Thank you Thank you for that kind introduction. It really is That's not true. I'm not really none of it. The truth is that I'm local. I'm from Houston I'm always humbled when I get invited to speak here at Texas Heart and I was on faculty at Baylor and I'm really proud of all you've done for women's health and cardiovascular disease So I may have too many slides, but I'll go through to try and keep us on schedule What what I'd great what I'd like to do today is really describe the important in a relationship between diabetes and cardiovascular risk and Then utilize the ADA guidelines which really have overlap with some of the speakers earlier from dr. Taylor and dr. Varani as far as creating a multifaceted approach to cardiovascular risk in patients and women who have diabetes and Then spend some time about this issue of the new medications and integrating Antidiabetic agents with proven cardiovascular safety and efficacy into the management of the patients who have diabetes Which is really a remarkable step forward compared to where we were four or five years ago We would not say that right because we didn't have a lot of CV safety or efficacy data so we'll hit some of these highlights and go from there, but I thought I would frame it in a case and And then maybe I'll just take a poll and we'll come back to this at the end So this woman is a Margaret I think is the usual name We I had given shown this case before 56 year old woman who presents for routine care She has heart failure with reduced ejection fraction mildly reduce an EF of 40 percent Strong family history of heart disease, but she doesn't have typical obstructive coronary disease her angiogram Showed small vessel disease, but nothing to be fixed He has a ten-year history of type 2 diabetes and you recently started her on a DPP for inhibitor Saxagliptin an oral agent in addition to the metformin that she had been on for years As I mentioned she was diagnosed with heart failure with reduced ejection fraction type 2 diabetes hyperlipidemia and hypertension Which reminds us that type 2 diabetes rarely occurs in isolation. How are we spend a day? We know that there are lots of other Medicines I didn't list all the others for medications are Lysinopyrus 40 pervada law 12 and a half twice a day Metformin 1000 milligrams twice a day Saxagliptin then laxate faxing and atorvastatin at 40 Her exam she has occasional dyspnea with exertion on review of systems and some P. Deledema on occasion. She's 5 6 weighs 185 pounds her BMI is right is near 30 Her blood pressure is 142 over 85 or heart rate 62 exam is essentially unremarkable Lipids are shown there a 1c of 7.8 percent total cholesterol 150 LDL 55 in HDL of 50 in The rest of her labs are normal with an eGFR of 52. So there's a lot of things we could talk about I didn't include triglycerides, which I should have and we'll talk about that a little bit But we'll focus on the glucose issue So the a1c was just about a 7.8 percent So given Cynthia's Cynthia's existing type of diabetes Diagnosis and a diagnosis of reduced left ventricular ejection fraction. What changes would you suggest making on her regimen? Would you leave her alone? No changes. Would you increase the saxagliptin to 5 milligrams daily? Would you change the saxagliptin and replace it with galliburide and sphonia rea? Would you replace the saxagliptin with an sgl2 and hember empirical frozen or replace it with a glp1 receptor agonists? And then finally add insulin to her regimen. We realize that based on all the options we have available I could have made this like 20 20 things sixes enough, huh? Just to show hands anyone with one two three four five six Most people picked four but we had a few hands for almost all of them. We'll come back to that so regardless of how we spend our day job What clinical you know our specialty we know that the problems of diabetes continues to increase seemingly unabated, right? It's estimated that about 30 million or nearly 10 percent of Americans have diabetes It's really important for us to remember from a public health policy as a lot of people still don't Recognize they have diabetes so a large portion of people have unrecognized diabetes and that Knowledge is not shared proportionately among different ethnicities. So we definitely have to work on health disparities And by 2030 this province has continued to rise estimated at 55 million as the population continues to age and as obesity continues to increase We also know that Diabetes the importance of this and I'm probably only talking about type 2 diabetes Is that it's associated with the years of life loss, right? It's shortens life and is associated with increased more morbidity So an average of 50 year old person will live five or six years less if you have diabetes than if you don't have diabetes And we realize despite how we improved diabetes the cardiovascular disease still accounts for most years of life loss in diabetes Which is shown on this slide In the emerging risk factors collaboration paper where we see years of life loss on the y-axis and age on the left For men and for women and vascular deaths is this dark portion And we can still see that vascular deaths account for the majority of premature Years of life lost for both men and women and perhaps even greater in women As dr. Eunice told us and i'll go over in just a minute Now I did mention that we have seen improvements in what we're doing right all this Our efforts to address lifestyle our efforts at um increase awareness of heart disease We are making a difference and here on the left hand side We see patients with type 2 diabetes and we see total mortality as well as cardiovascular mortality We have patients with type 2 diabetes in blue. We have patients um match controls in red This is from a publication last year in the new england journal And we can see that over this time period from 1998 to 2014 that for both groups we're making improvements So this is good But what we see is that we still have this residual risk and this is what we're trying to close that those individuals with Diabetes still have increased risk despite our efforts to implement evidence-based Strategies to reduce their risk But this is a residual risk of diabetes Now diabetes is interesting because of these gender effects that we really don't understand right the impact of diabetes appears to be greater in women We know that in general right being a woman is protective from heart disease before you develop menopause right that there's this lag in the disease Once you in menopause this these numbers quickly catch up And women actually as we've heard before die more of heart disease in men because they quickly catch up And and there's a lot of them to develop heart disease But we've learned that diabetes attenuates this protective effect of female sex Further development of coronary heart disease So if you're a type 2 diabetes diabetic woman that you lose any protection that you had from being a woman And so that's very important lots of studies have shown this framing ham a lot of community studies I just highlight the Rancho Bernardo study which were diabetes had a 2.4 excess risk for coronary heart disease in men, but in women. That's around three and a half fold Mock heart infarction tends to occur earlier in women with diabetes and men with diabetes And as alluded to earlier those women who have diabetes have a higher mortality than men And then the framing ham heart study This is not limited only to the manifestation of coronary artery disease or a heart attack But also extends to different manifestations of cardiovascular disease and heart failure has been an area of a personal interest in as far as Research in diabetes seems to associate with a two-fold greater risk of heart failure in men But this is a five-fold greater risk in women And why this is the case we really don't know So when we see someone with diabetes as we saw our patient Cynthia Or someone who has probably primary prevention what we do We know that we have to be very aggressive about risk factor management in type 2 diabetes Blood pressure control lipid lowering therapy aspirin therapy and glucose control is what i'm going to describe And really focus on cardiovascular outcome studies I'm going to fly through some of this because we've heard about it earlier But they can't stress the importance of blood pressure control as a risk factor to be modified in general and particularly in individuals with diabetes So these are taken from the new ADA guidelines which reflect a little bit of what dr. Taylor said in the overall guidelines They're more harmonized So the guidelines say that we should blood pressure targets should be individualized through a shared decision making process addressing both risk benefits and patient preferences And so this is an important and a new line that was added to the ADA guidelines For individuals who have diabetes and hypertension who have higher cardiovascular risks So not all diabetes is equal when I was finishing my training There was a study from steve hafner from finland that said diabetes with a coronary heart disease risk equivalent Well, that's probably not true, right? There are different flavors of diabetes And depends on what are the risk factors you have and boy if you've had a heart attack or you have heart failure That's a really high risk group So we have so we do have to individualize even among people with type 2 diabetes And this is what dr. Varani was saying earlier is using risk scores or risk tools to help stratify So in people who have either existing atherosclerotic disease who have a 10 year risk greater than 15 percent In general blood pressure target less than 130 over 80 may be appropriate if you can get there safely The data here if you look at the clinical trials is a bit mixed because of the accord blood pressure study which specifically looked at type 2 diabetes and didn't show a statistically significant benefit although the Point estimate the reduction was kind of consistent with brandon's