Barbell Medicine Podcast

Muscle is where most of the glucose goes, and muscle insulin resistance is the first thing that breaks on the road to type 2 diabetes. Both of those are true, and neither one means that building more muscle is the treatment for obesity. This episode works through what actually decides whether a tissue handles fuel well: not how much of it you have, but how fast it's moving fuel through. We go through the one-legged exercise studies, the 18,000-person analysis of what body composition actually predicts, the athlete's paradox, the energy cost of building a kilogram of muscle, the GLP-1 lean mass panic, and why sarcopenic obesity is named after the wrong organ.
This is part two of a two-part series on storage capacity. Part one covered where body fat goes and what happens when the storage runs out. 
Timestamps
0:00   The one-leg study, and the muscle-centric claim
02:06   What obesity is, and the garage analogy
05:06   How glucose gets into a muscle cell
11:21   Insulin sensitivity improves without building muscle
17:11   The best case for muscle-centric medicine
21:13   What predicts falls and death: strength, not lean mass
25:18   Separating muscle size from muscle function
31:33   Liver fat: amount, type, and flux
37:54   Should you build muscle first? The arithmetic
42:37   Building muscle in a calorie deficit
50:29   GLP-1s, DXA, and the lean mass panic
58:23   Sarcopenic obesity, and why the name is wrong
01:04:37 Why size still tells you something
01:11:46 So what is obesity?

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Most men who start testosterone never needed it, and some who genuinely do never get treated. In the final episode of the Signal series, Dr. Jordan Feigenbaum and Dr. Austin Baraki work through who actually needs testosterone replacement, who got sold it, and what the evidence says about the risks that scared the field for a decade. We cover the blinded trial where men couldn't tell real testosterone from placebo, what the heart and prostate data actually show now that we have the trials, what testosterone does to fertility, and the framework we use to decide. We also close the story of Mark, the patient whose lab result started the series.
This is educational content, not medical advice. Talk to your physician about your personal situation.
Here we cover the real diagnosis of testosterone deficiency, primary versus secondary low testosterone, how the system both over- and under-prescribes, the SHBG trap that makes a normal level look low, the gray-zone crossover study, what replacement should actually target, why most men quit within a year, testosterone as a male contraceptive, the TRAVERSE cardiovascular results, the saturation model and prostate safety, the blood side effect worth monitoring, and when not to start at all.

Timestamps:

00:00 The study almost nobody mentions 
01:31 Who this episode is for 
03:35 What a real testosterone diagnosis requires 
07:18 Primary vs secondary low testosterone 
10:12 How testosterone gets over-prescribed 
11:35 The SHBG trap: when a low number misleads 
18:10 Would GLP-1 plus testosterone work better? 
22:19 Why genuine deficiency gets under-treated
 24:15 The cardiovascular scare and where it came from 
34:11 The gray-zone study, in full 
41:02 What TRT should actually target, and the "900" myth 
47:38 Running TRT as a trial, and why 70% quit 
52:36 Testosterone as a contraceptive: the fertility cost 
57:19 Does TRT cause heart problems? The TRAVERSE trial 
01:01:40 Testosterone and the prostate 
01:09:13 The blood side effect worth watching 
01:12:02 When not to start testosterone 
01:14:26 Who actually benefits from TRT 
01:18:28 The Signal framework, and what happened to Mark
 01:21:14 Five things to take away
 01:23:33 Our conflict of interest, and the book

Resources:
Buy the book, Signal: https://www.barbellmedicine.com/shop/learning/signal/
Part 1: Is the testosterone crisis real?
Part 2: Is you testosterone actually low?
Part 3: What's actually driving your testosterone down?

New Barbell Medicine Hybrid 5K and 10K Run + Lift Programs
Barbell Medicine coaching and templates: https://www.barbellmedicine.com
Testosterone Action Plan: https://www.barbellmedicine.com/testosterone-action-plan/ 

