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Matt Stranberg, MS, RDN, LDN, CSSD, CSCS is a licensed registered dietitian nutritionist and certified strength and conditioning specialist. He is the dietitian and exercise science advisor for the Walden GOALS program and the Sports Nutrition and Exercise Science Specialist for Walden Behavioral Care. Before working at Walden, Matt devoted the early part of his career to refining the art and science of training elite collegiate and professional athletes. In graduate school, he developed expertise in nutrition, behavior change and eating disorders. Matt now devotes his practice to translating nutrition and exercise science into practical solutions. As Walden's Sports Nutrition and Exercise Science Specialist, Matt is known for his dedication to educating and empowering patients of all backgrounds to facilitate a full and meaningful recovery from disordered eating and problematic physical activity. Matt holds a B.S. degree in Kinesiology from the Honors College at The University of Massachusetts Amherst, a master's degree in Applied Exercise Physiology and Nutrition from Columbia University and was a dietetic intern at Boston's Brigham and Women's Hospital.
We've interviewed you before back in ERD 37 where we talked about more general nutrition questions ranging from the nutritional training of health professionals to your own personal diet. But we didn't really focus on your main specialty: recovery from disordered eating and problematic physical activity.
Q. Can you tell us a bit about what led you to specialize in that area and your experience with regard to it?
Given the specificity of this niche, many people often assume that this was my life’s calling. My entrance into the field, however, was more so an idea that came to me during the inevitable existential crisis many students face upon completing graduate school. Towards the end of my dietetic internship training program at Brigham and Women's hospital, I began to feel inspired.
During my experiences as a strength and conditioning coach, nutritionist, and counselor, I had always felt that nutrition, physical activity, and psychology were inherently intertwined. My experiences in the field, as well as my own personal struggles with disordered eating, eating disorder behaviors, compulsive exercise and body image issues, further reinforced these links. Although I was able to recover, during my time as a coach, I observed I was not alone. Many teams I worked for presented a multitude of similar problems related to mental health. Countless athletes I encountered were suffering in silence and had nowhere to turn for help. After reflecting on these experiences, I became determined to start working on solutions to solve this problem.
Based on my skills, research, and years working in the field, I was confident I could collaborate with other professionals to create a groundbreaking program that offered evidence-based treatment to an underserved population. The CEO and executive team at Walden Behavioral Care recognized and embraced this opportunity. With the help of my colleagues, we started the GOALS program. This ultimately started my journey to further developing my specialty position helping athletes and non-athletes alike heal their relationship with food, body image, and physical activity. Now that I have been in this line of work for over 5 years, I feel like this has become an actual life-calling. I never imagined working in a field that is so rich with learning, challenges and personal fulfillment while also making a great impact. I am excited to see how this field continues to evolve over time.
Q. What exactly is "disordered" eating and "problematic" physical activity? And do these manifest differently in athletes and non-athletes?
Before discussing these topics in-depth, it is important to note that the following sections pertain to the demographics I work with in the United States. Research and experience have shown that the understanding, cause, treatment, and experience of mental illness cannot be separated from culture and its related beliefs and expectations. Attempting to generalize these concepts is often ineffective and possibly iatrogenic. Disorders related to food, body image, and physical activity operate within these constraints, and I would advise against any attempts to apply these approaches or ideas to other contexts.
Now that I have provided my disclaimers against the potential dangers of proceeding without knowledge of these assumptions, I can safely state that there is one observation that remains consistent throughout my work and can be generalized. Problems involving eating, body image, and physical activity can impair one's mental, physical, social, and occupational wellbeing to varying degrees. These problems do not discriminate and can afflict anyone regardless of age, race, gender, sexual orientation, sport, socioeconomic class, and so on. Additionally, these disorders sometimes present as a psychiatric illness, and in other instances they present more as a maladaptive coping skill. They often also exist with other comorbid conditions such as anxiety disorders, depression, PTSD, and obsessive-compulsive disorder and frequently influence each other. Eating disorders, for instance, can be a means to cope with symptoms of depression, anxiety, and PTSD and/or are further intensified by obsessive-compulsive impulses. Temperament and personality likewise play a huge role. From my experience, it is rare to meet someone who struggles with an eating disorder or problematic physical activity in isolation. For the most part, in the United States, eating disorders are expressed as a combination of psychiatric illness and maladaptive coping. Irrespective of an official diagnosis or background, distress in these areas are often why people seek my help.
