Strong Medicine Questions and Answers

by Dr. Chris Hardy on December 1, 2016

Chris Hardy Strong Medicine Questions and Answers

This is the fifth and final post in a series of articles developed from Dr. Chris Hardy’s live presentation at Dragon Door’s Inaugural Health and Strength Conference. Click here to read the first article of the series. These questions were from the coaches, trainers, and fitness instructors in attendance.


Q: How do I measure HRV (heart rate variability) if I have eight people coming in for a group fitness class?

A: You would set this up with your clients beforehand. They would measure it first thing in the morning. In the back of Strong Medicine, I discuss how the optimum time to measure HRV is at first waking, before anything has an opportunity to fill the stress cup. This measurement will give them a baseline. Most HRV apps require two and a half minutes to measure and will use data from a chest strap like a Polar Bluetooth heart rate monitor. The app will determine the HRV as a number. It’s important to measure it first thing in the morning, because if you measure it throughout the day, even someone angering you in traffic will change it.

Measuring HRV is not perfect, but if you measure it the same time every day before anything else has effected your stress cup then it will be a good reference. It will also reflect if you’ve been up all night tossing and turning.


Q: I have a client who has a lap-band, so she’s only eating 200 calories a day. If she eats more she vomits yet she wants intense exercise. She’s stressed and thin but with a huge belly. How would we work with her if we can’t get her to eat more? Do we just take down the intensity?

A: First, it sounds like she’s protein deficient. And you won’t be able to workout with her—you can’t—it will hurt her. It’s like when people come to me and want antibiotics for a viral infection. Then, when I don’t prescribe the antibiotics, they just go to someone else who will. But you should not be training that person, because she could go off the rails in a second.

She’s protein deficient and malnourished. That large belly is basically a bunch of fluid because there’s so little protein in her bloodstream that an osmosis effect happens and draws water from the bloodstream, then it goes into the tissues. It’s called ascites, and patients will sometimes develop huge protuberant bellies. We see it happen in sub-Saharan Africa, and other places where people are malnourished. You need to say no, and she needs medical attention.


Q: We lead boot camps and have workouts on the board, what do you think about having our clients do their self reported health scale on the 1-5 range (will link to article) then adjust the workout accordingly?

A: Or they can monitor their own heart rates. This is also where you can use your creativity and find your own opportunities. You can stratify the workouts. Educate them to let them know that if they’re lower on their rating scale to be smart and that “this isn’t a punishment”. They need to know to be smart because they won’t do themselves any good by crushing themselves on that day—they’re just end up with a lot of cortisol. You’ve seen the ultra-skinny marathon runners that still have a little bit of a belly? It’s because of a cortisol response.


Q: You said that you have your clients measure their heart rates in the morning. My training classes usually take place at 8PM after they come from work and have done finished their day. How will the HRV measurement from the morning reflect how they are when they walk into my gym at 8PM?

A: It’s true that it isn’t perfect, and that’s the problem. But, as long as they’re not doing intense physical training before they get to you, if they measure their HRV in the morning, the biggest thing they will be affected by is sleep. Since HRV is the variability of the heart rate as measured on an app, it gives you an idea of where you were that morning. If your HRV is already low that morning, it will just get worse throughout the day. So, if they come in with a low HRV recorded in the morning, by the time they see you—especially if they have had other stresses during the day—then their HRV will be even lower.

HRV and Stress diagram

The morning measurement will give you a baseline, but that’s why you’ll also want to use the self-reporting scale. There’s too much that can happen during the day, and you’re trying to work with a consistent baseline. So, let’s say I usually run an “80” I’m picking an arbitrary number for my HRV, but that’s pretty high. But, this morning I measured my HRV and it was 62. When I come to train with you later that night I’ll tell you that my HRV was 62 this morning. Since I usually run in the 80s you would drop my workout down some. So in other words we are discounting what happened through the day unless a client did some other kind of training. It’s not a perfect system.


Q: What your favorite strategies for sleep? How do you feel about the different amounts of melatonin in supplements?

