mark Rippetoe:
Without stress there is no adaptation.

Mark Rippetoe:
Without stress there's no adaptation and the adaptation then becomes to to take us down in physical capacity as opposed to up in physical capacity.

Dr Abeel Mangi:
It's a maladaptation.

Mark Rippetoe:
It's a maladaptation. It's nonetheless an adaptation act to the stress. The stress is a negative stress instead of a positive stress.

Mark Rippetoe:
And stress is an interesting... stress is an interesting thing. We talk about the stress-recovery-adaptation cycle as the basis of of the the construction of the method by which we train people. We apply stress, we create the conditions for recovery from the stress, that stress when recovered from produces an adaptation. And then we produce and other stress. And we... and this escalating stress produces an escalating adaptation and that's the basis of the of the method.

Mark Rippetoe:
I think cardiac rehab and in all types of physical rehabilitation suffer from a logical continuity here. All right. If if I was going to rehab a person with an injured knee, all right. Knee's been operated on, you come in the gym two or three weeks post-op and we start loading the knee through as full range of motion as we can load the knee because that's where the knee is going to return to function. It has to return to function through this through this full range of motion.

Mark Rippetoe:
So what we do is we seek out the greatest range of motion that you can operate in in the context of the injury, load it progressively, go up two pounds a workout, five pounds a workout just like we would do for a novice trainee. And what does the knee do then? It adapts to the stress by healing itself up in a way that that returns it to function. In other words it goes back to normal morphology it heads in the direction of of original equipment.

Mark Rippetoe:
It won't ever get back to completely original equipment but it gets back...

Dr Abeel Mangi:
Get it pretty close.

Mark Rippetoe:
You get you can get pretty damn close with it. But, the process of stressing the knee occurs in the gym every day and outpatient physical therapy doesn't do that under normal circumstances and outpatient cardiac rehab doesn't do that either. And the reason I think - and you tell me what you think about this idea - the reason I think they don't is because those people, that profession, those two professions -cardiac rehab and physical therapy - have the idea that the stress was the injury, or the surgery. Not something that they must apply in an escalating, accumulative fashion in order to return the structure to to normal function. What do you think about this?

Dr Abeel Mangi:
I think you're onto something here because that's - and this is important to understand - I think once you have had heart surgery... It's so let me just take a step back... The reason I wanted to become a heart surgeon is that it is one of the few areas in medicine where you do something very invasive, very big...

Mark Rippetoe:
Very, very big.

Dr Abeel Mangi:
But you know what? The next day they actually look better than the day they did before the operation. OK because you have restored blood flow to the heart. You have either fixed a leaky heart valve or a stiff heart valve, you've replaced an aneurysm. You've actually improved the functioning of that heart, okay.

Mark Rippetoe:
And even though the the... even though the procedure was invasive. the function has improved as a direct result of the of the of the intervention.

Dr Abeel Mangi:
Exactly. That's the goal of the heart operation. Right. We don't do heart surgery to make people look better. You know, to cure certain symptoms. We do heart surgery so that people live longer. All right. That's the only reason we do heart surgery.

Mark Rippetoe:
So that hearts work better. So the heart works better immediately after the procedure.

Dr Abeel Mangi:
Immediately, right. So now the question is why don't you stress that heart during recovery? Now, I can tell you. Let let me. Let me make an observation OK. You can take someone... This happened last week. You can take someone whose heart function is down to a third of normal. OK so normal ejection fraction of a heart's about 70 percent. That means it takes in 100 cc of blood, it can squeeze out about 70 cc. That's normal.

Dr Abeel Mangi:
You can take someone who's ejection fraction is down to about 20 percent. OK. But under the appropriate circumstances they can generate more than double their cardiac output that your body actually needs.

Mark Rippetoe:
Post-op.

Dr Abeel Mangi:
Post-op. Cardiac output is what actually matters. Is how much blood... how many litres per minute of blood can the heart generate.

Mark Rippetoe:
So if the procedure is correctly performed the heart is performing at a higher level immediately...

Dr Abeel Mangi:
Immediately.

Mark Rippetoe:
...Than it was prior to the intervention.

Dr Abeel Mangi:
Unless you screwed something up right.

Mark Rippetoe:
And that of course happens, but under normal circumstances...

Dr Abeel Mangi:
If you do that, if you screw something up, they will usually not survive.

Mark Rippetoe:
Right. The operation itself. Right. Right.

Dr Abeel Mangi:
So. So the stakes are high, but because the stakes are high the reward is also high. It's a high risk, high reward venture.

Mark Rippetoe:
Yes.

Dr Abeel Mangi:
Right. So when you fixed the heart it has never made sense to me that when you send a patient out to rehab that that heart is actually not being stressed under controlled circumstances.

Mark Rippetoe:
It's not being stressed sufficiently. They want to tell you that it's under a bunch of stress. We're going to meet a friend of mine tonight for dinner. And those of you that read the website, my buddy Scott Davison had a had a double-bypass procedure and he went through his cardiac rehab and he decided about a week after he got through with cardiac rehab that he was going to come in and finally take the advice I'd been yelling at him for about 20 years and get in the gym and get back in shape and start training for strength.

Mark Rippetoe:
The first night we did essentially nothing in the gym. Everything we did with an empty bar. We squatted, bench pressed, deadlifted and I had pushed a prowler back and forth one time. His report upon completing the prowler, which was the last thing we did, is that at no point during his cardiac rehab had his heart rate been that high.

Mark Rippetoe:
And this is a this is a bad sign. You know a lot of time has been wasted because he clearly survived that that event. He clearly survived that evening and every time he has been in the gym. Now he's been severely ill a couple of times. God he had got sick and got dehydrated and had to be in the hospital a couple of days I don't know what kind of bug he had. But there have been a couple of fairly decent little setbacks, but every time he has been in the gym we have gone up in terms of the stress that we applied to that system.

Dr Abeel Mangi:
And let me guess: he came off his diabetes meds. He came off his blood pressure meds.

Mark Rippetoe:
They've got him almost off of all of his medication.

Dr Abeel Mangi:
That's incredible.

Mark Rippetoe:
They've got him off of his. I've got... we'll talk to him about it tonight. I'll let him explain. But they had him on quite a bit of stuff. He was not all full blown polypharma, but he was headed in that direction and all of that stuff's been cut back. All of it's cut back to the point where he is a star... he's about ready... He could probably go off of everything right now if he if he needed to. And I've argued with him that he does need to.