From a nutritional standpoint, disordered eating and eating disorder behaviors can describe a wide range of potential conditions that exist on a spectrum of severity. Disordered eating often involves elements of behaviors, patterns, and mindsets that could potentially become a diagnosable eating disorder but do not necessarily meet clinical criteria with respect to severity and related impairment. Examples can include, but are not limited to, rigidity around food selection, distress related to the thought of eating particular foods or potential weight gain, preoccupation with food, weight and body image that negatively impacts quality of life, a feeling of loss of control around food, including compulsive eating habits, as well as using exercise, food restriction, fasting, or purging to ameliorate distress related to consuming certain types or amounts of food.
The line between disordered eating and eating disorder behaviors can be blurry at times, as an individual can experience numerous negative side effects without meeting the criteria for an official eating disorder diagnosis. Another challenging facet of my work involves confronting the reality that many of the previously mentioned behaviors and mindsets are ingrained into the culture of the United States and internalized by both patients and medical providers. Given the time constraints of doctor visits, the dominant weight management paradigm, and lack of education regarding eating disorders, many providers will encourage restriction and congratulate weight loss under the assumption it will improve health, without ever inquiring about the patient's methods or intentions until serious problems begin to occur.
Left unchecked, some manifestations of these behaviors and mindsets might eventually worsen and meet the DSM-V diagnostic criteria for an eating disorder. Examples might include, but are not limited to, Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. Most patients I see fall into a more nebulous category: Other specified feeding or eating disorder (OSFED). This diagnosis refers to eating disorders that display some of the characteristics of the disorders, but do not fit the full criteria of these conditions. Overall, these diagnoses can help us understand and describe potential archetypal patterns and related treatment models, but it is my job to approach each patient as a unique individual. The ensuing treatment is tailored to the individual and involves working to understand their life, help navigate ambivalence, and potentially shift motivation for change.
With respect to physical activity, the aforementioned guidelines, constraints, and treatment goals remain. Unlike eating disorders, the DSM-V is yet to develop diagnoses related to problematic physical activity but there are whisperings that criteria for various behavioral addictions detailing exercise are being discussed for future editions. Similar to nutrition concerns, it is often difficult for clinicians and patients alike to discern the difference between therapeutic physical activity and problematic physical activity. Additionally, pathology in this area can present as a psychiatric illness, a maladaptive coping skill or a combination of the two. To understand the various possible pathologies, it is important to first understand the difference between physical activity and exercise.
Physical activity is any movement involving skeletal muscle and is not necessarily planned, structured, repetitive, and intended to influence any particular fitness qualities. Examples might include chores around the house, walking to the store, or enjoying a leisurely bike ride. Exercise, on the other hand, is a subset of physical activity and typically refers to the systematic performance or execution of planned physical movements or activities intended to influence particular fitness qualities. Both physical activity and exercise can be therapeutic when they help maintain or improve the overall quality of life, and I typically use physical activity to broadly describe both activities. With respect to clinical application, differentiation between movements is needed. Over time, these activities can become problematic when they are a manifestation of psychiatric illness and/or are used as a maladaptive coping skill to manage uncomfortable thoughts, feelings, emotions, and sensations. When activity or exercise is expressed in this manner, it typically begins to interfere with overall wellness and wellbeing.
Research and clinician experience indicate that problematic physical activity or exercise typically develops in four archetypal variations; exercise dependence, compulsive exercise, obligatory exercise, and excessive exercise. Exercise dependence conceptualizes pathological exercise as a cluster of cognitive, behavioral, and physiological symptoms, similar to those of substance dependence disorders. Similar to other substance use or behavioral addictions, exercise dependence typically involves the following themes: 1) Establishing tolerance, 2) Experiencing withdrawal 3) Intention Effects (i.e., exercising more or for longer than was intended) 4) Lack of Control 5) Salience 6) Reduction in Other Activities and 7) Continuance (i.e., persistent exercise despite negative physical and/or psychological consequences. As with other forms of dependence, it can vary in intensity and how it affects the patient's life. Although these themes can present in eating disorder patients, the research often indicates that compulsive exercise is often more relevant to eating disorder pathology.