Mulligan T, Frick MF, Zuraw QC, Stemhagen A, McWhirter C. Prevalence of hypogonadism in males aged at least 45 years: the HIM study. Int J Clin Pract. 2006;60(7):762-769. doi:10.1111/j.1742-1241.2006.00992.x
Baillargeon J, Urban RJ, Ottenbacher KJ, Pierson KS, Goodwin JS. Trends in androgen prescribing in the United States, 2001-2011. JAMA Intern Med. 2013;173(15):1465-1466. doi:10.1001/jamainternmed.2013.6895
Bhasin S, Brito JP, Cunningham GR, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744. doi:10.1210/jc.2018-00229
Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and management of testosterone deficiency: AUA guideline. J Urol. 2018;200(2):423-432. doi:10.1016/j.juro.2018.03.115
Corona G, Goulis DG, Huhtaniemi I, et al. European Academy of Andrology (EAA) and European Society of Endocrinology (ESE) recommendations on the diagnosis and management of male hypogonadism. Andrology. 2020;8(5):970-987. doi:10.1111/andr.12770
Morgentaler A, Zitzmann M, Traish AM, et al. Commentary: who is a candidate for testosterone therapy? A synthesis of international expert opinions. J Sex Med. 2014;11(7):1636-1645. doi:10.1111/jsm.12546
Mok SF, Fennell C, Savkovic S, et al. Testosterone for androgen deficiency-like symptoms in men without pathologic hypogonadism: a randomized, placebo-controlled cross-over with masked choice extension clinical trial. J Gerontol A Biol Sci Med Sci. 2020;75(9):1723-1731. doi:10.1093/gerona/glz195
Clift AK, Johnson H, Huang DR, Morgentaler A. Real-world outcomes and safety of testosterone therapy: a longitudinal, retrospective cohort study of over 9,000 men. World J Mens Health. 2026;44(2):438-450. doi:10.5534/wjmh.250245
Malik RD, Wang CE, Lapin B, Lakeman JC, Helfand BT. Characteristics of men undergoing testosterone replacement therapy and adherence to follow-up recommendations in a metropolitan multicenter health care system. Urology. 2015;85(6):1382-1388. doi:10.1016/j.urology.2015.01.027
Donatucci C, Cui Z, Fang Y, Muram D. Long-term treatment patterns of testosterone replacement medications. J Sex Med. 2014;11(8):2092-2099. doi:10.1111/jsm.12608
Saad F, Aversa A, Isidori AM, Zafalon L, Zitzmann M, Gooren L. Onset of effects of testosterone treatment and time span until maximum effects are achieved. Eur J Endocrinol. 2011;165(5):675-685. doi:10.1530/EJE-11-0221
Ly LP, Liu PY, Handelsman DJ. Rates of suppression and recovery of human sperm output in testosterone-based hormonal contraceptive regimens. Hum Reprod. 2005;20(6):1733-1740. doi:10.1093/humrep/deh834
Liu PY, Swerdloff RS, Christenson PD, Handelsman DJ, Wang C; Hormonal Male Contraception Summit Group. Rate, extent, and modifiers of spermatogenic recovery after hormonal male contraception: an integrated analysis. Lancet. 2006;367(9520):1412-1420. doi:10.1016/S0140-6736(06)68614-5
Ko EY, Siddiqi K, Brannigan RE, Sabanegh ES Jr. Empirical medical therapy for idiopathic male infertility: a survey of the American Urological Association. J Urol. 2012;187(3):973-978. doi:10.1016/j.juro.2011.10.137
Kohn TP, Louis MR, Pickett SM, et al. Age and duration of testosterone therapy predict time to return of sperm count after human chorionic gonadotropin therapy. Fertil Steril. 2017;107(2):351-357.e1. doi:10.1016/j.fertnstert.2016.10.004
Wenker EP, Dupree JM, Langille GM, et al. The use of HCG-based combination therapy for recovery of spermatogenesis after testosterone use. J Sex Med. 2015;12(6):1334-1337. doi:10.1111/jsm.12890
Basaria S, Coviello AD, Travison TG, et al. Adverse events associated with testosterone administration. N Engl J Med. 2010;363(2):109-122. doi:10.1056/NEJMoa1000485
Vigen R, O’Donnell CI, Barón AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA. 2013;310(17):1829-1836. doi:10.1001/jama.2013.280386
Basaria S, Harman SM, Travison TG, et al. Effects of testosterone administration for 3 years on subclinical atherosclerosis progression in older men with low or low-normal testosterone levels: a randomized clinical trial. JAMA. 2015;314(6):570-581. doi:10.1001/jama.2015.8881
Budoff MJ, Ellenberg SS, Lewis CE, et al. Testosterone treatment and coronary artery plaque volume in older men with low testosterone. JAMA. 2017;317(7):708-716. doi:10.1001/jama.2016.21043
Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular safety of testosterone-replacement therapy. N Engl J Med. 2023;389(2):107-117. doi:10.1056/NEJMoa2215025
Huggins C, Hodges CV. Studies on prostatic cancer. I. The effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. Cancer Res. 1941;1(4):293-297.
Morgentaler A, Traish AM. Shifting the paradigm of testosterone and prostate cancer: the saturation model and the limits of androgen-dependent growth. Eur Urol. 2009;55(2):310-320. doi:10.1016/j.eururo.2008.09.024
Khera M, Crawford D, Morales A, Salonia A, Morgentaler A. A new era of testosterone and prostate cancer: from physiology to clinical implications. Eur Urol. 2014;65(1):115-123. doi:10.1016/j.eururo.2013.08.015
Bhasin S, Lincoff AM, Nissen SE, et al. Prostate safety events during testosterone replacement therapy in men with hypogonadism: a randomized clinical trial. JAMA Netw Open. 2023;6(12):e2348692. doi:10.1001/jamanetworkopen.2023.48692
Snyder PJ, Bhasin S, Cunningham GR, et al. Effects of testosterone treatment in older men. N Engl J Med. 2016;374(7):611-624. doi:10.1056/NEJMoa1506119