Dr Abeel Mangi:
Right.

Mark Rippetoe:
And. But it's a fascinating case. He was told in cardiac rehab to not just... here just ride this bike, just ride this bike. Let's monitor your heart rate and let's get that heart rate up to oooh... you know, 65 percent of resting heart rate and this sort of thing.

Mark Rippetoe:
And you know at no point was he under any stress load. And the only thing that that makes any sense to me is that instead of viewing the rehab as stress-recovery-adaptation, stress-recovery-adaptation, stress-recovery-adaptation with that kind of a slope... that they think that the injury, the surgery, was enough stress and that we don't want to stress the system in a way that would challenge the repair.

Dr Abeel Mangi:
And the injury was such - so severe - that it is something that no one will ever recover from. Or back to a meaningfull quality of life.

Mark Rippetoe:
Apparently all they want you to return to is baseline.

Dr Abeel Mangi:
Well I'll tell you what they want you to do because I've no idea. I've actually studied this.

Mark Rippetoe:
Let's hear this.

Dr Abeel Mangi:
So at no point. So the target heart rate should be about 70 to 80 percent of your maximum. Right. Your calculated magnet if your heart for your age, sex, weight and etc... OK right. At no... So the goal of the aerobic component of that exercise is to get your heart rate about 20 to 30 beats a minute above that.

Dr Abeel Mangi:
So we're talking about...

Mark Rippetoe:
Above baseline.

Dr Abeel Mangi:
Above that 70 percent threshold.

Mark Rippetoe:
Oh above 70 percent.

Dr Abeel Mangi:
You're talking... you know that's a heart rate of 100. Maybe. And most of these people are on beta blockers. Right.

Mark Rippetoe:
They can't produce.

Dr Abeel Mangi:
You're never going to get 100. (Rip in background) That's one piece. The second piece - the Borg perceived rate of exertion score. Right. How hard am I working from six to 20. They want you in the 11 to 14 range. So moderate exertion like "This was a little bit difficult.".

Mark Rippetoe:
And right snd and our experience with the rate the RPE scale is that is that no one can adequately judge that for themselves.

Dr Abeel Mangi:
Yes.

Mark Rippetoe:
Everybody's perceptions of what is heavy, what is hard are inaccurate. Without exception they're inaccurate.

Dr Abeel Mangi:
Yeah, I believe it entirely.

Dr Abeel Mangi:
So once you've made it through these two thresholds then you will start very light resistance training - perhaps.

Mark Rippetoe:
Maybe.

Dr Abeel Mangi:
Usually it's... usually it's treadmill walking. You may go up on the incline, but if you do make it to resistance training, then you're working at 30 to 50 percent of your 1 rep max.

Mark Rippetoe:
Which they have no way of calculating.

Dr Abeel Mangi:
Which they have no of calculating. You're doing two to three sets of 12 to 15 reps right. You're not supposed to valsalva at any point. You're not supposed to...

Mark Rippetoe:
In other words you're not supposed to squat, deadlift, bench press.

Dr Abeel Mangi:
Do any...or pick up any heavy object that you need to pick up in your home.

Mark Rippetoe:
Anything ever. Right.

Dr Abeel Mangi:
OK. So it should then come as no surprise that when you look at randomized, controlled trials looking at the benefits of cardiac rehab there is no improvement in survival. There is no improvement in readmission to hospital. There is no improvement in quality of life. There is absolutely no decrease in cost of care.

Mark Rippetoe:
Please, please repeat that. Because this is so critically-ass important. Just repeat those four points.

Dr Abeel Mangi:
Randomized controlled studies looking at the benefits of cardiac rehab: No advantage in long term survival. No advantage in readmission to the hospital, nor advantage in quality of life which to me is the reason you should be doing this. And no decrease in cost of care.

Dr Abeel Mangi:
So if you think about it about the value...

Mark Rippetoe:
Utterly pointless.

Dr Abeel Mangi:
What is the value? Where is the value?

Mark Rippetoe:
It is utterly pointless. The way it is approached in the conventional approach to create rehab it is utterly and absolutely pointless. But everybody is required to do it.

Dr Abeel Mangi:
You require or you are heavily encouraged...

Mark Rippetoe:
You're heavily encouraged to to it.

Dr Abeel Mangi:
You're given advice about nutrition...

Mark Rippetoe:
In some cases your insurance company will refuse to pay for it if you don't do it.

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
Which is a form of blackmail and I would hate to think that the cardiac rehab people had anything to do with it, but it has occurred to me. So I really... It's... and this is this is the... so cardiac rehab and physical therapy are basically the same thing. They are fatally flawed in that they are so conservative in their approach that they cause insufficient stress to produce an adaptation. Right.

Mark Rippetoe:
And it all this is biology. This is if an organism receives stress from its environment and that stress is not so large as to be overwhelming and unadaptable, then the organism will adapt to the stress of the environment and become capable of dealing with the stress.

Dr Abeel Mangi:
And let's not forget that heart has already endured the most stressful event that it will ever endure.

Mark Rippetoe:
Yeah it's got your grimy hands on the damn thing. Well you know... you're holding on to it... "I've got this man's heart." So they're very damned little that he's gonna be able to do to it that's going to approach the level of stress that you've applied to in the surgery.

Dr Abeel Mangi:
Just think about it. We've opened the chest. We've drained all the blood out of the heart. We've stopped the heart. We've cut open the heart.

Mark Rippetoe:
You've slapped it around. You made fun of it.

Dr Abeel Mangi:
Show it who's boss.

Mark Rippetoe:
If it was a woman's heart you were sexist to it. If it was a gay man's heart you were transphobic or whatever they... and then you...

Dr Abeel Mangi:
I can neither confirm nor deny these...

Mark Rippetoe:
Put it back. Then you refill it with blood and then that's probably the wrong temperature. Maybe you're restarting the thing with electricity. You get a car battery....brrzzzzzzz!

Mark Rippetoe:
Right. But you guys are worried about making it beat too fast. Right?

Dr Abeel Mangi:
I mean to me it has never, never made sense.

Mark Rippetoe:
Right. No it doesn't make sense.

Dr Abeel Mangi:
Particularly when you look at all the data. So let's talk about data and survival with strength training. OK. So this is something I guess the question I asked you back in Maryland as well. That if you take all comers in the population and you make them exercise, you know, hat do you see? So the data are as follows. There's one study take 30000 adults. You make them exercise twice a week. This is only U.S. sort of physical activity guideline recommendations, this is not strenuous exercise. This is 150 minutes a week or so, but these patients are actually followed for 15 years which is what makes this interesting. So you're actually following the same cohort of people.