other studies have shown that Indeed, they're not so different. Maybe we can talk about that in Q&A if someone has questions, but and this is what's recommended 130 over 80 And people who are lower risk. We still can keep our goal of 140 overnighting assisted in the third bullet point A reminder that when we take care of patients with diabetes or hypertension in general that when someone comes in And they're really high and i'm sure you do this too as I warn them that the average person to get their Blood pressure control will need between two and three medications to get their blood pressure control Just so they won't get mad at me when I start giving them a bunch of pills If they're really high initiation of two drugs or a single combination pill is recommended if they're greater than 160 over 100 Multidrug therapy is generally required And in patients who have type 2 diabetes and micro ovuminuria, this is where we start thinking well Maybe there is a preference to medicines and an ace or an ARB is recommended as first-line therapy After that we can use size i diuretics or calcium channel blockers And then I think as was mentioned earlier that mineral oil quarter cord receptor antagonists Can be considered in patients not meeting blood pressure targets who are on three anti-hypertensive medications So spironolactone should be a choice if we're having trouble Getting that as long as we are cautious about measuring potassium and their candidates based on their renal function Dr. Rodney talked about this a little bit more, but we remember the atherogenic Dislipidemia of diabetes, which is usually characterized by Relatively normal or maybe mildly increased LDL, but a different type of LDL this small dense LDL, which is more atherogenic This dyslipidemia associated with metabolic syndrome insulin resistance is also characterized by low HDL As well as elevated triglycerides and those really two components are very can be modified with Lifestyle modification diet and exercise We're going to come back to that and really it's again the same issue That we talked about with blood pressure is really focusing on what type of risk that person has and then deciding on How we should treat them Stattons remain the main state of therapy. This is for again from the guidelines and in your handout So they the guidelines survive people into those less than 40 and greater than 40 And those of us again who are taking care of patients realize that we see more and more people who have type 2 diabetes Who are less than 40 or less than 30 and so even now, you know Teenagers so what we do with them is is debated, but again, we use ASCVD risk score If they're high we we uh, it's a statin is um recommended Um, and then a pcsk9 inhibitor if we can't get it less than there If you're over the age of 40, it's considered you could use a moderate dose statin In general, I think um, if you have a one one additional risk factor We should probably be using moderate those statins if you have ASCVD you go high So this is pretty consistent with what the other guidelines say What about the other two components of the of the um Dislipidemia, what about HDL and triglycerides? How aggressive do we treat them beyond lifestyle modification? And what data do we have for that? So for fasting triglycerides that are greater than 500 It's it's recommended and it's pretty clear that we should treat those after we evaluate for secondary causes of hypertricosidemia After we make sure they don't have nephrodic syndrome. They're not They're not hypothyroid ask about alcohol We ruled out secondary causes and they're greater than 500. We should probably treat that to reduce the risk of pancreatitis Below 500 it's sort of a gray zone and the studies which have looked at Adding a phenofibrate on top of a statin and people with diabetes two studies one accord lipid and one the field study Have both shown this adding a phenofibrate on top of a statin did not improve outcomes um in people with diabetes so the cardiovascular outcomes were not Improved so the guidelines suggest we should not be using phenofibrate on top of a statin in that group of people Who have a triglycerides less than 500 if you look at um databases It's used to see fibrates are used a lot in this population There is still a little bit of debate about those people who had high triglycerides in low HDL A value of 204 over 34 in in secondary analysis of those studies which People who enrolled didn't have really high triglycerides at baseline if you did have higher levels in low HDL Maybe there's a signal, but but in general it's not recommended that we do that And then niacin the treat the HDL has been a real disaster on top of adding a statin right niacin has not helped at all And so it has not been shown to prove additional cardiovascular benefit about statin patients don't tolerate it. They become more This uh Glycemic and it's not recommended that we use it. Um in general Aspen how many people prescribe aspen for people with type 2 diabetes? in the clinic The rest of your line I ask this question. I have the pleasure of I have a pleasure of going around the country and I talk with this primate group and I talk to primary care doctors I talk to cardiologists and I ask this question. I want to prescribe aspirin to the um To your type 2 diabetes and all the cardiologists raise their hand But they know the data the data is not good at all for the use of aspirin and people who have type 2 diabetes Clearly aspirin should be used for secondary preventive strategies and those with passive stroke of disease clearly right If you have a q-corner syndrome as dr. Eunice described, we need to have dual anti platelet therapy after a q-corner syndrome or a sense been placed The guidelines say that aspirin may be considered as primary prevention and those who have increased cardiovascular risk after a discussion with the patients on benefits Versus increased risk of bleeding. So to me, this is kind of a wish to wash your statement, right? I'm not sure what to do. I think if someone is high risk for bleeding It's clear in primary prevention. They should not you probably do not need to push the aspirin They have lots of risk factors Maybe maybe and so it really there there probably is A modest benefit related to aspirin and people who have diabetes probably and I say that because there have been about Four randomized controlled trials of which three were neutral and then the last one was positive And so I decided today for Saturday morning. I would show you the positive one, right optimism optimism Optimism right and and so um This is the ascent study that was published at the end of last year It shows the effects of aspirin for primary prevention and people who have diabetes Randomize a lot of people 15,000 individuals to aspirin 100 or placebo All of them for seven and a half years And what's shown on the right hand side of the slide are the events that happen So there were serious vascular events that occurred in 8.5 of those who randomized to aspirin Versus 9.6 on placebo so we can see that there was about a 1 percent difference at about seven and a half years Major bleeding occurred major bleeding in 4.1 percent in aspirin and 3.2 percent in uh control So about a 1 percent difference 0.9 percent difference Over seven and a half years the number needed to treat is 91 to avoid a vascular event in 112 to cause a major bleeding event So it is this really this balance that exists Between the two and when they try to look at risk within this study higher risk lower risk It didn't really pan out that you could identify that individual who would benefit from aspirin based on risks alone but I think in general All right, we cardiologists love our aspirin and and I despite showing this everyone will use it but in general I think If someone has bleeding risk or has had a bleed I would not push it in primary prevention If someone has lots of risk factors, I might use The data would suggest that I'm a bit off so In the next 10 minutes or so, I'm going to show you a lot of data And really this idea data on glycemic therapy because I really think the last Five six years we've entered this new era Where we move beyond hemoglobin a1c to one of cardiovascular safety efficacy Um in choosing which diabetic medication we're going to use and these are going to be reflected in the guidelines Right before we just thought about a1c We had some data on safety But now we have outcome data and it wasn't until 2008 a little over 11 years ago that the fda mandated that when we Developed new diabetic medications that we prove that they're safe and people have diabetes first and foremost We didn't used to do that right they have to be safe And then wouldn't it be good if they were effective and there are lots of stories where there were medicines that had been developed that Could lower a1c That had some safety concerns And then even worse they may have had increased cardiovascular events and that was a story of rosy glideson Which was later exonerated and randomized controlled trials But because this was such high stakes so many people with diabetes We're treating so many people it was so costly We needed more information and the last several years We've had several randomized controlled trials that have been published I'm going to focus on the new medications that are available who have randomized controlled trial And I'm going to focus on the incretin Therapies and then the sgl-2 inhibitors So just for review the incretin signaling or the intricate effect Means that more insulin secreted after glucose is provided orally than intravenously. So if I eat a sandwich my My insulin will increase for the same amount of glucose that if I took at IV And this is a result of the gi hormones glp1 as well as gip equivalent like peptide 1 Which stimulate insulin release following food intake in type 2 diabetes. This incretin effect is reduced And so it is an early hallmark of the disease these These glp1 and glp they're rapidly degraded by an enzyme called dpp4 So to