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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

Resources:
Vital 5 (TyG , waist to height, etc. discussion):

https://www.barbellmedicine.com/vital-5-action-plan/
New Barbell Medicine Hybrid 5K and 10K Run + Lift Programs
Barbell Medicine coaching and templates: https://www.barbellmedicine.com
Plus podcast subscription:

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Signal (now shipping): https://www.barbellmedicine.com/shop/learning/signal/

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. doi:10.1056/NEJMoa033179
Mohammed BS, Cohen S, Reeds D, Young VL, Klein S. Long-term effects of large-volume liposuction on metabolic risk factors for coronary heart disease. Obesity (Silver Spring). 2008;16(12):2648-2651. doi:10.1038/oby.2008.418
Sommer I, Teufer B, Szelag M, et al. The performance of anthropometric tools to determine obesity: a systematic review and meta-analysis. Sci Rep. 2020;10(1):12699. doi:10.1038/s41598-020-69498-7
Donnelly KL, Smith CI, Schwarzenberg SJ, Jessurun J, Boldt MD, Parks EJ. Sources of fatty acids stored in liver and secreted via lipoproteins in patients with nonalcoholic fatty liver disease. J Clin Invest. 2005;115(5):1343-1351. doi:10.1172/JCI23621
Spalding KL, Arner E, Westermark PO, et al. Dynamics of fat cell turnover in humans. Nature. 2008;453(7196):783-787. doi:10.1038/nature06902
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. doi:10.1053/j.gastro.2010.04.056
Garg A. Acquired and inherited lipodystrophies. N Engl J Med. 2004;350(12):1220-1234. doi:10.1056/NEJMra025261
Al Yaarubi S, Alsagheir A, Al Shidhani A, et al. Analysis of disease characteristics of a large patient cohort with congenital generalized lipodystrophy from the Middle East and North Africa. Orphanet J Rare Dis. 2024;19(1):118. doi:10.1186/s13023-024-03084-2
Petersen KF, Oral EA, Dufour S, et al. Leptin reverses insulin resistance and hepatic steatosis in patients with severe lipodystrophy. J Clin Invest. 2002;109(10):1345-1350. doi:10.1172/JCI200215001
Miyazaki Y, Mahankali A, Matsuda M, et al. Effect of pioglitazone on abdominal fat distribution and insulin sensitivity in type 2 diabetic patients. J Clin Endocrinol Metab. 2002;87(6):2784-2791. doi:10.1210/jcem.87.6.8567
Cusi K, Orsak B, Bril F, et al. Long-term pioglitazone treatment for patients with nonalcoholic steatohepatitis and prediabetes or type 2 diabetes mellitus: a randomized trial. Ann Intern Med. 2016;165(5):305-315. doi:10.7326/M15-1774
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
Martin S, Cule M, Basty N, et al. Genetic evidence for different adiposity phenotypes and their opposing influences on ectopic fat and risk of cardiometabolic disease. Diabetes. 2021;70(8):1843-1856. doi:10.2337/db21-0129
Martin S, Sorokin EP, Thomas EL, et al. Estimating the effect of liver and pancreas volume and fat content on risk of diabetes: a Mendelian randomization study. Diabetes Care. 2022;45(2):460-468. doi:10.2337/dc21-1262
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
Bansal MB, Patton H, Morgan TR, Carr RM, Dranoff JA, Allen AM. Semaglutide therapy for metabolic dysfunction-associated steatohepatitis: November 2025 updates to AASLD practice guidance. Hepatology. 2025;83(5):1326-1340. doi:10.1097/HEP.0000000000001608
Tomiyama AJ, Hunger JM, Nguyen-Cuu J, Wells C. Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005-2012. Int J Obes (Lond). 2016;40(5):883-886. doi:10.1038/ijo.2016.17
Wildman RP, Muntner P, Reynolds K, et al. The obese without cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2 phenotypes among the US population (NHANES 1999-2004). Arch Intern Med. 2008;168(15):1617-1624. doi:10.1001/archinte.168.15.1617
Mongraw-Chaffin M, Foster MC, Anderson CAM, et al. Metabolically healthy obesity, transition to metabolic syndrome, and cardiovascular risk. J Am Coll Cardiol. 2018;71(17):1857-1865. doi:10.1016/j.jacc.2018.02.055
Gujral UP, Vittinghoff E, Mongraw-Chaffin M, et al. Cardiometabolic abnormalities among normal-weight persons from five racial/ethnic groups in the United States: a cross-sectional analysis of two cohort studies. Ann Intern Med. 2017;166(9):628-636. doi:10.7326/M16-1895
Ruderman NB, Schneider SH, Berchtold P. The "metabolically-obese," normal-weight individual. Am J Clin Nutr. 1981;34(8):1617-1621. doi:10.1093/ajcn/34.8.1617
Sims EA. Are there persons who are obese, but metabolically healthy? Metabolism. 2001;50(12):1499-1504. doi:10.1053/meta.2001.27213
National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication 98-4083. Bethesda, MD: National Institutes of Health; September 1998.
American Medical Association House of Delegates. Resolution 420 (A-13): Recognition of Obesity as a Disease. Adopted June 18, 2013.
American Medical Association Council on Science and Public Health. Report 3-A-13: Is Obesity a Disease? 2013.
Rey-López JP, de Rezende LF, Pastor-Valero M, Tess BH. The prevalence of metabolically healthy obesity: a systematic review and critical evaluation of the definitions used. Obes Rev. 2014;15(10):781-790. doi:10.1111/obr.12198
Hinnouho GM, Czernichow S, Dugravot A, Batty GD, Kivimaki M, Singh-Manoux A. Metabolically healthy obesity and risk of mortality: does the definition of metabolic health matter? Diabetes Care. 2013;36(8):2294-2300. doi:10.2337/dc12-1654
Herman WH, Ye W, Griffin SJ, et al. Early detection and treatment of type 2 diabetes reduce cardiovascular morbidity and mortality: a simulation of the results of the Anglo-Danish-Dutch study of intensive treatment in people with screen-detected diabetes in primary care (ADDITION-Europe). Diabetes Care. 2015;38(8):1449-1455. doi:10.2337/dc14-2459
Le MH, Yeo YH, Cheung R, Wong VW, Nguyen MH. Ethnic influence on nonalcoholic fatty liver disease prevalence and lack of disease awareness in the United States, 2011-2016. J Intern Med. 2020;287(6):711-722. doi:10.1111/joim.13035
Sutin AR, Stephan Y, Terracciano A. Weight discrimination and risk of mortality. Psychol Sci. 2015;26(11):1803-1811. doi:10.1177/0956797615601103
Amy NK, Aalborg A, Lyons P, Keranen L. Barriers to routine gynecological cancer screening for White and African-American obese women. Int J Obes (Lond). 2006;30(1):147-155. doi:10.1038/sj.ijo.0803105
Kramer CK, Zinman B, Retnakaran R. Are metabolically healthy overweight and obesity benign conditions? A systematic review and meta-analysis. Ann Intern Med. 2013;159(11):758-769. doi:10.7326/0003-4819-159-11-201312030-00008