This is a pretty good longitudinal study. What study is this?

Dr Abeel Mangi:
So I'll give you the data. But what you see in this case is a 46 percent reduction in all cause mortality. Take a bunch of adults who've never trained before, you make them exercise - this is strength training. Fifteen years. Half of them that should have been dead are still alive.

Mark Rippetoe:
Well this is pretty solid.

Dr Abeel Mangi:
You know this has been studied in multiple environments. So there's a there's another meta analysis. Eleven randomized controlled studies 300,000 patients followed over nine years. 20 percent decrease - only strength training - 20 percent decrease in all cause mortality at nine years.

Dr Abeel Mangi:
Now if you add...

Mark Rippetoe:
God knows what they mean by strength.

Dr Abeel Mangi:
T hat's a whole other... a whole other thing.

Dr Abeel Mangi:
But now you add some aerobic exercise to that - 40 percent decrease. Okay. You study men separately you see the same thing. You see women separately you see the same thing. Now the thing that surprises me is how few people actually strength train. And this is a very broad definition of strength training.

Mark Rippetoe:
Right. Very broad.

Dr Abeel Mangi:
Very, broad so we'll talk about that...

Mark Rippetoe:
As evidenced by the fact that the addition of aerobic conditioning to it actually improved the mortality. Because you and I both know that...

Dr Abeel Mangi:
We're talking single joint, you know, machines..

Mark Rippetoe:
Standard Gold's gym.

Dr Abeel Mangi:
You know lots of curls, right all that stuff. So this is the Journal of the American Heart Association in 2017 looked at only women. Okay. And 21 percent of women had admitted to doing any type of strength training in their lives. 20 percent. Only 20 percent. Only 10 percent of women said they actually strength trained more than one hour per week. When you looked at that cohort that was training for this for one hour a week, again 20 percent increase in long term survival.

Mark Rippetoe:
See it's just...

Dr Abeel Mangi:
So the question, the question to me is...

Mark Rippetoe:
You know what's amazing about this, Abeel, is that this is so intuitively obvious to anyone that has considered this for more than a couple of minutes.

Dr Abeel Mangi:
Let me tell you one other fascinating... Let me tell you one fascinating study. OK. This is out of New Zealand. And this goes to the point about physical therapy in general. They took any elderly frail woman who came into their hospital system with a hip fracture. OK. They operated on her for the hip fracture and then took her and did formal strength training. So we're talking barbell strength training - little eighty-year-old grandmas. Guess what they found?

Dr Abeel Mangi:
An 80 percent reduction in mortality. I mean this is this is just astonishing stuff.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
And you look across the spectrum, Rip. You look at cancer, cancer. You look at diabetes. You look at high blood pressure, high cholesterol, you treat patients with kidney diseases, to get orthopedic patients, you will get patients with mental illness, schizophrenics -- strength training improves survival and quality of life across the board in everyone you look at.

Mark Rippetoe:
Yes. Yes.

Dr Abeel Mangi:
And which by the you know that's why I love this T-shirt.

Mark Rippetoe:
It is in fact true.

Dr Abeel Mangi:
It is true. It is truism.

Mark Rippetoe:
It it it really is a truism.

Dr Abeel Mangi:
It's a truism. It's a biological fact.

Mark Rippetoe:
Strength is life.

Dr Abeel Mangi:
It's a biological fact.

Mark Rippetoe:
Strength is life. And everyone that's paid attention. Anybody who's been on a farm. Anybody that's had dogs and cats. Anybody that has had brothers and sisters. Anybody that has an old relative in the family knows that physical strength is associated with a long life. And more importantly a productive life.

Dr Abeel Mangi:
Rip, my dad is 84 years old. He squats. Every day.

Mark Rippetoe:
This is this is a... And once again... And Dr. Sullivan has written about this in The Barbell Prescription. This is far and away the most powerful intervention that can be undertaken in terms of longevity and in terms of quality of life. Far and away the most powerful. But nonetheless people want a pill.

Dr Abeel Mangi:
Yeah.

Mark Rippetoe:
And you know most people are always going to want a pill. And I don't know how to make people not want the pill and want to do stuff hard.

Mark Rippetoe:
There's the famous case - and I've talked about this several times - I had a when I... oh god... this happened 15-20 years ago. I had a girl come in the gym with borderline... well it wasn't borderline diabetes - she was waking up in the morning with blood sugars at 300. And she was like 5'2" and one ninety five. Yeah just fat...

Dr Abeel Mangi:
Full metabolic...

Mark Rippetoe:
Full metabolic and she's 25 years old. And this is just you know this is ridiculous. And so she wondered if I could help her so I said well let's try. So I took her out into the into the gym and I had to do some higher rep stuff. A little bit different approach than I normally take which is fives, because I wanted to produce a glycolytic insult. As profound a high-rep glycolytic just to burn up some sugar just because I'd been experimenting with some stuff in terms of the effects of of high-intensity glycolytic exercise on insulin sensitivity and GLUT-4 this sort of stuff.

Mark Rippetoe:
So we went out and did some we did some sets of 20 on the leg press and we benched and did some lat pulls. You know, pretty much just real simple stuff, but all high reps. And I her for six workouts and the... she came in the last... she came in on a sixth workout and I said "What was your sugar this morning?" She said eighty five.

Dr Abeel Mangi:
Wow.

Mark Rippetoe:
From three hundred to eighty five in two weeks.

Dr Abeel Mangi:
That's incredible.

Mark Rippetoe:
And she quit. She quit.

Mark Rippetoe:
Now I don't... This was an interesting experience for me because here you have, you have handed this girl her.. you handed it.

Dr Abeel Mangi:
The key to life.

Mark Rippetoe:
You handed her the key to to continued health and life and you've handed her the key to not shooting insulin, not taking glucophage. Not having her feet chopped off. Not having macular degeneration and blindness. But she quit.

Dr Abeel Mangi:
Why?

Mark Rippetoe:
Because I don't know.

Dr Abeel Mangi:
See this it the thing...

Mark Rippetoe:
She just left and I was... It was I guess it was too hard. I don't, I don't know what it would... I mean it was it was just a bizarre thing to realize about people, you know. That here we are dealing with.. we're dealing with this is this is this here is the fix this for you life and but I don't want that because it's too hard and it's it's just God damn it.