Compulsive exercise is characterized by persistent and excessive exercise, performed to relieve anxiety or distress associated with perceived negative consequences when abstaining from the behavior. Unlike dependence, these patterns are compulsive and do not necessarily lead to reward or pleasure. The nature of the activity often presents with five overall themes: 1) Avoidance and rule-driven behavior, 2) Weight control exercise, 3) Mood improvement, 4) Lack of exercise enjoyment, and 5) Exercise rigidity. An important distinction for eating disorder cases compared to non-eating disorder compulsivity is that starvation can sometimes induce a compulsive hyperactivity state that is unique to individuals suffering from prolonged caloric restriction. This phenomenon is commonly observed in malnourished rats, as well as human case studies, such as the Minnesota Starvation study in 1944. Interestingly enough, prolonged caloric restriction can also increase OCD symptoms and related psychopathology. Evolutionarily speaking, these manifestations make sense as famished individuals would most likely benefit from increased attention directed towards finding and consuming food. Unfortunately, the eating disorder pathology typically associated with this behavior enhances the obsession with food and compulsive movement but paradoxically discourages the food intake required to survive. In the United States, all of these variations of compulsions can sometimes masquerade as dedication, passion, or a lifestyle choice, but are nonetheless harmful.
In addition to dependence and compulsion, another variation that often flies under the radar are features that appear obligatory in nature. Obligatory exercise is often characterized by obligatory attitudes toward exercise which might entail exercising despite physical injury or illness, rigid exercise patterns, disengaging from social or occupational activities, as well as feelings of guilt or anxiousness when not exercising. The nature of these behaviors can be especially hard to recognize for practitioners and patients because they are sometimes interwoven into sport and fitness culture. This is exemplified by adages like "no pain no gain," or "no days off," and attitudes that promote the "win at all cost mentality." Due to the high value Western societies typically place on the capacity to delay gratification and inhibit public displays of destructive emotions and impulses, problems linked with disorders of over-control and related obligatory behaviors, have received little attention or are regularly misunderstood. Many of these individuals who engage in obligatory behaviors are considered highly successful by others, even if they suffer silently and alone.
Similarly, excessive exercise can also be hard to discern, as what may be excessive for one individual may be therapeutic for another. To help determine what might be deemed excessive, I will analyze the patient's allostatic load in relation to their recovery capacity. Although there is no official consensus regarding criteria, I typically consider exercise to be excessive if a patient is regularly exceeding their capacity to recover outside of a planned overreaching phase, as this is not therapeutic and involves inappropriate risk exposure.
Overall, patients typically present with a combination of the previously mentioned manifestations. Many practitioners, including myself, often employ a battery of tests such as the Exercise Dependence Scale, Compulsive Exercise Test, and comprehensive interviews to help elucidate the nature of the patient's patterns and beliefs. Regardless of the variations, my overarching objective tends to focus on collaborating with the patient to understand the meaning and function behind the behaviors. The individual's psychological relationship to exercise, such as the degree of distress associated with fluctuations in physical activity routine, is often more informative than the quantity of exercise in predicting negative outcomes, eating disorder pathology, and recovery. Furthermore, understanding the beliefs and intentions are key to helping patients and modifying maladaptive components which helps navigate ambivalence and facilitate a shift away from problematic patterns and beliefs to more therapeutic expressions.
In relation to athletes versus non-athletes, the main differences are with respect to identity and understanding the unique factors that relate to sport. All of the previously mentioned manifestations can occur in athletes, but a critical consideration is that athletes must engage in exercise to be able to participate in their sport. Additionally, it can be hard to navigate concepts like salience, as well as obligatory and excessive exercise as overreaching and extreme dedication is sometimes needed for advanced athletes to achieve at a high level. Considering these nuances, my work with athletes typically entails more intensive interviewing and analyses of costs and benefits while managing the interplay between a multitude of complex biopsychosocial interactions. These challenges are one of the main reasons why I find the field so rewarding. Working with high-level athletes in these areas often pushes both of us to our limits and culminates in a deeply meaningful positive impact.
In 2014, the International Olympic Committee released a consensus statement updating a previous 2005 consensus statement on the "female athlete triad". The 2014 statement updates the term to "relative energy deficiency in sport", or RED-S for short.