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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.
To become a member and have us answer YOUR questions, join today:
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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

New Barbell Medicine Hybrid 5K and 10K Run + Lift Programs

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Signal (pre-order)
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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

Resources:
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1. US Food and Drug Administration. FDA Briefing Document: Pharmacy Compounding Advisory Committee Meeting. July 23-24, 2026. Silver Spring, MD: FDA; 2026.
2. US Food and Drug Administration. FDA review of BPC-157-related bulk drug substances. PCAC Briefing Document. July 23-24, 2026. Media 193343. Accessed July 24, 2026. https://www.fda.gov/media/193343/download
3. US Food and Drug Administration. FDA review of TB-500-related bulk drug substances. PCAC Briefing Document. July 23-24, 2026. Media 193349.
4. US Food and Drug Administration. FDA review of KPV-, MOTS-c-, Semax-, Epitalon-, and Emideltide-related bulk drug substances. PCAC Briefing Documents. July 23-24, 2026.
5. US Food and Drug Administration. Questions for the Pharmacy Compounding Advisory Committee. July 23-24, 2026.
6. US Food and Drug Administration. Pharmacy Compounding Advisory Committee meeting roster. July 23-24, 2026. Media 193772.
7. US Food and Drug Administration. Pharmacy Compounding Advisory Committee meeting roster. 2022. Media 159040.
8. openFDA. FAERS adverse event reports for BPC-157. Accessed July 24, 2026. https://open.fda.gov
9. Pharmacy compounding; 503A bulk drug substances. 21 CFR §216.23 (2026).
10. Federal Food, Drug, and Cosmetic Act §503A, 21 USC §353a (pharmacy compounding).
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