Dr Abeel Mangi:
People at work and asked me, "What have you done? You look different." I think I found the fountain of youth. Which is, which is I really believe that.

Mark Rippetoe:
Yes, you did.

Dr Abeel Mangi:
But the question is you know... the problem with this is that you require someone to be motivated, to keep coming.

Mark Rippetoe:
Yes, and you can't motivate them.

Dr Abeel Mangi:
But that's. But if this doesn't motivate you then what...

Mark Rippetoe:
What will. If your life, your continued existence doens't motivate you. And amazingly enough it doesn't motivate many people. We have somebody in the seminar every weekend ask us, "What do I do. I've my mother my father I need they need. They need this. They need this. They're fat. They're out of shape. Their sugars about out of control or blood pressure is up. What do I do to get them in the gym?".

Mark Rippetoe:
And I said what... have you explained the benefits? Yes I have. But I. But they won't go. How do I get them in the gym? And I have to tell them you don't. You can't get them in the gym. You can't make people act like you want them to - which is what's largely wrong with many aspects of the government. And you can't make people act like they need to act - which is wrong with, which is what is wrong with most of the human race.

Mark Rippetoe:
So there are profound hurdles here that there are actually no way... there's no way to address those. There really is not. I mean, what we have here is the answer to heart disease, to the conditions that predispose for heart disease. We know what to do. We know how to fix this. This is not complicated.

Mark Rippetoe:
We know what dietary interventions to make. We know what exercise interventions to make. We know how to make you stronger. We know that getting you stronger makes you live longer. We know that a stronger person is a healthier person. We know that a stronger person is a happier person, a person who is more capable of carrying on daily physical activities that are in... but that you run into when you're alive.

Mark Rippetoe:
We know all of this, but we can't do it for you. All we can do is inform you. And then you have to decide to do it yourself. And it's it's tough man.

Dr Abeel Mangi:
Rip, I texted you. Yeah so last Thursday I texted you from the clinic saying that yes I had seen five guys, all of whom I done bypass surgery on, all of whom in their early 60s, all of whom had formerly been athletes. Now all overweight diabetics, hypertensive etc. And so the question... So you know I find myself in this funny position now of counseling people about their diet and exercise which I don't think that many heart surgeons... usually it's you know look at the wound and...

Mark Rippetoe:
Right they're just mechanics.

Dr Abeel Mangi:
Yeah, but I spent probably two and half hours with these five guys on my diet, exercise, this this this. So then the question comes up. You guys are all athletes and they're all former football players right. Why aren't you... why aren't you exercising? Well, initiative etc is one thing. And the second thing is well "Where do I go and who's going to train me?"

Dr Abeel Mangi:
And, you know, certainly not for these guys because they're former athletes, but you know the little lady, a 72-year-old she's... [garble]... Yeah but she's like you know these barbell gyms are intimidating places. Sure. You go in there you got a big guy like Nick who's you know squatting 500 pounds. I'm not going to...

Mark Rippetoe:
Right.

Dr Abeel Mangi:
So how do we crack that nut?

Mark Rippetoe:
Well that's an interesting question. I think it is a normal human central nervous system response to be intimidated by people who are physically stronger or more aggressive than they are. That's that's a very old, deep in the brainstem kind of response. Pecking order type behavior. And I don't know that that can be... I don't know that can be fixed to the point where a 72-year-old woman is gonna walk into a powerlifting gym and say, "Hey! Help me." Yeah yeah that's that's probably not going to occur.

Mark Rippetoe:
So obviously what we would have to do is provide a different venue for her to go to that would that would show her what she needs to know about barbell strength training in an environment that is not intimidating right to her. And but that still encourages the kind of performance that you would typically also associate with a serious black iron barbell gym. And the Starting Strength franchise gyms and our affiliate gyms are those places and we just need to have more of them. We need more coaches. We need... there's a there is a demand for this product that exceeds our current ability to supply and we're doing everything we can to address that, but that is the answer.

Mark Rippetoe:
In other words the answer is that the paradigm in a exercise facility must change from treadmills and cardio. You know silly bullshit waste of time stuff that doesn't improve the health of a cardiac patient and certainly as hell does not improve the health of a healthy person. To do something that's physically challenging enough to make them stronger and it's just going to take a long time before a strength adaptation becomes mainstream in the fitness industry. But that's really the the answer. And it's a more broad availability of the the correct idea of "What should we be training for in a gym?" Strength. And "How should we do it?" Stress-recovery-adaptation. Gradual accumulation of a of a of a strength stress and a strength adaptation.

Mark Rippetoe:
And it's just going to take a lot more education. It's gonna take a lot more time and unfortunately a lot of people are going to die in the meantime.

Dr Abeel Mangi:
Yeah, that is true.

Mark Rippetoe:
And that's just all there is to it. And I mean that's not unusual. People been dying for hundreds of millions of years. And you know just becoming protein for the system.

[off-camera]:
So our goal over the next five to 10 years is to make Starting Strength synonymous with - get stronger, resistance training - because you know when your colleagues recommend to somebody what they should do. Because your patients are asking you what they should do. Right. And they should not only say "strength training" but they should say "Well how do I do strength training?" "Starting Strength." And then it's just a top down effect. What's the old lady going to do? She's going to go find a trainer. She's going to say my doctor says I need to do Starting Strength. The trainers are going to have to learn what Starting Strength is and even if they're trying at it

Dr Abeel Mangi:
It's tough.

Mark Rippetoe:
Yeah. And he and his colleagues have the moral authority to say that to 72-year-old women whereas we don't. We they're just, you know, what do we know?

Dr Abeel Mangi:
You got the relationship. So it's it's interesting, the relationship between a patient and a heart surgeon is a very special thing.

Mark Rippetoe:
I think it is. I've talked to enough of them to know that it is.

Dr Abeel Mangi:
You know when I when I was in medical school people used to you know my elders used to say to me. Yeah. "Aren't you worried that you know you want to be a heart surgeon? You won't have a relationship with your patients." Because you know that usually you think of a primary care doctor who has someone sees you from your 18 to 60. And I'll tell you what. When I used to do a heart transplant on artificial hearts it was as though I was their primary care doctor.

Mark Rippetoe:
You were there primarily care doctor because without you they're dead.

Dr Abeel Mangi:
They're dead. So it's the same dynamic. You know, for this little lady or you know these five guys in the clinic last week, they want to know what I think about these important matters.