take advantage pharmacologic advantage of this system you had to either inhibit the enzyme that broke them down Or make the glp1 resistant to degradation. So they're the glp1 Receptor analogs that are resistant or the dpp4 inhibitors In addition to the incretin effect affecting glucose, there's a variety of other effects They're cns effects where it promotes satiety and reduction of appetite as well as delayed gastric emptying So it's associated with modest weight loss or sometimes significant weight loss there's decrease Gluconeogenesis within the liver. So a variety of effects that may Be beneficial beyond just glucose and the the glp1 receptors ubiquitous So there are some some data in animal studies, which I wouldn't show Which suggests that it may have some hemorrhagic effects It's there may be some off-target effects as well in the vasculature and in the heart So today we'll start with the dpp4 inhibitors They have been four studies that have been published with the dpp4 oral inhibitors like our patient Who was on saxaglyptin, right? These are the four studies The first one was saxaglyptin and saber to me 53 Examine alaglyptin ticos citaglyptin and carmelina, which was just published at the end of last year the very end I think is online right now And we can see that these are a wash right that for the dpp4 inhibitors neither were they safe Um, no, I take that back. They were safe for their primary outcome. So they didn't increase the hazard ratio So there's important safety study first They had to meet a non-imperiality margin of 1.3 and they all met their non-imperiality margin So they were a safe medication in general with regard to the mace outcome But we can see that it didn't really improve things So it's a good it's a medicine you can use for people with diabetes an oral pill well tolerated Not going to reduce cardiovascular risk and in general it didn't include mace But one thing that came out within the study Is that there was some heterogeneity with regard to the effects on heart failure So that there's been this difference that we've seen in the first study Saxaglyptin showed an increased risk for the development of heart failure With saxaglyptin compared to placebo So our woman who had any ejection fraction of 40 who had some volume retention We might be careful about using this medication Examine and alaglyptin also went on the sit side of not being good for heart failure events So these two caught the attention of the FDA who then put a warning on both of those agencies They should be Used with caution and people at risk for heart failure and maybe should be withdrawn and people who have a symptomatic heart failure The next study said aglyptin Which was a bigger study didn't show any risk and the last study also didn't show any risk of heart failure But the FDA I think had enough and I think that's probably unfair for the last two agents But they put that warning on the class So that we just have to be careful with dpp4 inhibitors and people who have heart failure Knowing that the studies are a bit header. There's heterogeneity within them According to the glp1 receptor agonist, we realize that we have lots of choices from which to choose from Often driven by what the What's the right term the pharmacy or their healthcare plan? formulary tells us it's on the formulary that we can prescribe but Really what the difference is in large part has to do with their half-life beginning with exenotide twice daily Which is a short-acting one Extending all the way down to exenotide once weekly as well as these other agents that are are given once weekly Aragotide as well as once a day. This is probably the weakest of the glp1 receptor agonist And uh, although listed once daily probably is a twice daily medication But we can see that in general that's the main difference. There is some difference as well as the chemical structure and whether it's an human based modification of a human based glp1 or whether it's based on exenotide So to date there are five five studies with glp1 receptor agonist and they are shown on this slide And so this is a little more tricky because within the studies themselves There's a little bit of again some heterogeneity as far as the outcome of the mace outcome, right? Very importantly some studies have shown benefit and have showed significant benefit So elixir the first study that was published Was neutral and that's a shorter acting medication. So I don't think anyone uses this one. So we'll skip that Somagotide showed benefit Leader which was a first study to show To show benefit for a glp1 receptor agonist is here excel favored treatment And then there was a most recently harmony Abiglutide which is not commercially available the company stopped The development of this medication but they did finish the trial and they may bring it back Because they did signal but you get a feeling that beyond the first one They all seem to trend in the right direction for these medications which is important Just spending a little time on some of these because loraglutide leader has an FDA indication for the reduction of Cardiovascular disease and people who have type 2 diabetes. These are the data Which showed the primary outcome was reduced by 13 percent Not only was a primary outcome reduced, but we see the mortality remember CV mortality was a big black part of Years of life lost on the first slide or second slide I showed but accounts for the majority of death was reduced by 22 percent and total mortality was also reduced with loraglutide excel is the once weekly form of Exenotide by durian. This is the name and so I was a us coordinator for this study This was showed again that there was a trend in the right direction. The hazard ratio was 0.91 favoring exenotide Because it didn't meet its superiority outcome everything after that is sort of hypothesis generating But if you look at total mortality, we see that it's very similar to loraglutide And the total mortality would have the same hazard ratio As loraglutide so again a signal that This medication may be beneficial So far for the glp1 receptor agonist all trials have met their primary goals showing that there's no increased risk of atherosclerotic cvd Leaders are saying six in harmony have all demonstrated a benefit on mace and mortality and loraglutide Has this fda indication Not for treating glycemia right for the reduction of cardiovascular disease and people who have type 2 diabetes But let me turn now to the sgl2 inhibitors again as a review the sgl2 inhibitors in the proximal 2 build a kidney and they're responsible for glucose Reabsorption 90 percent of the glucose reabsorption is for the sgl2 receptor So if you block the sgl2 Reabsorption you have glucose geria And so you have spilling of the glucose in the urine a relatively I think simple mechanism action if you think about it Um, but when I asked when I say that we'll show why do they have cardiovascular benefit? Because a relatively simple mechanism of action associated with a hemoglobin a1c of a fall of a Point seven percent modest effects on blood pressure Modest weight loss in a weak diuretic that after time is probably not that strong of a diuretic Lots of excitement with this class of medications right lots and lots of excitement So these are the completed cardiovascular outcomes of the sgl2 inhibitor studies there have been Three of them empa canvas and declare They're all shown here declare the last study that was published in the new england journal At the beginning of this year a release at the aha It had two primary endpoints. It had a traditional mace Endpoint as well as a cardiovascular death and heart failure endpoint They changed that endpoint during the middle of the study when they started to see benefits in the other studies of the splitter But when we see this for empirical frozen and people who had established cardiovascular disease We saw that there was a benefit And the study canvas chemical frozen was associated with the benefit in the reduction of cardiovascular disease For mace in this study. It did not reach statistical significant This study is a little bit different and it has implications on how we practice This study had a larger proportion of people who had primary prevention Some of the two first studies They were mostly people who had a heart attack who had heart disease who were high risk The apical frozen specifically had a group of people who were lower risk And some people think well, maybe that's why we didn't see this difference When we look at cardiovascular death and heart failure is a combined endpoint We did see that there was a benefit associated with apical frozen Again, what's remarkable at these studies and I spend a lot of my time talking about heart failure In my previous life and about medications that increase your risk for heart failure They're associated with greater rates of heart failure like the tzds Insulin whether probably just a maybe a mark of disease severity But also associated with greater heart failure events. So we spent a lot of time talking about How medications and people who had heart failure for diabetes were maybe bad, right? And so we in the how they might cause heart failure and a lot of this so that when we saw this, this is remarkable Here we have a class of medications that seem to prevent heart failure This is what's shown on this slide. We have um, empirical frozen mechanical frozen and apical frozen And we can see that the the hazard ratio is pretty similar across the group of medications. So a very exciting um finding We look at emper reg empirical frozen was associated with mark reductions in cardiovascular mortality is shown here Has a ratio of 0.62 Heart failure shown here empirical frozen versus placebo and we can see that these survival curves begin to For a heart failure begin to split very early and remain separated throughout the study The one question that comes up is that what's going on? Why does the medicine that makes you spill blood sugar in your urine, right? How does it make you