RED-S is a new movement from a group of researchers that are seeking to broaden the understanding and criteria for the condition previously known as "The Female Athlete Triad." The Female Athlete Triad describes the interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density. The research in the past indicated that it is relatively common among young women participating in sports.
The IOC chose to update its terminology because "The Female Athlete Triad," did not include males and failed to describe the wide range of impaired physiological functioning caused by low energy availability. Another key feature, not previously stressed, was the researcher's emphasis on highlighting the bidirectional relationship of psychological factors and low energy availability. Overall, I consider RED-S to be a monumental advancement and a critical concept for educational purposes with both my athletes and non-athletes alike.
RED-S is something that track athlete Mary Cain says women and girls are particularly susceptible to in a recent New York Times piece. She states that this is due to a mix of inappropriate weight standards being forced onto female athletes coupled with cultural issues ranging from a lack of certified sports psychologists, nutritionists, and women being involved with training to the use of public weight shaming.
Q. Can you speak to the unique cultural challenges that female athletes face with regard to weight, why female athletes are training predominantly under male coaches, and whether things are changing?
Both male and female athletes alike, are 2-3 times more likely than non-athletes to develop an eating disorder. This elevated risk can be attributed to a wide variety of factors including, but not limited to, strenuous training demands, stressful competition, nutrition, and training misinformation, normalization of disordered practices, as well an emphasis on weight management, and physique ideals. Attributes that can help athletes succeed in sport, such as drive, perfectionism, increased pain tolerance, dedication, and commitment can also help an athlete reinforce an eating disorder. Unlike men, however, women often face a host of additional unique risks related to female-specific nutrition, body image, identity, and related cultural challenges within the United States.
The United States is rife with disordered attitudes towards health and performance. The messages regarding food, exercise and body shapes and sizes are often characterized by confusing, neurotic, paradoxical, moralistic attitudes, which set the stage for disordered eating and problematic physical activity. For a long time, women were the primary target of these forces, so much so, that researchers in the 1980s have coined the term "normative discontent" to describe the widespread negative body image reported by women in the United States. Take a moment to read Cosmo or Fit Tea ads on Instagram and you can easily see why attitudes and beliefs regarding food and exercise continue to remain equally as confusing and disturbed. These facets of diet culture now pervade every level of sports culture. Combined with the hypercompetitive world of sports and marketing, and the result has been the perfect storm for dysfunction. One of the major catalysts for these trends is the collection of societal ideals, manufactured by companies and the media, that specifically target women.
Over the last couple of decades, marketers and the media have consistently helped shape our understanding of sports and athletes. After Title XI, women's sports emerged as a huge market and the commercial forces that helped drive the diet industry were ready to transform these female athletes into marketable brands and products. Financial motives encouraged companies to join forces with professional sports to help advertise concepts to the public. To sell sports brands, images and messages were propagated through every channel with the intent of grabbing your attention and cultivating a particular theme. These campaigns tended to highlight athlete bodies and unrealistic ideals that are the product of performance-enhancing drugs, genetic anomalies, possible disordered behaviors and, in some cases, photo editing. This helped shape norms which associated outlier bodies with athletic performance. In turn, these ideas have merged with the "athlete identity" and related avenues for marketing deals, fame, and financial success. These pathological developments largely occurred in parallel with the recent economic cultural evolution. The artificial mythos of the American athlete synchronized well with the messages of 1980's America, dividing the world into "deserving winners and undeserving losers." The story of the mythic, competitive, heroic, larger-than-life individual who rises to the position of CEO in the business world is regularly transposed onto women entering professional sports culture. Like fancy watches, suits, business cards, and expensive cars that serve to signal financial success; lean, muscular bodies have been promoted as a testament to the athlete's individual sacrifice, asceticism, grit, determination, and dedication to succeed, no matter the cost. Similar to the purported "American Dream," marketers typically chose to omit the critical role genetics, luck and resources played in the "heroine's success." All of these overarching narrative changes produced a troubling emerging world view. When things don't go as planned, instead of understanding that lack of success can involve countless uncontrollable variables, individuals engrossed in this paradigm instead tend to internalize the failure and conceptualize the situation as a reflection of their own shortcomings. This includes struggles to fit an aesthetic ideal, as this ethos often conflates body esteem, self-esteem, and athlete identity.