Mark Rippetoe:
Because you're responsible for them still being here. A primary care physician to those kind of patients. Primary care physician is a vacuum cleaner repairman. But the you are the doctor that's saved their asses.

Dr Abeel Mangi:
But to that point... that we you know what we should be imagining and you and I have emailed about this, is some sort of partnership here. Yeah we can partner. So if I have people that I'm like Look here's someone who's motivated this guy is gonna show up. I just need to tell them where where to go, where to show up and I know he will get a coach who's familiar with the things that he's endured in his life and how to get them up to speed. You know that I'm not just casting this guy out to someone I don't know or recognize.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
Now I have personal relationships in the community in which I know that there's something that's not Starting Strength but it's something else. At that point you know anything...

Mark Rippetoe:
Anything that's hard.

Dr Abeel Mangi:
Anything that's hard.

Mark Rippetoe:
That gets progressively harder will force... anything to force the stress-recovery-adaptation cycle upon someone who desperately needs the adaptation.

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
But if they are in a situation in in the exercise community that doesn't understand that things must escalate, things must become progressively harder. That exercise selection is not the variable. That load is the variable.

Dr Abeel Mangi:
Correct doing water aerobics at the Y is not going to cut it.

Mark Rippetoe:
That is a bath. They're going to take a bath when they get home.

Dr Abeel Mangi:
Exactly. So yeah. This is what I'm grappling with. This is why I reached out to you. Say we need to figure out a way together to at least start to pick away at this. You're doing it in your world... I'm doing in my world...

Mark Rippetoe:
I completely agree. Our reach into into the broader community is at this point limited quite thoroughly by the general perception of the medical community of what we do.

Mark Rippetoe:
They don't know. They have no idea. What is the most common response to an orthopedic injury or post-op or anything else in the medical community? "Now don't pick up now 20 pounds for the next year.".

Dr Abeel Mangi:
Yeah. Nothing heavier than a book.

Mark Rippetoe:
Nothing heavier than a book for the next year. Don't valsalva. Don't get your heart rate up. Take these beta blockers to keep you squarely on your ass. And as long as people are willing to believe those professionals over us professionals, then we will be hamstrung. We will always suffer the short end of that stick.

Dr Abeel Mangi:
That's why there needs to be a partnership.

Mark Rippetoe:
There has to be an education program and you know Dr. Sullivan's book is an excellent place to start. The Barbell Prescription's an excellent place to start, but how do we get doctors to read that?

Mark Rippetoe:
I don't know. Yeah I'm damned if I know it. I don't understand how we do it. I don't know about you but it's been my perception that a very very common attitude among doctors and especially among both heart surgeons and orthopedic surgeons is, "Hey, we got this. We're the professionals. You're just a gym owner, right? We're the professionals and what we say goes." And more important than that, "We already know this. We already know things that you...as just a simple gym owner with, you know, an average college education can't possibly know." Because after all my hundred and thirty six IQ can't possibly match that of a doctor with 120 IQ.

Dr Abeel Mangi:
You're right, they don't match.

Mark Rippetoe:
I'm sorry they don't. Average IQ of doctors is 120 and I happen to be a little smarter than that. And, you kno,w I'm not real bright but I understand.I've

Dr Abeel Mangi:
I've read your book so I beg to disagree, but I think that when one digs deeper they're within all of these communities there are people who believe.

Mark Rippetoe:
Yeah there are people in... there are isolated instances of people with their heads out of their asses. There absolutely are. But the problem starts in medical school.

Dr Abeel Mangi:
Absolutely. I agree.

Mark Rippetoe:
The problems of the medical education paradigm is is the problem here.

Dr Abeel Mangi:
It's about treatment, not about prevention.

Mark Rippetoe:
It's about... it's about this - do this. This - do this.

Dr Abeel Mangi:
It's prescriptive.

Mark Rippetoe:
It's training, it's not education. And I really hate to say that, but I'm I'm firmly convinced that doctors are trained.

Dr Abeel Mangi:
Right. Well you're absolutely right...

Mark Rippetoe:
They're not educated, they're trained.

Dr Abeel Mangi:
That's what that's what we refer to it. It's training. It's surgical training.

Mark Rippetoe:
I've heard I've heard you say that and that can't be that can't be any more accurate. It's absolutely - you're thought to do things in response to other things.

Dr Abeel Mangi:
Just like...

Mark Rippetoe:
But you're you're not taught to think through your... You have general physiology as a junior in an undergrad and that's never applied. As you get out of school you quit thinking like that.

Dr Abeel Mangi:
No. I mean I'll tell you from my own perspective right. So in cardiac surgery we use physiology every day, but it is never normal physiology it's pathologic physiology. So I think that if you're open minded, if we as a community are open minded about this, you quickly realize that you can alter pathologic states. In fact, we do this every day. You are altering pathologic states in order to enable normal physiology.

Mark Rippetoe:
As you as you observed earlier, the minute you're through with your procedure physiology has been improved.

Dr Abeel Mangi:
It's better. You have to have improved it.

Mark Rippetoe:
Or the patient dies on the table.

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
One of the two things occur.

Dr Abeel Mangi:
Exactly.

Mark Rippetoe:
And and this physiologic response to the surgery must be continued with activity post-op.

Dr Abeel Mangi:
That is exactly right.

Mark Rippetoe:
So that we get back on this trajectory. That we got to be on. But. You know, good luck explaining this to...

Dr Abeel Mangi:
Well your point is right on because what we tell... what I tell people is that if this is the normal survival curve of a population, you're currently down here. The goal is to get you back up here.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
Right now that's the long term goal. The operation is one piece of that.

Mark Rippetoe:
Yes.

Mark Rippetoe:
Yes. It's the first full it's the first piece of that. It's obviously necessary.

Dr Abeel Mangi:
And the most hazardous phase.

Mark Rippetoe:
Right.

Dr Abeel Mangi:
That's the riskiest phase...

Mark Rippetoe:
Because because that's where the greatest amounts of.

Dr Abeel Mangi:
Stress.

Mark Rippetoe:
...invasiveness. That's the greatest invasion any human being will ever endure is having their heart in the hands of another human being. I mean previously we only saw that with the Incas, right? And that was real unproductive. Right. That was never survival.

Dr Abeel Mangi:
Right. Right.

Mark Rippetoe:
But you guys got... you're one step away from that. You don't throw it off the cliff, but you are handling the damn thing right.

Dr Abeel Mangi:
Yeah. And so the question is then how do you continue that. Like why would you pay such a high hazard, if you weren't going to, if you weren't going to reap all the benefit?