have less Chance of dying from heart disease, right? And so that's an area of intense interest You know, if you go back a term we call reverse translation a finding that we're happy to see but we don't completely understand What happens and so lots of mechanisms have been proposed Some people say well, maybe it's the effects on the blood sugar or weight But to date we didn't see really any studies that have shown Reducing blood sugar a strategy of being intensive with blood sugar improves events. So I don't think that's really it Perhaps some vascular effects. I think Stephanie culture has been studying this a little bit Perhaps it's its diuretic effect that's associated with reduction in events Well, that may be true for heart failure But we know that from cardiology that diuretics don't really make people live longer They keep them out of the hospital Maybe not live longer So there's a lot of interest on perhaps other off-target effects and this is moving forward I think probably one of the most important things is that there's also been this reduction in Renal disease seen with these agents and there's this cardiorenal access that there's a renal protection associated with stl2 inhibitors On the way, um, these affect the hemodynamics within the glomerulus Perhaps this is what we're seeing and we definitely see across the board for empirical frozen and the emperor regalcom study mechanical frozen in the Canvas and apical frozen in the recent timmy study and we can see that for all of them There's a reduction in cardio and renal events in addition to the cardiovascular events on that But so far all trials have met their primary goals showing there's no increased risk of a scvd Emperor rag and canvas demonstrated a benefit in mace and mortality with empirical frozen as well as hospitalization of heart failure I didn't talk about this mechanical frozen in that study was associated with a slight increased risk in amputation As I'm sure you may have heard before the numbers are very small Why that's the case? We don't know whether it doesn't necessarily seem to be a class effect from some of the large studies But when emperor regalcom was started, they weren't really looking at this closely We're looking at that really closely now and really the great thing about these studies is because they're large and they're high risk patients We didn't have this data before so we can really begin to look in different studies and see these Unexpected signals and see if they're real so that we don't expose our patients to increased risk Both empirical frozen and mechanical frozen have an fda indication for type 2 diabetes and ethosclerotic Very important apical frozen probably we'll get one too So I'm going to finish up here with a couple of comments more related to cardiologist So we started with these blood glucose medications that were used to treat blood glucose that we're trying to show We're safe and effective and we end up with benefit benefits It's very welcome benefit that we hope for benefit. It's a little hard to explain and we're working on that So now there are several studies for example in the sgl2 inhibitors looking at not the reduction as far as In people who have diabetes But reduct using these medicines not as glucose lowering medications But as heart medications the card like good cardiologists. We try and take everything over And so the question is this is not not a diabetic medicine, but it's actually a cardiac medication So right now there are several ongoing studies at least four that I know of and probably more looking at the effect of sgl2 inhibitors to prevent heart failure events and people with heart failure Kind of irrespective of whether they have diabetes or not and that's what's shown on this study Oh, I better go fast. So I'm going to just um Just show the recent guidelines Here which have now incorporate this information. This is from the late last year the A combined report from both the american guidelines and the european guidelines and echoed and the recent ada guidelines Which are really a change right what they recommend is that we still use metformin And this is if hyperglycemia and people who have atherosclerotic disease or heart failure or ckd But those are the predominant comorbid conditions knowing that There are many comorbid conditions or many things that are involved And once we use metformin and lifestyle that we choose A glp1 receptor if atherosclerotic if a scvd risk is the predominant comorbidity that we're worried about That we either choose a glp1 receptor agonist with proven benefit Or we choose an sgl2 inhibitor with proven benefit as our second therapy And people in which heart failure or chronic kidney disease are the predominant feature that we're the patient may have It's preferred that we use an sgl2 inhibitor with evidence of reducing heart failure or ckd Progression and if not then we can go to the glp1 receptor agonist If it's above target then we can start adding the other medications that are listed on the slide Just to quickly go through the guidelines also suggest that if you in different groups This is just in your handout if you need to minimize hyperglycemia There's an important motion the second line. Maybe are these medications? If weight loss is your main concern Then a glp1 receptor agonist or an sgl2 inhibitor may be your first line after metformin And then finally the issue of cost right these medicines are costly And so cost is the main thing that sometimes we're just limited to the old medicines So funny rear tzds, but we have to be careful with those medicines and our patients who are high risk for scvd So in our woman Cynthia Who had type 2 diabetes and a diagnosed to reduce ejection fraction? I think that you could go I think that increasing sex eglipsum probably wouldn't be my first choice Just because of the fact that it has been associated with greater heart failure events since he has some edema I probably would not choose gliburide And I don't think many people are these days unless cost was really an issue But you'd have to be concerned about the risk of hypoglycemia already She's overweight obese And so associated with weight gain. So I might not choose that. I think you could go with either Four or five. I think the guidelines would suggest that we should try empa first But again, if weight loss is an issue then sometimes we can use the lagrotide or a glp1 receptor agonist And I would probably hold on insulin But I agree that with most people that we probably wouldn't leave her alone Hemoglobin 7.8. We would probably want to get that closer to seven Last comment is what Stephanie said she needed game going into this Is that what is so now that we have a medication that's associated with cardiovascular disease reduction Right now the cardiovascular disease is one of the main things that we use to guide to help decide what our second late Agent is for the treatment of diabetes What is the cardiologist's responsibility in the treatment of diabetes? We sort of take over for hypertension. I mean we have to take over we share right a piece I know that we but we feel comfortable managing that that's I guess the right word We feel comfortable managing lipids. Should we feel comfortable managing diabetes if we don't start A medication that's been associated with cardiovascular reduction and cardiovascular mortality and someone's who's high risk Should we is that our responsibility? And so that is really a big question And so a recent acc panel try to address it. They said a cardiologist a minimum Needs a screen for diabetes and those who uh with or high risk for cvd We have to treat risk factors And then we do have to incorporate the data for newer anti aproposemic agents in the routine practice. This is recommended And whether that's increasing shared decision increasing awareness, it is not not clear yet, but this is a Paper that just published from um From my old institution partners and Stephanie cultures as well in boston Just looking at the prescription patterns of sgl2 inhibitors within that healthcare organization And so we have a data 2013 up to 2017 and we have different people here We have pcp internal medicine and gray We have endocrinologists and red and we have cardiology here in this deep purple And it's just the absolute number of prescriptions by quarter And on the top we have can the fda approval for the different medications When the study came out for embryo outcomes showing that there was benefit Uh, kennecophosicin and the variety of different things. Um, and what we can see is that Cardiologists aren't really prescribing these medications. So they account for about five percent We can see that endocrinologists are really are doing a fair amount But within the system even pcps were less So I think that as we move forward we have to begin to ask these questions of how we're going to incorporate In them into our patients who are high risk So in conclusion patients with type 2 diabetes are at high risk for cardiovascular events We require a multifaceted approach to treat these individuals larygotide, endocrinophosin and kennecophosin are now fda indication Indicated for the reduction of adverse cardiovascular events in patients with type 2 diabetes and ascvd Um, both endocrinophosin and kennecophosin have shown reductions in heart failure as well as dappical frozen And future studies are underway to test the sgel 2 inhibitors in patients beyond just diabetes. So stay tuned Thank you very much


