Barbell Medicine Podcast

In 2004 a surgeon removed about ten kilograms of fat from fifteen women and measured everything that mattered. Nothing improved. Four years later, it still hadn't.

That result should have ended an argument about body fat. Instead the argument got more specific, and the version you've heard most recently is that visceral fat, the fat around your organs, is the dangerous kind. I've said a version of that myself on this show, and in this episode I expand upon it.

This one starts from the beginning: what your fat is actually for, what insulin is, and what insulin resistance means, in plain terms and assuming nothing. Then four experiments that all point the same direction. Fat removed surgically, and the disease doesn't follow. People born with no fat tissue at all, who get the entire disease anyway. A hormone that reversed a 48% fatty liver without adding a gram of fat. And a diabetes drug that made people heavier and healthier at the same time.

The second half is practical. What a fatty liver actually does over twenty years, what BMI can and can't do, why the Lancet Commission changed the definition of obesity in 2025, and the exact order of tests I'd use, including the TyG index, FIB-4, and where each one stops working.

Part one of two. Next episode is about muscle.

Timestamps:

00:00 The Liposuction Experiment
02:06 The Visceral Fat Correction
05:47 What Fat Is For
08:14 The Carb Insulin Model
10:51 Filling The Garage
14:35 Taking The Fat Out
17:57 Born Without Fat Tissue
22:52 Heavier And Healthier
25:05 Neptune And Vulcan
29:57 The Patient Nobody Checked
33:59 What Every Ruler Missed
36:00 What To Actually Order
40:29 What Obesity Actually Is

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Taylor R, Barnes AC, Hollingsworth KG, et al. Aetiology of type 2 diabetes in people with a 'normal' body mass index: testing the personal fat threshold hypothesis. Clin Sci (Lond). 2023;137(16):1333-1346. doi:10.1042/CS20230586
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Sanyal AJ, Kaplan LM, Frias JP, et al. Triple hormone receptor agonist retatrutide for metabolic dysfunction-associated steatotic liver disease: a randomized phase 2a trial. Nat Med. 2024;30(7):2037-2048. doi:10.1038/s41591-024-03018-2
Portillo-Sanchez P, Bril F, Maximos M, et al. High prevalence of nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus and normal plasma aminotransferase levels. J Clin Endocrinol Metab. 2015;100(6):2231-2238. doi:10.1210/jc.2015-1966
Hagström H, Nasr P, Ekstedt M, et al. Fibrosis stage but not NASH predicts mortality and time to development of severe liver disease in biopsy-proven NAFLD. J Hepatol. 2017;67(6):1265-1273. doi:10.1016/j.jhep.2017.07.027
Rubino F, Cummings DE, Eckel RH, et al. Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025;13(3):221-262. doi:10.1016/S2213-8587(24)00316-4
Guerrero-Romero F, Simental-Mendía LE, González-Ortiz M, et al. The product of triglycerides and glucose, a simple measure of insulin sensitivity: comparison with the euglycemic-hyperinsulinemic clamp. J Clin Endocrinol Metab. 2010;95(7):3347-3351. doi:10.1210/jc.2010-0288
Sánchez-García A, Rodríguez-Gutiérrez R, Mancillas-Adame L, et al. Diagnostic accuracy of the triglyceride and glucose index for insulin resistance: a systematic review. Int J Endocrinol. 2020;2020:4678526. doi:10.1155/2020/4678526
McLaughlin T, Abbasi F, Cheal K, Chu J, Lamendola C, Reaven G. Use of metabolic markers to identify overweight individuals who are insulin resistant. Ann Intern Med. 2003;139(10):802-809. doi:10.7326/0003-4819-139-10-200311180-00007
McPherson S, Hardy T, Dufour JF, et al. Age as a confounding factor for the accurate non-invasive diagnosis of advanced NAFLD fibrosis. Am J Gastroenterol. 2017;112(5):740-751. doi:10.1038/ajg.2016.453
Mózes FE, Lee JA, Selvaraj EA, et al. Diagnostic accuracy of non-invasive tests for advanced fibrosis in patients with NAFLD: an individual patient data meta-analysis. Gut. 2022;71(5):1006-1019. doi:10.1136/gutjnl-2021-324243
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A popular paper claimed the longevity benefit of lifting disappears once you train more than an hour a week. It's a real paper, but the claim is a misread. This is the free cut of this month's Direct Line, where Drs. Feigenbaum and Baraki also take on whether GLP-1s affect your mood, the "same calories, more weight loss" protein argument, and what you can actually do in the gym when you have chronic fatigue syndrome.
For education and infotainment, not medical advice.
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Timestamps:
0:00 Intro
0:38 The paper: does lifting stop helping after an hour?
3:19 The newer 147,000-person, 30-year study
13:21 GLP-1s, mood, and motivation
14:50 The FDA reverses the suicide warning
19:29 What happened when they gave people a GLP-1 in a bar
24:54 Is a calorie just a calorie?
28:17 The "same calories, more weight loss" protein study
30:48 Does keto break the laws of physics?
34:56 Lifting with chronic fatigue syndrome
36:14 The identical-twin experiment
37:36 Can lifting in bed do anything?
45:33 Get the full Direct Line