Mark Rippetoe:
If you were not going to continue the trajectory that's established by the operation.

Dr Abeel Mangi:
So the way I see it, is I have a role to play in this. Yes. And you have a role to play in this. Which is why we need to think about doing you know...

Mark Rippetoe:
I could not possibly agree more. But until you convince your cardiac rehab community that they are behaving in a suboptimal fashion with respect to causing that trajectory to be re-established then I mean... this is the whole thing [demonstrates trajectory curve with hand] Over and over again our discussion leads back to the fact that that has to happen right.

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
But if if what they're doing post-op does not directly contribute to that, if all they're doing is in their covering their ass about a lawsuit you know and I mean let's just be honest. ou know. That's kind of what's going on isn't it. They're in there covering their ass.

Dr Abeel Mangi:
It's fear, Rip. People are afraid.

Mark Rippetoe:
Sure they are.

Dr Abeel Mangi:
Being afraid is not going to help anyone get better.

Mark Rippetoe:
But I think that the the the the best point to take away from this discussion is that when you're through with what you do on the table... if what happens in OR goes like it's supposed to and that - in other words, if you get out of the OR - you're already better than you were when you went into the OR. And as a result of that you can now handle more stress than you could before and now it's important to understand that you must be subjected to more stress than you were before in order to establish that positive slope of that line.

Dr Abeel Mangi:
Correct. You know in order to get you back on that slope right. Yeah.

Mark Rippetoe:
Absolutely.

Dr Abeel Mangi:
I mean there's so much more we could talk about you know. Why this is important and what it does to your whole body and...

Mark Rippetoe:
Let's talk about some of these other topics. Shall we?

Mark Rippetoe:
Let us... because I mean we got you here and and this is a excellent opportunity to to talk to somebody that's operating in his community at a very high level. What do you what do you think about oh the pharmaceutical industry and its relationship to cardiovascular disease? What is what's good, what's bad, what's complete bullshit? What do you think about Lipitor? What do you think about the number one prescribed medication on the planet? What do you... what you think about the effects of all of these all these drugs? What what do you think about the the designed dependence upon these this chemical intervention situation?

Dr Abeel Mangi:
Well, this is a great question and my answer may not completely satisfy you, but it's an honest answer.

Mark Rippetoe:
Let's hear it.W

Dr Abeel Mangi:
Which is that, I think when you're recovering someone from something as traumatic as they've been through - a heart operation or a heart attack or something - I believe that there are certain types of medications that have their place.

Mark Rippetoe:
Sure.

Dr Abeel Mangi:
So aspirin.

Mark Rippetoe:
Sure.

Dr Abeel Mangi:
A beta blocker.

Mark Rippetoe:
Certainly.

Dr Abeel Mangi:
Some sort of statin whether it is Lipitor or something else, but some sort of anticholesterol statin is important.

Mark Rippetoe:
Anything to soften the blow.

Dr Abeel Mangi:
You need these to get through. You've got to get through because of course don't forget we're manipulating physiology, manipulating blood vessels, you don't want blood clots form on the inside. And you want to get the maximum mileage that you can out of the operation.

Dr Abeel Mangi:
However the question though becomes is that in the long run do you need them? And that's why I think that in the long run, by not exercising people the way they should be exercising, you're actually creating this culture of dependency.

Mark Rippetoe:
Right. You're you're substituting medication for activity.

Dr Abeel Mangi:
Correct. Because why do we need this? What is the goal of this is what's the goal of these medications right?

Mark Rippetoe:
Well it should be to get you off of them.

Dr Abeel Mangi:
Our goal should be to get you off, but what did the medi... what of the medicines designed to accomplish?

Mark Rippetoe:
Immediately post-op we don't want a clot to form...

Dr Abeel Mangi:
And it's my belief...

Mark Rippetoe:
And we know that they do.

Dr Abeel Mangi:
...that you don't want. You want to subdue inflammatory... the inflammatory milieu inside the body.

Mark Rippetoe:
Right.If the inflammatory load is such that...

Dr Abeel Mangi:
It's overwhelming...

Mark Rippetoe:
The flame the inflammatory load itself becomes a stressor.

Dr Abeel Mangi:
Correct.

Mark Rippetoe:
Then there has to be mediated.

Dr Abeel Mangi:
You have to mitigate that. So that's the short term goal. Now what we also know about strength training is that over time it independently mitigates this anti-inflammatory burden. Right, so all those cytokines and interleukin and stuff like that - all that stuff gets down regulated.

Mark Rippetoe:
Right. And the amazing thing about exercise is is that when you put in a medication it usually has one, two, maybe in some isolated circumstances, three axes of intervention.

Dr Abeel Mangi:
Sure.

Mark Rippetoe:
But the system itself is so multivariate that you're going to have to take a second medication... a third medication and in some cases mitigate the side effects of the first medication. And anything that is... that can be approached from the from the level of that of the patient's physiology itself is going to be both more comprehensive and less invasive in terms of side effects.

Dr Abeel Mangi:
I completely agree with you. Right. So right. If you look at you know what does strength training do? So at the level of the heart it will cause the heart to enlarge as the human being doing the exercise enlarges. Right. So people get worried about this... is that paper that you sent me the question that you sent me - Why is that why is this patient's heart enlarging? Why is this guy's heart enlarging? Well, it's enlarging because he's enlarging.

Mark Rippetoe:
Right. It's enlarging because demand. The stress response...

Dr Abeel Mangi:
The heart is a muscle!

Mark Rippetoe:
The stress-recovery-adapatation. The adaptation - it'ss a muscle and the thing is going to hypertrophy.

Dr Abeel Mangi:
It's going to get bigger.

Mark Rippetoe:
But that so often gets interpreted by lots of people as pathology.

Dr Abeel Mangi:
Is not pathology. It's not pathologic.

Mark Rippetoe:
It's adaptation.

Dr Abeel Mangi:
Exactly. And when you index it to someone's body mass or body surface area it is actually normal. Right, and what you will similarly see is when they stop training, just as your skeletal muscle will regress, so the size of the heart.

Dr Abeel Mangi:
So that so you know I know we had talked about that before via email but that's why that's important to bring up. And the other thing that is interesting that happens is that arteries develop elasticity when you exercise. This is why you know hypertension is curable by exercise.

Dr Abeel Mangi:
When you're not exercising, the endothelium in the lining of the arteries is dysfunctional. It's critically dysfunctional. That's why exercise... that's why the blood pressure response exercise is abnormal in people who don't train. You can actually get it normal by exercising.