Welcome back to the school cast. It's challenge Tuesday. That's why you're not questioned master This is question answer session number eight We just did an intro and then second taking a piss out because apparently I don't know what's going on, but it turns out you it's Q&A a and I've lost my job Yes, that's a lot of work. Although that's a question. I've got a couple of questions for keep things up One is Billy dragon. I've got a question for him Thanks for your comments But is that really a name and I mean is your surname dragon? I missed a dragon like and even if you're not just reply and lie Because it'll make that will make me a place that you change your name But now I've told you to lie then I don't know if you are lying when You know, yeah, that's been Dave dragon. It's like on Yeah Much better than Jack. What film what film that's well Farrell on that stepbrothers, but it's like you have to come in dragon What's the one one thing he said about Davies? He's only ever seen about three films. Oh, it's not that's one of them It's him. I'm gonna say the other one That's right. Yeah, and then the other question was Someone wants to see our camera man or woman. Oh, yeah It's a Harvey victory visuals. He is coming in. There we go. I was the legend. This is a guy. I actually made some look after he said But check him out. He's a photography video work. Just Google victory visuals and check him out. He's a ledge very good I want you know this right so let's kick things off in True school cousin. It's Q&A fashion, but I'm not true because it's not me asking person at 10 upgraded calisthenics just Keep it on the theme of an enormous number of Complements first to get your question right out. Yeah, I have to say well done You are definitely people getting So this question comes in on YouTube from Andy me 203. He says he doesn't really know possibly He loves the videos more than Kim Kardashian loves a camera. Okay, that is a that's pretty up there with a lot of Yeah, I don't really Watch it. I've got no I think I could walk past her in the street You know I wouldn't know agreed. I'm the same but I've heard other I have a general disdain for people that are famous for doing nothing Yeah, I don't know what she's famous for apart from I really don't know anything's going on in the world That's not the question though. Sorry So he says as someone in their mid 40s who has been doing cardio and calisthenics training for about a year I'm totally impressed with the more advanced calisthenics moves My question is are calisthenics and bounce moves achieve achievable for and realistic for older people I would like to just start very quickly Just by saying and how old did he say what? 41 I don't know if he actually I didn't say That was maybe a different mid 40s. Yeah, it's 40s. Yeah And so in I think answer or add something very quickly that no one will necessarily believe but You're not in your mid 40s But one is that I'm not in my mid 40s But Tim is closer to his mid 40s than I am so Tim is not as spring chicken as these boys Egypt to believe so My answers like yes, like age and number in my I'm 36. Yeah, that's our calisthenics three and a half years ago So I didn't start when I was like, yeah 15. So this is this is relatively new So I would and David's back a year younger than me I think you would believe it But and yes, I come yeah, no and that and that It doesn't like it doesn't matter like obviously like that old like there's certain Physiological things start to happen as we get older and like I'd still love to be able to be that random that guy on Facebook You see that 65 years on it does a it does a flag and everyone thinks it's amazing. It's still shredded Yeah, but it it depends like you can be you could be 20 and starting out And you've got if you've got no training history of literally you haven't done anything other than just eat Chris on the sofa Like it's gonna take you a long way to get to an area to achieve certain things that you might want to do but it's also like You may people this might come as a bit of surprise like I love doing some of like the the cool stuff and it's great But the the whole point is to just to it for me is enjoy training Enjoy what we do and be like healthy and The the sort of being up to a flag or a lever or having something to try and do like a plank I can't do yet is that's just like one of the motivators to like carry on training and That enjoyment of doing something I'm done before like that that inspires me or keeps me motivated But the long term is about like being able to still use my body and being able to do stuff when When we're older and if there's gonna be a stage When I die Same for everyone, but it's gonna be a stage when I can't do a flag anymore Yeah, and if like I get if it's if I get to that's gonna be like then a really sad day if I like get really If that's my thing rather than actually which I guess but join if my thing is actually I want to be I just want to be able to use my body and be healthy Then I can be confident that when I'm if I make it to 75 80 90 As long as I keep moving to keep using it effectively and correctly then I'm gonna have that yeah Yeah, I agree I think one of the big things that I've as I've come to kind of sense I think about is what I want to do when I'm 70 and I want to be able to move well And there's a little bit around some of the S&C side stuff which comes into this is I've got to point out We've from being in history for sort of nine years or so like I've tried pretty much all the different forms of training I've lifted heavy stuff. I've trained for size. I've trained for endurance train for power So I kind of know like you're like don't start But one of the things that I'm gonna lead on to that point is how do I feel? Yeah about sticking China stick 150 kilos on my back like compressing my spine trying to squat with it How's my knees feel like I've seen videos of Ronnie Coleman fair play to him But a guy I don't think he can I was going home. I don't even know but he can't walk And he's certainly got a good probably If he lives to in this full life, he's got a good 25 years on him But he'd be like I don't get one moment of that. Oh, come on Ronnie. Like you actually you can't walk So there's some stuff around that we got you when I'm not now trained for sport I've experienced those forms of training. I know what I need to do from work perspective I understand adaptation. So now it's about enjoyment and what do I want to do longer to I want to stay healthy So that's one of the major driver forces for me about why I love that and then you can kind of start looking at some stuff Science of it like your body or my bone mass is quite light when I first started training I remember I was in Australia as far as the way into the gym. I weigh myself out of 68 kilos That's light. I haven't got a big frame.  So 2.4 times muscle mass related to bone mass So if I've got a light frame and I come in at 68 kilos There's going to be an upper limit of how much those bones are going to want to handle in terms of muscle mass So me trying to be 90 kilos is just ridiculous And why I'm talking about that is it it just feeds into going like I've come to accept what I'm good at And I'm not good at lifting heavy weights. My shoulders are hyper mobile trying me to bench 120 kilos I'm going to dislocate I'm going to have problems Calisthenics makes me feel great. I really enjoy it. Can you start when you're older? Yes, you're just going to have to undo more years of potential neglects and and issues around postural Postural correction work because you've just smashed your body for a bit longer than if you start when you're 60 I've got a little boy home like you don't know if you let over this morning It's sat on the floor and you put his nose on the ground. I'm like crack your hip mobility is good like But here he over years that's just going to get worse whether you play sports and we talk about that your body tells a story The decisions that you've made in your life and whether that's you've made a decision to sit down a lot We have to undo some of that sort of stuff if you want to get into some like lower body Plimetrics or pistol squats. What's nice is you're talking about Going being not trying to be someone in not or not trying to make a body that you're not like just working with What you've got and just being the best version of yourself And I think the assumption is if you're in your mid-40s, then you've got a lot to undo but you could be 25 and you've like smashed your body to pieces because you were doing Marsha, I don't know like some con some heavy contact sport and actually got a load of past injuries Compared to a guy who's 40 actually has just been relatively steady goes to yoga every now and again Actually, it's quite flexible. Yeah. Yeah, like it's more that idea of like storage Your body currently now does a story of what you've done in the past and like your starting point is your starting point We're quite big on this like it's your journey like Understand where you're at now what you need to improve on and there isn't necessarily like a right or wrong Whether you want to be able to do a flag or not That's up to you if you want to just do some like some of the basics and just and just build just build some Strength and some good ranges of motion just with the body weight and you can do that at home I'm just a gym and that's like your thing Then that's awesome as well It doesn't my take on if you're starting later in life is trained intelligently like train smarter life you if you're 18 And you want to get to calisthenics from do anything like your body will adapt and you'll you'll be absolutely fine Are you probably because you've got to do more volume you will get where you're doing more when you're a bit older? You're gonna feel that recovery a little bit more and I'm not a big on for me to make excuses about being older But the reality is the body starts to kind of change in certain ways as you refer to So just be clinical and just be just actually put more structure in place But I don't think if I started my mid 40s rather than three and a half years ago Knowing what we know now. Yeah, I don't doubt that I'd be able to do some of the things I can now do I think it just comes down to the fact that like you don't get strong because you get old you get Oh, you don't get weak because you get old you get weak because you stop trains to be strong Like you see these people are older like it's I've seen 80 year olds on on YouTube and whatever and yeah Maybe they're genetically doing all