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

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

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

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

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

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

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

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

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

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

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

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

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

Timestamps:
 | 00:00:00 | The FDA voted 8-6. What it actually means
 | 00:01:25 | What I am, and am not, claiming
 | 00:03:21 | How they got here: Category 2 and the paperwork
 | 00:07:17 | Who was in the room: the panel that flipped
 | 00:10:57 | What they voted on: compounding and the bulks list
 | 00:15:37 | "No money in it, you can't patent it"
 | 00:18:24 | The trials already run: Plevna and MK-677
 | 00:22:55 | "I took it and it worked": placebo and fake surgery
 | 00:27:02 | The one human trial: Ruenzi 2005
 | 00:32:28 | Is it natural? Is it even a drug?
 | 00:36:58 | Harm reduction, or follow the money?
 | 00:42:45 | Three times a missing trial went wrong
 | 00:50:58 | Safety: known, unknown, and unknowable
 | 00:55:22 | The other six peptides
 | 00:58:22 | What I'd actually tell you
 | 01:02:08 | What actually works, and what would change my mind

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25. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790-802. doi:10.1111/j.1600-0838.2009.00949.x
26. Langberg H, Skovgaard D, Karamouzis M, Bulow J, Kjaer M. Metabolism and inflammatory mediators in the peritendinous space measured by microdialysis during intermittent isometric exercise in humans. J Physiol. 1999;515(Pt 3):919-927. doi:10.1111/j.1469-7793.1999.919ab.x
27. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-469. doi:10.1001/jama.2013.129
28. Kearney RS, Ji C, Warwick J, et al. Effect of platelet-rich plasma injection vs sham injection on tendon dysfunction in chronic midportion Achilles tendinopathy: a randomized clinical trial. JAMA. 2021;326(2):137-144. doi:10.1001/jama.2021.6986
29. Pavlova AV, Shim JSC, Moss R, et al. Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis. Br J Sports Med. 2023;57(20):1327-1334. doi:10.1136/bjsports-2022-105754
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34. Graham DJ, Campen D, Hui R, et al. Risk of acute myocardial infarction and sudden cardiac death in patients treated with cyclo-oxygenase 2 selective and non-selective non-steroidal anti-inflammatory drugs: nested case-control study. Lancet. 2005;365(9458):475-481. doi:10.1016/S0140-6736(05)17864-7
35. Smith RM, Schaefer MK, Kainer MA, et al; Multistate Fungal Infection Outbreak Response Team. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med. 2013;369(17):1598-1609. doi:10.1056/NEJMoa1213978
36. Adunsky A, Chandler J, Heyden N, et al. MK-0677 (ibutamoren mesylate) for the treatment of patients recovering from hip fracture: a multicenter, randomized, placebo-controlled phase IIb study. Arch Gerontol Geriatr. 2011;53(2):183-189. doi:10.1016/j.archger.2010.10.004 [Trial terminated early for a congestive-heart-failure safety signal.]
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47. Associated Press. Financial ties reported among FDA peptide advisory panel members. 2026. Accessed July 24, 2026.
48. Leerink Partners. Equity research note: PCAC peptide vote and the telehealth compounding market. 2026.
49. Examine.com. BPC-157 research breakdown. Accessed July 24, 2026. https://examine.com/supplements/bpc-157/
50. Jarry J. Body protection compound: no proof required. McGill Office for Science and Society. Accessed July 24, 2026. https://www.mcgill.ca/oss

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

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

Resources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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