These narratives and images colonized our minds, and eventually seeped into the unconscious of the populous. When women enter my office, they often reference Instagram photos and magazine covers of lean muscular athletes as the ideals they aspire to embody. The majority of my life, well-defined abs for women was rarely discussed but due to the infectious marketing of CrossFit and the professional sports that followed suit, almost every female athlete I work with nowadays has come to associate defined abs with performance. It's been shocking to see the emergence of these phenomena and the extreme amounts of damage it's inflicted on women who strive for these types of bodies. Many of the athletes I interview share their stories explaining how their strategies for athletic success instead resulted in under-fueling, over-exercising, permanent bone disorders, and infertility.
To complicate matters further, this dysfunctional sports environment is further reinforced by trends that leverage female sexuality for personal and financial gain. Sex sells, and companies like Sports Illustrated and movements like CrossFit know that female athletes can be used as a commodity to sell the athlete's brand and affiliated products. Female athletes are aware of this Faustian bargain and know that selling a purported societal ideal might help extend their career and finance their retirement. Even athletes that promote themselves as spokespeople for female empowerment often can't resist the allure, and frequently use a lean physique and sexual prowess to cash-in during their five-minutes of fame. The secret no one shares, however, is that a great cost can be incurred both with respect to performance and health. This is especially true when these body ideals are the product of disordered eating, pathological exercise, and drugs.
In addition to the societal pressures for thin, lean, muscular bodies, another problematic feature of female sports culture, are the mismatches between training and diet programs and the realities of female biology. A lot of ruthless, oppressive, old-school methods and mindsets employed by authoritarian societies, such as Soviet Russia and its various satellite states, continue to dominate various sports such as track and field, dance, and gymnastics. These systems employed neo-Social Darwinian "meat grinder" programs which push hundreds of athletes into the grinder with the hopes of producing a few "fit" champions; casualties be damned. For many, choosing the right parents and drugs were the key to surviving these programs, but drug-free imitators nowadays, pay a steep price. Due to the emphasis on competition, these systems and endemic drug use remain today. When problems occur, women seek guidance from healthcare and from coaches, and are often treated like "small men" despite exhibiting distinctly different biological makeups. Similar to Mary Cain, I have heard countless athletes recall their coaches telling them that "lighter equals faster," or "losing your period means you are training hard," while also being subjected to exercise and diets as punishment for not reaching a particular performance standard. While these approaches might produce short-term results, they are often disastrous for most athletes in the long term. The methods and low body fat percentages achievable by genetic outliers, drugs, and oppressive authoritarian coaching cultures, exposes a lot of women to menstrual dysfunction and RED-S. In turn, athletes like Mary Cain often feel the pressure to sacrifice their health for a chance to win the coach's approval and slot on the roster.
All of the factors listed above typically culminate with a double-bind predicament for women in all areas of sport. Societal ideals for thin, "toned bodies" often conflict with performance demands needed to excel in the sport. Extreme pressure to perform at sometimes unrealistic levels are often juxtaposed with societal pressures to successfully navigate the stress of being a student-athlete while achieving perfect work-life balance on the path to self-actualization. These contradictions and intense burdens across all fronts can harm both mental and physical health and significantly increase the risk for the mental and physical disorders I see in my practice.
As for why female athletes are training predominantly under male coaches, I cannot state an answer with confidence since I am not a true expert in this area. I would speculate though that coaches who reach these positions are either deemed "most component" by the organization that employs them and/or, obtain the position through connections. Sports organizations are tight-knit communities and typically operate with a tribal mindset. From my experience, connections and networking play a critical role in hiring. Like often hires like, and by that extension males often hire males and athletic directors are often men. I have not analyzed the trends in-depth, but some theorists have suggested that Title XI ironically played a huge role in the process. After Title XI passed, there was a significant increase in funding for women's sports, which subsequently increased salaries for coaches. This resulted in more men applying for said jobs. Coupled with the unconscious cultural biases portrayed in movies and media that tend to portray men as natural leaders, and women as "overly emotional," and we can begin to see why patterns in business and politics would soon replicate in the female sports arena.