right. They're not weak. They're sitting great Nick because they didn't stop training most people have become sedentary and a bit more mobile and Fall over in the streets because they stopped training. Yeah, I think I had life. Yeah, like I But find things from it. Just you just made me think of something like I finished playing have a time from rugby when I was 32 I think 31 and then done It's only a little bit time to recover but like got three years of calisthenics or three and a half years of calisthenics and now 30 my 35 2017 45 35 That if I'd have gone from so when I was playing rugby we were doing lots of weight training loads to be fair but weight training sprinting power stuff and if I'd have Finished calisthenics and just unlike it. Sorry finish rugby and actually just carried on doing what I would have wanted to do And just maybe done like I did on loads of weighted pull-ups and weighted dips and stuff like that I'm not calling it guys. So it's just general training the gym bench press and whatever else I like doing But just got really strong for like three four five six years and then seeing calisthenics when I'm 40 and go Yes, I'd have been chronically probably tight in the shoulder believe it would have been horrific But I would have been in I reckon I would have been in a great position In terms of strength and stronger now than yeah I am because I don't do enough of that basic stuff now Yeah, I thought they're like and that's something I'm going to do but like I'd be in a really good position from that. Mm-hmm All right good. I hope that helps. Okay Tim I'm going to call you question master for various reasons, but what it'll hit us up with question number two So this one's from Jerry Street I'm actually going to paraphrase a little bit because it was a really long but thanks Jerry It's a great point. So he says that he loves our videos I was gonna say he really starts with the confidence because that's how you get on And it's a lifestyle that we take a realistic approach to the way they look at new movements So his question is based around like he trains a lot of people in parkour American Ninja Warrior Obstacle racing free run as well as castings but finds that people want to Come into castings and they want to do the exciting stuff straight away So the and they might do a flag or a single on push-up and they say tomorrow What's the trick? The one then when he writes a program for them puts in like body weight rows pull-ups squats and lunges That I can't as boring like I don't know. So they want to do it. I want to do the exciting stuff So his question really Is that how do we get our clients to take a realistic approach to strength and fitness and Getting to work through I think some progression rather than just go. I want to do a front lever. Yeah So this is a this is something that we we've actually kind of we talk about loads Because we obviously we've got our school of calisthenics framework Which gives people a progression so we look towards learning anything So literally someone can come to the go right I want to do a flag and we'll go right here's the steps You need to go through and that's based on exercise sign and strengthening condition principles We're gonna have to do some movement preparation We have to learn a new movement pattern and then we've got to get specifically strong and increase increased global strength to be able to do that so We to support that we've then got some of me call our locker which is a series of different tools and within that We've got things like isometrics eccentric Waiters stability angles and levers so we've got lots of different ways in which we can adapt and change an exercise So even if we take something like a back lever for example We'll use a band across the rings to be able to get anybody to feel what a battle feels like safely if we go Through a few progressions on let's improve range of movement Let's teach you the move pattern of the skin the cat and now let's put you on a band It might be a green band so slows the resistance and then you can actually feel what a battle feels like But on the back of that I'll take home message from workshops often Don't get stuck at the movement pattern phase don't come in and try and do a human flag You can only which you can't hold or you can hold for a split second because it's not an effective way to learn The one thing that you need to do is go away and get strong But I think we get away with that because we can because of the tools in the framework We can give people a glimpse of it Yeah without necessarily overloading the system like you mentioned in the question like not risking injury or Increasing the risk of injury too highly we can do that quite safely so people can feel the dude calisthenics and then we're going to Load the program in the direction of getting strong. I think like there's two things from me completely based on those lines in that We get it's getting them to buy in to what we're going to show them Yeah Partly and the two of those reasons we were brutally honest with them at the beginning and go I made these mistakes When I was learning to let's use human function I made the mistake of coming in and just once on the other TV I was just kicking up and holding for like point one of a second and it's just for them near the waste of time That's Bruce. Honestly about our trip not about where they're at. Yeah, not where they're going This is what these and that and then it took me three four five six months to be able to do a flag whereas when we've we've got like evidence like one on YouTube using the Human flag example of like three guys. We took through our progressive program. We've since developed That they learn it in seven weeks. Yeah, and I'm like massively jealous because they've learned it I've been ten times faster than I did because we had out the chaff from all that confusion around yeah There's so much stuff you could do We've actually stripped it down to first principles around each one of those movements But within that giving people the opportunity to feel like they're actually doing something Which is a bit like a flag and then the and then the other thing is and some of the Tim's like very very good That is going when we because we do it with the when we're training a Paralympic athlete the same When we're giving you an exercise to do or giving somebody an exercise to do it might just be as simple as a push-up or Abuse the human flag as everyone again are like tea push-up progression for the bottom arm is basically a side plank for the straight arm Yeah, and we don't just go and Tim wouldn't just go Right, you know side plank ten thirty seconds three three three lots of holding that and we'll go right This is going to be your bottom arm We're going to adjust it with this Externally take position on a slide because that is the same shape you're doing for The human flag and it's a it's a it's a foundation exercise. It's a beginner's exercise. It's really simple but they are feeling like and they're generating some some Movements that are exactly about the flag. So they feel like they're working towards something rather than I Do that if we were at a workshop, we just said I won't now do a side plank with this arm straight It'd be like this is boring. Yeah. Yeah, go do it doing this do it like this to do to do because it's for your flag It's like you're doing the same thing that you're getting that buying from them But it's also like you say it's that progression of what we do next for that. So we're going to go on the floor Let's do this basic tea push-up movement And then our next progression from there to tip into a flag might be like a vertical flag or an angle flag Yeah, and straight away they get to go. Okay. They can see where it's going important That gets that buying. Yeah need that buying if you're gonna have somebody carry on doing it And the phrase that we use is Pete you have to earn the right to progress if you don't you jump too far ahead So you want to try and do I don't know trying to work on a muscle up or whatever or handstands of great example You're just trying to kick up You're trying to finish the movement you get to a point where you go. Do you know what I haven't either got a movement pattern I haven't got the skill acquisition not strong enough and you have to go all the way back to Somewhere close to beginning and re-blow that stuff up. So if you actually earn the right to progress It's a real humbling thing about going actually you're gonna earn the right to the human flag safely properly then just Take your time I do it go through the stages Seth one about the guys you started working with us As one of our coaches he quotes CS Lewis and says the longest way around the shortest way home Sometimes it feels like it you gotta go a bit longer to get actually back But if you actually just try and jump stages it takes ages and what happens is you do stuff like he said in this question You do then you end up doing stuff that's too hard for yourself And the danger with that is you aren't strong enough and like things like your connective tissue and all that that hasn't actually developed And then the risk of injury is super high and I make that mistake all the time and that's something I'm honest with the people and it's like something that I need to really try to be better at But at the same time Making this make it as a coach making mistakes helps us Yeah, fine-tune what we then give you to do so that you learn quicker you stay injury free Because you're not doing the mistakes Yeah, you know Yeah, cool, right. I missed that. We've got a question for Tom Miller I'm gonna do that last because it's gonna open a can of worms if I'm saving myself for it But the third one I'm going to do is saying try and squeeze in four We're gonna go through a guy called John go. Oh, well now I'm a question master team We never do for well I think I like to offer more value to the people My position is question master. It's just Right, so I'm gonna be five next time John has given us a six-minute out slightly He says hi guys loving the videos in brackets obligatory compliments as requested I'm not sure I'd about I'm not sure.  