A: Sleep might be the same thing as attacking the circadian rhythm first. I hate to keep referring back to the book, but I do have a whole chapter on how to give your brain the right signals. So 2-3 hours before bedtime, no blue light from broad-spectrum sources. You can either use the goggles or my wife and I put yellow lights in the rooms where we spend our evening hours. We also follow basic sleep hygiene ideas—no electronics in the room. In the mornings we make sure to get bright, broad-spectrum light exposure, since most of us go to an office with poor lighting.

As for supplements, I am not a huge fan of melatonin, though I think it is very valuable for getting yourself back into another rhythm in the case of jet lag. The problem is most of the doses are supra-physiological. The pineal gland in the brain actually secretes melatonin on a pulse, about every 40 minutes since it has a very short half-life. Your body metabolizes melatonin supplements quickly, so it may help you fall asleep, but then you’re going to be back up again if you haven’t fixed your circadian rhythm. And it may also suppress your endogenous (internal) melatonin secretion.


Q: On Saturday and Sunday, 25-30 people come in to our gym for group classes. Either myself or the other trainer will greet the people as they are coming in and ask them how they are doing and how they are feeling. If they come in and say that they slept badly, just came home from an intense two-day conference, or they are still sore from working out, then we will then tell them that we will scale the workout of the day. We put up the workout and a scaled version in terms of volume or intensity and say that if we spoke to you and said you should do the scaled version, we can now train 20-30 people together.

A: I love it, but would say from a psychological point of view I would have them self-label.

Q: That was my follow up question. This is a physical/psychological assessment based on how they feel about today themselves that day, etc.

A: If a client comes in and says that they are feeling kind of cruddy, and then you say, “well we are going to do this to you” that takes some of the control from them. Instead you could have them self-label and say “I’m a 3 right now”. Since they put themselves in that category, it will be easier for them to understand that it’s not a punishment. They will just be doing the #3 workout today. It’s part of the psychology of getting them to buy in more because they have self-labeled.


Q: My question is goes back to using heart rate. How would you use the heart rate protocol with someone on beta-blockers?

A: That can be very inconvenient! Beta-blockers basically stick a wrench in the system, and prevent the heart rate from going up. It depends on why the client is on a beta-blocker—and if it is for arrhythmia then you don’t want to mess with it. But if someone is on a beta-blocker because their doctor is trying to use it as an inappropriate way to control high blood pressure, then you might suggest that they ask their doctor about alternatives. When someone is on beta-blockers, they will not be able to get their heart rate up, so rate of perceived exertion may be a better indicator for them.


Q: Melatonin was already discussed as a supplement for sleep, but how would you say performance supplements like pre-workout or protein supplements would affect allostatic load?

A: That’s a great question and, they do affect the allostatic load. It goes back to the idea of feeding your activity. We need the proper amount of protein so that amino acids hit our anabolic pathways—mTOR, the anabolic pathway where certain branched chain amino acids will hit. It can give the body fuel for activity. You need to fuel your body and give it the precursors of what it needs—whole regular food is always the best, but that is not always possible. So, supplementing something like whey protein, or a post-workout combination of protein and some glucose sources can work well, but be sure to tailor it to your activity. Do you really need to load up with a huge serving of starch or glucose for strength training? Probably not. You’ll want to use amino acids instead.

Q: But in regards to pre-workout energy supplements, I’ve tried some that just made me feel extremely crazy and full of false energy…

A: Honestly, if you are going to do one, the supplement I think is best for pre-workout is creatine. It hits the phosphogen energy pathway. But I am not a fan of the supplements that “jack up the nervous system” they can work for younger people, but in the older population it can affect the stress cup.


Q: What are your recommendations for determining optimal heart rates for training and interval training? Do you have any recommendations for estimating or determining maximum heart rate? What if someone is on a beta-blocker? Is a VO2Max test, a stress test, or a simple calculation the best?

A: It depends on your client. If you are working with an elite athlete, then you should probably do one of the more clinical assessments. This is because we all know that the samples for calculating max heart rate are estimates and they’re for a general population. They aren’t necessarily appropriate for everyone because they can be underestimated. If you used the formula on an athletic 50-year-old, it may underestimate their max heart rate. Some of the formulas are better than others—certainly better than 220 minus age.


Q: When working with individuals who are nurses, police officers, fire fighters, and other shift workers, how do you help them make improve the sleep they are getting?