In relation to cultural change, I think the work of Mary Cain, Joey Julius and other athletes speaking out against eating disorders have increased overall awareness and helped the movement gain momentum. I am hopeful that these stories will inspire others to speak up and incite significant reforms. Unfortunately, I think we have a long way to go as many of these issues are probably a side effect related to deeper more systemic issues like the pervasive internalized fatphobic, diet centric culture of the United States as well as the pressures of the hyper-competitive, billion-dollar industry of professional sports. As evidenced by controversies surrounding concussions, sexual abuse, domestic violence, substance abuse, and eating disorders, companies like Nike, and organizations like the NFL and NBA typically view and treat their athletes like commodities. They have often gone to extreme lengths to suppress these issues and keep the public in the dark while promoting a "win at all cost attitude" both on and off the field. The problems related to RED-S and eating disorders are ultimately symptoms of a much greater issue that plagues our sports culture and the United States as a whole. It will take a lot more work, over many years to create and sustain widespread cultural changes both in the United States and in sport.
Q. Finally, what's one thing you'd like someone living with problematic physical activity or disordered eating to know?
As previously discussed, in the United States, attitudes regarding eating and physical activity are often disordered and confusing. Nutrition and physical activity are typically conceptualized by laypeople and clinicians alike in an overly reductionist manner focusing on nutrients, biomarkers, weight, and other quantitative values that have been associated with a myopic distorted conception of health and wellbeing. Unfortunately, both patients and providers commonly don't understand how to appropriately interpret these data points in a meaningful way, and when people attempt to seek help, many professionals are woefully unprepared to provide adequate holistic care. To make matters worse, food companies have dominated the research literature, distorting studies to promote particular views that have fractured the medical community and the public's understanding of nutrition. Every day a journalist will publish a new story proclaiming the health benefits or dangers of a particular food group and completely flip-flop the next week. Additionally, opportunistic marketers and "wellness authorities" like Dr. Oz, are free to readily exploit unsuspecting customers. The forces of pseudoscience have come to dominate the public discourse by pumping obscene amounts of misinformation into the mainstream. Unfortunately, as Alberto Brandolini once said, sometimes this feels like an uphill battle since "The amount of energy necessary to refute bullshit is an order of magnitude bigger than to produce it."
This lack of basic nutrition training, combined with misinformation, and insufficient education regarding interpreting research and combating conflicts of interests, probably accounts for a large number of patients in my office daily, who are perplexed by the conflicting nutrition recommendations they've heard over the years from various doctors throughout the system. Additionally, clinicians’ significant lack of eating disorder and problematic physical activity education combined with embedded diet culture also explains why so many of these cases fly under the radar or are ironically praised for the patient's "commitment to weight loss, exercise, and healthy eating." The consequences of these failures are considerable, because, in the end, culture is a more powerful tool in addressing disordered eating and physical activity than any medication, government regulation, or legal intervention. Nowhere in the multitude of messages and signals sent by popular culture and social institutions about eating is there any consensus about what eating or food is supposed to mean.
What does this all mean? It means that if you are struggling with your relationship with physical activity, eating, and body image, you are not alone. It is not a sign of a character flaw or moral defect. For many individuals, it is a natural reaction to an abnormal culture, devoid of healthy attitudes or appropriate resources. The good news, however, is that this environment is slowly beginning to change. Due to movements across the nation, and research-based publications like Examine.com, practitioners and activists are beginning to fight back against pseudoscience, misinformation, stigma, and ineffective approaches.
If you or someone you know might be struggling with their relationship with food, body image, or physical activity, do not despair. There is hope. Programs like Walden Behavioral Care and the athlete-specific GOALS program offers a wide range of services. Feel free to reach out if you are interested in learning more. I only wish you the best on your journey towards healing.
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Other Articles in Issue #64 (February 2020)
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Omega-3s may make mild cognitive impairment a little bit milder
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Deep Dive: Investigating the effects of folate and zinc on male fertility
While folate and zinc are essential for processes necessary for male fertility, it may be possible to have too much of a good thing.
Deep Dive: Elevated protein intake can benefit lean mass
People who resistance train got the biggest bang for the buck, but the benefit is less clear in other populations.
NERD Nulls: November–December 2019
Welcome to the first installment of NERD Nulls — a rapid-fire roundup of some nutritional studies that didn’t find a clear effect!