So you'll benefit where we've been a new question Yes And look at the idea that you can use your you're that you are your own gym And he says that we can use that phrase if you want to however You go on to the road to know somebody wrote a book about that with that same title you are your own gym Is he got is he got is he got a yeah, I don't think I do when your question master talk over you What's that has he got a trade man? We have have you finished talking? Yeah And so you start with the free guard of handstand book is wondering do we do any weight training or free weight training to support? Our calisthenics training or not also a lot of videos and techniques focus on the body and core But presumably would incorporate low body into your routines and how do you achieve this and finally would love a workshop in Glasgow And so I'll go first. We've got one in Newcastle. That's as far north as we go in this year And next year for the length of the question. Yeah, definitely come to that. We had a lot. We did one in Newcastle Last year was it might have been in the show? We have done one in Newcastle before and there was a number of guys come down from Edinburgh and Glasgow So since you've got so much to say why don't you carry on? Yeah, so I've back in the day like and it depends what you what you have to when I was playing rugby I needed strong likes I need to be powerful like I don't need to be fast. So like I've probably something around. I think I've done like 160 kilo for like three reps and was my best and for everybody I was one of the smallest guys in the team. It was really reasonable strength aspect, but like I didn't need my legs to be that strong now and I actually enjoy working on I used to being able to move whilst they're like for me A pistol squat so a single squat with that leg out like really challenges like my ankle mobility my hip mobility my hamstring length on that leg that's outstretched and for me like on that that load on one of my whole body on one leg Is tough like I can't do 10 like easily And then with shrimp squats and stuff as well and actually quite enjoying like I'm doing a bit of yoga stuff at the moment And I enjoy just like trying to for me You're much more mobile than me like for me Trying to open up my hips and get into better positions like my straddle position To like I can probably do a straddle planch if I could actually spread my legs apart But in the same time that it's like The same place together because it can't actually get them apart Um and like that press the handstand like if I've got better hamstrings So like working on range for me at the moment is more Um important because I'm understanding that actually that's where I'm most deficient That's where I'm weakest or worse than actually working on what you find most difficult can be beneficial But I think there's some stuff I people pick out some things occasionally for us They send us a question You are you boy skip a leg day again I was like, do you do leg day and as I've got a couple of points I'm going to put out of this because it did Burn me. I've got a little bit of blogs right on this. The first thing is yes I do sometimes skip leg day I also skip up a body day quite regularly because of what my schedule is like So it's not like I intentionally don't do it I've got a certain amount of training time in the week That means I can get a certain amount of stuff done and there's things that I prioritize over others Yeah, I don't I was like Yeah, but I have got I use I will use some like some some lunges we do some Like Nordic curls. We've got our put some squats back in my program. So it isn't a very thing I do some cleans for my lower body. It's more of a kind of like a holistic thing I'm not a bodybuilder. I've absolutely no interest in doing gym and volume training 10 times telling squats So that people can look me go. I've got big quads. I've got no interest in that And the other thing is we talk about pistol squats So people got a body weight single squat movement Like I know a lot of strong people in the past who's strong because they lift weights to do squats There were nowhere near being able to do a pistol squat because they don't have the stability They have the range of movement and actually that means they can't even be strong in that bottom position So for me, it's a little bit like yes, we do we focus the beginner's guide on Upper body movements because that's where we're going to start to push the people through with the calisthenics The flags and the handstands that sort of stuff And also for us from a professional perspective as s and c coaches to start to open up that that box of lower body training People are so dysfunctional in the in the hips knees and ankles That for us to start to train people in or give advice around a lower body training is a whole bigger subject Than what was within the scope of the beginner's guide I didn't want to open up at that stage because we do it. It's not Yeah, this is if you go back we actually did a video on pistol squats There's two videos part one part two of pistol squats looking at Anchor range of motion hip range of motion and how to train and develop that for your pistol squat 10% of the only how to do a pistol squat 90% of it is the preparation We're able to enable you to actually get into the shape in the first place If people want a bit more like lower body stuff You can do some of the things like shrimp squats are definitely One we should be doing and we can it is a question we've had before work So like would you ever do a lower body? You know, whatever people want we're keen to provide for you. So if it is something a bit more interesting We'll do low body. So we're in terms of how do I look at lower body training single leg Like jack says pistol squats and shrimp squats. I like the idea of plyometric being there But again, that's a big thing. You've got to have good lower body mechanics before we want to start introducing Plyometric training into into workouts I like lunge patterns and just to throw something to mix the conversation we've been speaking about this week is Is calisthenics or it is squatting a calisthenics movement or it's lunging a calisthenics movement Or a resistance training exercise because a body weight squat would be calisthenics But when you put a back squat on it becomes a resistance exercise Well, that's both the resistance training exercises we're moving a set amount of it We're moving a weight. There's the muscle is under tension Just like a weighted pull-up is that is that a free weight exercise or is that a body weight exercise because a pull-up is calisthenics So I think let's More often change what that looks like rather than going. This is you do calisthenics means you don't do back squat Well, maybe I just see back squat as a calisthenics weighted exercise Different way because just yeah to wrap up its question about Do we use weights at all? Is it just calisthenics it fits in nicely with that in that? I would say upper body wise I just do calisthenics But for me that does involve because pull-ups are strong like if I want to create an overload I'll put a weighted belt on and do 10 15 20 whatever kilo pull-ups and I'm considered that Calisthenics that's the only sort of where I'd use weights and then actually go in well That makes that point relevant in terms of going well What's the difference between putting on you can put on a weighted vest You do your squats and do your pistols and go that's all right But as soon as it's a bar on your back, then we're going on it's different, but really It's the same. We're just creating an overload But it's it's understanding like do you need to create an overload or a five pull-ups still hard for you? And therefore just with your body weight and therefore you like you're working in that sort of max strength rep range And actually you just need to stick with that and the final four is it depends what you want Like do you want to move well or do you want to do quads illa like There's two different approaches there. Yeah, yeah, and it's not right and wrong. It's just like what it's not Yeah, right last question and tom miller with tom kinsman bonus question Yeah, it is number four So tom miller came to one of our workshops in I want to say ashbourne. Yes starbyshire. We live south Tom's a great guy. He's a Trains of pti and physical training instructor in with the marines. He's not afraid of giving out a compliment. Absolutely legend Yeah, no, so some I'm gonna do it like there's only so much I can handle actually without feeling slightly embarrassed And you've definitely tipped me over that. You know that edge there, but I got about 500 read about 500 I think he's joking so Tom I'd a chat about this on the workshop But it's an interesting one because it links to how we might incorporate conditioning or metabolic conditioning into a calisthenics type work I obviously when tom's working with the marines. He's got people that are Training away from home not always got a lot of kits. They've got body weight Maybe a basic rig, but it's they haven't certainly got like a fully functional gym or kitted out gym all the time that they can train it so Tom's question sort of fits in he goes So how do we sort of basically maintain a basic level of strength and some some cv or some cardiovascular training? Where short bursts of force production required? That's what the guys need for their jobs He thinks it could be a lot of it is a lot of benefit But basically how do we see the calisthenics fits into a conditioning type workout? Dave Let me draw upon my own experiences and then you can go into like what that might actually look like so Tim's already mentioned a little bit about like being realistic and like what you watch your schedule like There's certain things I'm working on and want to work on that like pretty much take up my week So I might get like three decent sessions done if I'm lucky and then I'll touch on some other things But that is basically strength based calisthenics stuff some of that might be at home and some of that might be at the gym and then in terms of like conditioning or or cv work, but if like in terms of The trends what you've asked a lot of people I think you're talking about conditioning to actually get Sort of fitter. Whereas a lot of people might be looking at again conditioning because they want to like Lose like improve their body composition.  