A: Shift work is actually classified as a carcinogen by large governing agencies. But they have done studies with shift workers and found that their environmental clues are the most important. Your circadian system is free running—they’ve done studies in caves in isolation—and will advance itself without external cues. Another study with police officers and nurses exposed them to maximum bright lights during their shifts at night—which was their mornings. Even though they are coming to their shift at night, they should get maximum bright light exposure. When they are coming home, they should use amber glasses or something to block out blue spectrum light. When they sleep, blackout curtains can make their environment as dark as possible. Are they getting perfect sleep? No, but these environmental cues can make a big improvement.



Chris Hardy, D.O., M.P.H., CSCS, is the author of Strong Medicine: How to Conquer Chronic Disease and Achieve Your Full Genetic Potential. He is a public-health physician, personal trainer, mountain biker, rock climber and guitarist. His passion is communicating science-based lifestyle information and recommendations in an easy-to-understand manner to empower the public in the fight against preventable chronic disease.



HRV and the Self-Rated Health Scale

by Dr. Chris Hardy on September 8, 2016

HRV and Self-Rated Health

This is the fourth in a series of articles developed from Dr. Chris Hardy’s live presentation at Dragon Door’s Inaugural Health and Strength Conference. Click here to read the first article of the series.

In the previous posts of this series we were estimating the size of the stress cup. But, there’s a more reliable way to measure it. We’ll use the interrelationship of the brain, the cardiovascular system, and the musculo-skeletal system for another window into the stress cup. The first window is heart rate variability, the beat to beat variation of the heart rate.

We will use HRV as a window into the autonomic nervous system and how it relates to the heart. This will show us the stress load on a given day. On a high stress day, the sympathetic nervous system is dominant—the fight or flight system will drive the heart with a machine-like precision (low variability). This indicates a state of allostatic overload, poor health, and an overflowing stress cup.

Caption: In this chart, the beats are the same distance apart. That machine-like precision is not good. It's a sign of bad health and stress to the system.

In this chart, the beats are the same distance apart. That machine-like precision is not good. It’s a sign of bad health and stress to the system.

Now, in the normal state—when you have good readiness and a manageable stress cup—you’re in parasympathetic dominance and will have that good, high variability.

In this chart, the time between each beat is slightly different. That's how a healthy heart and nervous system actually works. It's imperceptible, but if you measure it accurately you'll see the variability between beats.

In this chart, the time between each beat is slightly different. That’s how a healthy heart and nervous system actually works. It’s imperceptible, but if you measure it accurately you’ll see the variability between beats.

There are several apps that calculate HRV and will give you a score. There’s also a section in Strong Medicine that shows you how to do that in training. It’s a very simplistic approach, but its good for our purposes.

Joel Jamieson, a Seattle area MMA trainer uses HRV in training in a very sophisticated way so definitely look him up if you want to learn even more. But, I prefer a more simplistic and intuitive approach. But, before I show you my approach I want to quickly review another simple way to assess the state of the nervous system.

MiniHomuncDiagA homunculus is a representation of what we would look like if we were physically configured according to the proportion of brain required to operate our body parts. Do you see how big the hands are? A huge portion of the brain is involved with the sensation and motor control of the hands. For example, grip training has a huge impact on the nervous system. Grip strength is also a good way to tell the status of the nervous system. This idea has been used in the former Eastern bloc countries for a long time, and Charles Poliquin wrote about it pretty recently.

Charles Poliquin’s protocol starts with recording a baseline using a Dynamometer. You can get them pretty cheaply on Amazon. Be sure to measure grip strength in kilos when you (or your client, if you are training others) are feeling good. Then on the morning of training, measure it again, and if you drop 2kg, then you may want to reconsider training. If you drop 4kg from the baseline, then you might even consider taking a rest day. it’s a simple way to do it. Do you have to continually measure grip strength or HRV with all your clients? No, that would be ridiculous, fortunately there’s another method.


The Self-Rated Health Scale

In terms of predictors of who will develop chronic diseases, and who is at risk of dying, what is the best marker to use? We’ve used all kinds of blood tests, and every other imaginable test, but the best predictor we’ve found is to ask this one question:

“In general, would you say your health is on a one to five scale? With one being the best and five being the worst?”