Dr Abeel Mangi:
You know mitochondria efficiency in skeletal muscles - the number of mitochondria, how efficiently they extract oxygen - that goes up. All the genes, your genetic expression changes in as little as six to eight weeks.

Mark Rippetoe:
The the system is so complicated, so multivariate, and this is why it's so damned hard to do research on these topics. You can't tease out... you can't perturb one variable and correctly deduce the response to that one variable because other variables participate in the response and you're not you're not controlling that.

Dr Abeel Mangi:
Is impossible to tease out causation.

Mark Rippetoe:
It is.

Dr Abeel Mangi:
All you can do...infer...is correlation.

Mark Rippetoe:
That's all you can do is correlate.

Dr Abeel Mangi:
Not good enough. Not good enough. And then you look at other things like the whole you know well what are they doing? What is their definition of strength training? Usually it's you know, leg presses.

Mark Rippetoe:
Leg extensions and arm curls is what it usually it is. Resistance training they call it, they don't even call it strength training. Call it resistance training, it's on a machine, and it's not systemic, and it does... not hard enough to produce an adaptation. Yet it still shows...

Dr Abeel Mangi:
Better than nothing.

Mark Rippetoe:
Positive - statistically positive outcomes. And it's not even what we would consider to be resistance training at all, but it's still, it's still that powerful. It's still a... So you imagine if you if you if you subject somebody to an optimum... to an optimum situation.

Mark Rippetoe:
You know like you're gonna meet Davidson tonight. And Davidson dead-... he rack pulled 330, no 310. He rack pulled 310 and this is a guy with bad arthritis in his index finger on his left hand. And he did that without any stress. You know, and this guy was laying in a hospital bed two and a half years ago about to die.

Dr Abeel Mangi:
It's fantastic.

Dr Abeel Mangi:
And not to say what it does your overall sense of well-being and you know. There's something to be said about lifting something heavy off the ground.

Mark Rippetoe:
Well I told him a while back. I told him a while back. You know you're you know in fact I... I got him up to a 300 deadlift. Oh, it's been a while. I had him pull 300 off the floor and he didn't think he could do it. At the time he was doing a triple with 265 off the floor and I said "I want you to put a quarter, a ten, and a two and a half on that." And he goes, "That's 300." I said, "Very good at math. Very good. Load it. And he put it on there and he was real apprehensive and I just browbeat his ass into it. Pull it, pull the goddamn thing. It's there. Do it. Don't be a pussy. It's time to stand up and get this thing done.

Mark Rippetoe:
And he went over and deadlifted it and I said, "Guess what, Scott? You're no longer a heart patient, you're now a lifter.".

Dr Abeel Mangi:
There you go.

Mark Rippetoe:
You're now a lifter. And that's pretty cool.

Dr Abeel Mangi:
That is pretty cool.

Mark Rippetoe:
You know, to hand a guy that. That's pretty cool.

Dr Abeel Mangi:
Yeah, absolutely.

Mark Rippetoe:
You're no longer a heart patient. And that was real important to him.

Mark Rippetoe:
And it's a it's a fascinating thing to see what can actually happen to people and and back to the medications thing... he's you know we'll discuss all this with him tonight, but he's dropped several of these things that he was on. He had a big handful of stuff that he was taking.

Mark Rippetoe:
And like they had him on a beta blocker and I think he's completely off of that.

Dr Abeel Mangi:
Incredible.

Mark Rippetoe:
Because he was I mean you know at some point it's not helping you.

Dr Abeel Mangi:
No, it's actually hurting you.

Mark Rippetoe:
It's hurting you. It's preventing you from having a normal cardiovascular response which is one of the stresses we want to impose on the heart for the adaptation.

Dr Abeel Mangi:
Exactly.

Mark Rippetoe:
You know and so he's off of that and he's off of a bunch of stuff. Now I've got another old guy in there that just... he's he's guilty of Doctor worship. And one of these these criminal GPs here in Wichita Falls has got him on about 10 things and he just can't bring himself to... can't bring himself to question why.

Dr Abeel Mangi:
Why am I on this?

Mark Rippetoe:
And the guy keeps telling him "Because I've got you on them."

Dr Abeel Mangi:
Just keep taking them.

Mark Rippetoe:
And you know guys like that are... they're the problem. I know not all doctors are that way but there's a there's a there's enough of them out there operating especially in this demographic, in the older demographic, that are so quick to hand out a prescription. That "oh you've got a symptom? Here. Oh you've got another symptom? Here.".

Dr Abeel Mangi:
I'ts all people know, Rip.

Mark Rippetoe:
Yeah I know but you know.

Dr Abeel Mangi:
But look at all the patients. But you know what. Three years ago that's all I knew.

Mark Rippetoe:
You know. Yeah but so. So what do you think it is? Is it the lack of education?

Dr Abeel Mangi:
It's not what... I mean.

Mark Rippetoe:
Is it just a reluctance to think in terms of....

Dr Abeel Mangi:
What was I trained to do? And you... you know like....

Mark Rippetoe:
You were trained to do...

Dr Abeel Mangi:
I was trained to become a damn good heart surgeon.

Mark Rippetoe:
You're you're trained to do physical repair.

Dr Abeel Mangi:
Correct. Under those conditions....

Mark Rippetoe:
A set of hands skills and a physical I have to physical repair your physical task you're a plumber.

Dr Abeel Mangi:
In so many ways.

Mark Rippetoe:
And extremely extremely talented talented plumber, but you're performing things with your hands that you get very very very good at.

Dr Abeel Mangi:
And you have to get very good at

Mark Rippetoe:
Yes. Oh God.

Dr Abeel Mangi:
Because you know John Smith, next door has a heart attack.

Mark Rippetoe:
Look look at these things [Rip examines Abeel Mangi's hands].

Dr Abeel Mangi:
Don't break them.

Mark Rippetoe:
Aren't they gorgeous.

[off-camera]:
Don't break them.

Dr Abeel Mangi:
You'll have to feed my kids if you break them. I'd love to box...

Mark Rippetoe:
But so why... Where does that limitation come from? Can you put your finger on where in your preparation is there?

Dr Abeel Mangi:
You're not prepared for it...

Mark Rippetoe:
Do you not step back and look at the whole physiology of the...?

Dr Abeel Mangi:
How many people have the wherewithal to step back from what they're doing every day? It's not many.