Believe it or not, that self-rated health question was more accurate than any medical test in predicting if someone would develop a chronic disease in the next 5-10 years. There’s a new area of neuroscience intensely studying interoception, the brain’s subconscious awareness of our organ systems. Many of you who read Strong Medicine know that our gut and intestinal tract has just as many neurons and nerve cells as the spinal cord. Some even call it the “second brain”. When you have a gut feeling about something or butterflies in your stomach, that’s the brain actually monitoring the state of our organ systems on a subconscious level. It can also induce stress responses, which is why diabetics have an on-going low-level “fight or flight response” due to this interceptive process monitoring the state of the internal organs and immune system. The brain knows something bad is happening and that we need to be on alert. This system also gives you an intuitive sense of how you are doing.

A new study came out about HRV and focused on measuring what correlated best to Self-Rated Health. We already know the question predicts disease very well—they measured every blood test, cholesterol, inflammatory monitors, and many other tests, but what correlated best with Self-Graded Health was heart rate variability. People with high HRV (good) usually said that their health was about 4-5 on the scale (the highest health scores). So, how you intuitively feel physically and mentally is very predictive of your stress cup. This is why an intuitive approach to a given day’s training could be very valid. Even though there are some really sophisticated tools such as the Recovery Stress Questionnaire For Athletes—which is a validated tool—I guarantee that none of your clients will want to sit down and answer 76 questions.

If you’re training elite athletes, it’s great, but it is not practical for those of us in the trenches. My next suggestion is not validated, and I haven’t tried it out—so you can be the test group—what if we replaced the Self-Rated Health question with the following:

“In general, would you say your readiness to train is… excellent, very good, good, fair, or poor?”

I would also suggest verifying it by testing grip strength and heart rate variability first before asking the question to see how they correlate. Over time it will help them get an intuitive sense of how they are and fine tune their conscious awareness of interoception. So, when they give you a rating, you can also look at the data (grip strength and HRV), and over time this will be a pretty good window into how they’re doing.


Getting Your Clients Onboard with Smart Programming and Recovery

How do you convince your client that this stuff really matters? It’s essential. If you want to train hard, you’ve got to recover harder. You need to tell your clients that they need to reduce their stress cup and earn the ability to train hard. The results they want will only happen with a proper balance of training and recovery.

The first thing they have to fix is their sleep, and there’s a whole chapter in Strong Medicine about doing that. Stress management, meditation, yoga, whatever you want to do is fantastic. Massage and acupuncture are unbelievable for helping to reduce stress and enhance the parasympathetic nervous system. If you like qigong, tai chi, all that stuff is fantastic as well to achieve the same goal.

Obviously, cleaning up the nutrition is a whole lecture into itself. As is feeding your activity levels. If you are going to crush yourself with high intensity training, you need to replace that muscle glycogen. If you’re only doing a walking and strength-based program, you can go very low carb and be fine. But if you want to push that anaerobic threshold, then you will need to feed that activity or you will overtrain.



First, estimate their stress cup size. Then, estimate what is filling it today, since it will be different that what fills it tomorrow. Then, we will prescribe an appropriate exercise volume and intensity—and that’s what you guys as trainers know how to do well already. Now, you have the extra information to help you adjust the sets and reps, intervals and modalities. And while you don’t have to assess the stress cup every time you train your clients, I think you should always ask the self-report scale question and then prescribe the appropriate amount of training.

I don’t think you need to use HRV on the average client. But, if you are working with elite athletes, you will need to cover all those bases. The most important thing for everyone is to always emphasize the importance of recovery.

Now, using this approach is very simple, and I provided the scientific foundation for how we came up with this very easy system. If you train someone this way, they will meet their goals. It will be sustainable, unlike those three or four weeks crash diets and radical exercise routines. With this method, every New Year, instead of starting over with a resolution, they can just continue building on the success of the previous year. This is just a framework, so use your expertise as a trainer to customize your programs.

The final post in this series will be the best of the question and answer portion of Dr. Chris Hardy’s presentation.



Chris Hardy, D.O., M.P.H., CSCS, is the author of Strong Medicine: How to Conquer Chronic Disease and Achieve Your Full Genetic Potential. He is a public-health physician, personal trainer, mountain biker, rock climber and guitarist. His passion is communicating science-based lifestyle information and recommendations in an easy-to-understand manner to empower the public in the fight against preventable chronic disease.


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