Mark Rippetoe:
That's a very good. That's a very good question.

Dr Abeel Mangi:
Many we all we all know...

Mark Rippetoe:
I'm probably guilty of that myself...

Dr Abeel Mangi:
We all do and we all are. Right. I mean for me this was serendipity in many ways right. Like right. I realized Jesus and I look at this [looks down at his body] I got to change and it changed and it opened my mind, you know. And I've talked to you and Brad and so... but a lot of people don't you know. We as surgeons, we don't take good care of ourselves. How many of my colleagues work out every day? Zero.

Mark Rippetoe:
Well you know that's a very good question and we get myopic. Everybody develops a certain amount of myopia and you're...

Dr Abeel Mangi:
And we live, breathe and eat this stuff. It's every day.It's like seven thirty in the morning to whenever it ends at night. Every day I'm cutting and sewing. That's what I do. That's my sense of identity. You know amongst other things right. But that that's how most of us think.

Mark Rippetoe:
Yeah. And if that consumes you know 95 percent of your time there's not much left. Not much time left for the...

Dr Abeel Mangi:
For contemplation...

Mark Rippetoe:
For the macro view of how all of these things fit together.

Dr Abeel Mangi:
We don't have time to contemplate. You're there to solve a problem. A life threatening problem.

Mark Rippetoe:
The problem is this aneurysm.

Dr Abeel Mangi:
Yes. And I'm going to fix it.

Mark Rippetoe:
I'm gonna go to fix this aneurysm.

Dr Abeel Mangi:
And once this one is done I will fix another.

Mark Rippetoe:
Yes. Then I've got to go down the hall to get to...

Dr Abeel Mangi:
Then I got to go help one of my buddies. Then I got to go pick up my kids and you know I got to help the kids with homework.

Mark Rippetoe:
I understand.

Dr Abeel Mangi:
Right so. Yeah that's life, right?

Mark Rippetoe:
So in... considered that way, it is the rare medical professional that's going to be able to do the step back thing you know because of the inherent limitations of the schedule.

Dr Abeel Mangi:
But but I'll tell you something...

Mark Rippetoe:
Motivation...

Dr Abeel Mangi:
But so one of the reasons that I wanted to talk to you guys about this, you in particular, is because you have figured out a way to make strength training something that resonates with someone like me. Right. So when I read your books it's fact. Right. This is the physics. This is the biology. This is why we do things this way. That... to people who have minds. That makes sense right. So I'm like, "Who am I going to talk to?".

Mark Rippetoe:
Do you realize what it is about our system that appeals to you? It's the simple logic.

Dr Abeel Mangi:
Yeah.

Mark Rippetoe:
It's the simple logic. It's the it's that it's taken all of the machines away. It's taken all of the commercial considerations of the gym away and going back to "what is gravity?" How do we operate in a gravitational framework? What is the simple physical science in operation here? How do we design an exercise system that will make people stronger? Why do we need to be stronger? What is strength? What are all these little, basic concerns? And what comes out the other end of this of this pipeline is a very simple, straightforward program that works every single time it is applied correctly.

Dr Abeel Mangi:
Right.

Mark Rippetoe:
And the simplicity of the thing is the draw. The simplicity of the thing is the draw to intelligent people. And as I just... in a recent podcast I made the observation -and I know this is going to be offensive to a lot of people - but stupid people like complexity. Complexity appeals to stupid people.

Dr Abeel Mangi:
You want to strip things down of everything that is complicated, reduce it to its simple essence.

Mark Rippetoe:
Right. Lowest common denominator and does the math make sense there? And if it doesn't, then the math's wrong.

Dr Abeel Mangi:
I'll tell you what that's what good doctors do to. We do the same thing. You take something very complicated, try to boil it down to something that is not going to take a lot of time, especially in the OR. Gotta give him exactly... give maximize the reward and minimize the risk. Right. Because the duration of the operation independently predicts mortality right.

Mark Rippetoe:
Minimum effective dose.

Dr Abeel Mangi:
Yes, we're talking the same...

Mark Rippetoe:
Minimum effective dose. A very simple concept that's been applied for decades, for generations. The minimum effective perturbation that's necessary to achieve the result.

Dr Abeel Mangi:
Result that you're looking for.

Mark Rippetoe:
The desired result. Not more than that - the minimum effective dose. And this is why 10 medications just essentially always reflect an absolute lack of analysis of the situation as a whole. Stepping back. Withdrawing. Big picture. Ten medications do not fall out of a global analysis.

Dr Abeel Mangi:
What you're doing when you're giving someone 10 medications for cardiovascular disease - you're treating 10 different symptoms, you're not treating the underlying cause. The underlying cause of all the stuff we talked about.

Mark Rippetoe:
Precisely right.

Dr Abeel Mangi:
So William of Occam. Occam's razor.

Mark Rippetoe:
Occam's Razor.

Dr Abeel Mangi:
Right. Reduce everything down to one identifiable problem. Yes that's what medicine supposed to be all about.

Mark Rippetoe:
The simplest analysis is almost always the correct analysis.

Dr Abeel Mangi:
Right. Exactly. So that's what we do day and night.

Mark Rippetoe:
Yes.

Dr Abeel Mangi:
That's why when I picked up your book, and I read your book I'm like this fundamentally makes sense to me.

Mark Rippetoe:
You recognized it as the same process.

Dr Abeel Mangi:
That's why the bar should be here and not here. It makes sense to me. What do I know about barbell training? Nothing. But the the way you explain it it makes sense to me. So when I go into my gym and then it's like back squat day and I have my bar down here and everyone has a bar up here and people are like "What are you doing man?" I'm like [pushes open hand away from him]

Mark Rippetoe:
"I got this."

Dr Abeel Mangi:
Exactly.

Mark Rippetoe:
That comes in handy.

Dr Abeel Mangi:
You to your thing and I'll do my thing.

Mark Rippetoe:
Right. Anything else you wanna yack about? I think we've covered most of the bases here.

Mark Rippetoe:
OK thank you guys for joining us. Abeel Mangi, thank you for coming down to Texas to talk to us.

Dr Abeel Mangi:
Pleasure.

Mark Rippetoe:
And thank you for joining us on Starting Strength Radio. We'll see you next time.

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Mark Rippetoe and Dr. Abeel Mangi discuss strength training and cardiac rehab. Dr. Mangi is an attending surgeon in the Section of Cardiac Surgery at Yale University, and is Associate Professor of Surgery at the Yale University School of Medicine.

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