We do park runs. So like they're park runs across the World I'm pretty sure Where it's like Saturday mornings. It's 5k. Um, so didn't I used to hate just long distance running Um, but quite enjoy that now. So like my cv and then and we've got a road bike and so go out Literally just for sort of fun. No lights training session reps and sets and all this sort of malarkey But going for a run going out on my bike. That's like where my I consider my like cv slash conditioning coming in And that's that's just whenever we do it. We try to do something once a week That's just for fun of us to sort of together. Yeah. Um, I'm not I don't have time my schedule to put in like, uh For a while I could I could just drop a different session and do like a master bike conditioning But uh for me, that's not what I want at the moment So I'll I'll pick up on this from a Let's go to an s and c sports performance side because effectively tom's working with military personnel So there's a there's a performance element to what they're doing a big performance component um So if you p90x insanity workout people are going to go. Oh, it's a good workout. I do that. No You know why it's a good workout because somebody went and picked a load of hard stuff and put it in a circuit and like So if you do loads of hard stuff and you don't rest in between it then you're going to get tired So if we're looking for anything which is going to improve cardiovascular fitness improve conditioning Where's anything which is going to create a sustained elevation and heart rate The high we get that the different sort of training adaptation We're going to be so if we're going to get people to work for short bursts of high duration work And we're going to get them to work up to 90 max zone fours and fives of our kind of heart rate Uh parameters Then we're going to get an adaptation We're stressing the boat to a point where it says I don't like what you've done to me there You've done enough to encourage me to make out so when you come and do this again You're going to be better because I'll change because of what you've done to me So as long as we're doing that it really doesn't matter whether that's a burpee A squat jump whether it's a 20 meter repeat sprint effort The the the simple job is look at the environment and go right I've got a 30 meter or 10 meter square Piece of space in the middle of a compound in in afghanistan Aware of you might be and go how am I going to use that space? How am I going to use the kit that I've got and just start to pick things which are hard Things which are tiring and keep the rest short Like if we're resting for more than 30 seconds and we want a metabolic out A metabolic improvement Then we just need to question why are we resting for longer if we want about three to five minutes worth of resting between that We're looking for more. You can you put down a maximum effort sprint time Where it might be you can actually consistently put down four or five reps which are roughly the same sort of duration Whereas if you're going to do six sets off the bounce and it's going to sprint there walk back recovery We're going to see some drop-off which means that we're then starting to create a little bit of aerobic anaerobic adaptation so Easily you could fit into some some some movers and the difficult thing with with body weights We've not got a lot of kit is pulling So have you got a set have you got something we can hang from can you do pull-ups? Can you super set that straight into a into a press up come we go pull up down Push up jump back up onto the bar. Can we start to rep some of that sort of stuff? I like that idea that like part of it I mean that's something we need to do in like Where someone holds and they're actually getting a bit of an isometric holding position where someone else is actually doing a body weight row Holding onto things like battle ropes. I'm a big fan of conditioning for your body We use those loads with serums because it's a great upper body conditioning exercise If you wanted to sort of get some of that that metabolic or that strength endurance in the shoulders Um, but I think it purely comes down to outside of programming metabolic It's easy to get someone tired.  I'll show you work out Which basically ends up in making someone sick and I'm like anybody can make anybody sick Like how you're actually going to create a physical adaptation which reduces injury and actually creates a performance change That's a little bit of science like you do is afraid of me before like more is not better Sometimes more is just more like yeah, we used to why I'm saying have you taken big say that Is that if we've done enough already or we just do more for the sake of doing more Swim coaching great doing more because we lost at the weekend and you're just getting punished So for you Thomas a guy who knows his stuff like my and for anybody you can take a message away from this Is when you write in a training program ask yourself Why like why is that exercise in there? What am I looking to achieve start with that? What do I want out of this session and then it becomes much easier And if you understand what your acute variables are within that red sets time recovery Intensity distance all those sorts of things Then that's how you then start to go right if I know that these are my parameters These are the exercises which I'm going to use. I don't want the guys resting And a push-up into a into three or four different push-up variations It's just movement and if it's difficult and the intensity is right and the rest is low enough The heart is going to have to work harder because we're going to start ourselves of oxygen You think you can't recover fast enough to continue to do the work Yeah, the biggest something doesn't get talked about a lot and the biggest thing you've mentioned there is about Um, it's about rest and like you've getting your adaptation based upon the amount of rest you're giving them Um, and then just if you want it to be like total body make sure there's some lower body There's some corners some upper body stuff if you actually want them to be You've got people that you need to you want them to go to the lower body Well, then it's not rockets out to make sure there's a little lower body stuff in there It's upper body, upper body It makes me think about a circuit I used to do so I knew that for example if I want to improve vo2 max There's a set which you can do where you work for four minutes work up to 90% of vo2 max And you can work that out or you can go on heart rate zones or whatever Um, but then you would do three minutes at 70% active recovery So it might be like push hard four minutes build up to that 90% heart rate I think rather than vo2 max so I think it's 90% max heart rate And then you give yourself that active recovery you drop it back down to 70 and then you go again You do that four times and that's been shown research has shown that actually gives you quite a good adaptation in terms of improving Vo2 max Well, I knew when I was training with squads I couldn't get them to run at 90% for four minutes because try and do that Like it's not easy your guy. You tell me you'll know that with the Marines They probably can push themselves to that so if you can push that zone great football players We'll I'll be like let's run hard and they'll be like most will never kind of hit that And we didn't have heart rate technology to go to monitor them So what I did was separate into five different circuits And I think I'd like it works out about 30 or 25 second or 20 seconds and five minutes of transitions in the next one And then each one of those ones was like squat jumps push ups Like get up on a floor forward roll getting up getting down just keeping people moving But like what the guys could do what my guys could do in those environments They could work half a 20 to 25 seconds And they actually they didn't know that they'd done four minutes in 90% And then I gave them an active rest jog around the pitch which they were right to bring the heart rate down So it's then it just comes to that's the art side of packaging up the adaptation and the way which your guys are going to engage with Yeah Right great that is we've yeah It's a lot Hopefully you've made it this far. Yeah, I know there was some good stuff in there Hopefully if you've got um if you've got to give yourself a panel If you've got any more questions for us related to training Um anything hairstyles Comment in the comment below and we look forward to uh answering those as much as we can the best ones or ones We feel are going to give most amount of benefit to other people Are we'll answer in the next Q&A Q&A 9? If you haven't subscribed I'm what yeah I'll go on but no guys if the ones have rubbed me at the wrong way they always can't If I like got some I've got my soap box If you haven't subscribed click on click up there If you haven't got our free beginners guide and you want to get started and I know loads of you follow our stuff We still haven't even got our free beginners guide that's down there and then last Q&A Q&A 7 is up by Tim's over there So until next week class dismissed


So, I'm here to give a talk, share my experience about working on Elixir and what I find people go wrong when they program Elixir, mostly when they come from some OOP-oriented languages. So, about me, my name is Nikhil More and I am presently working for Volances and I am presently staying in Ahmedabad. So, I am on Twitter as Nikhil Arias, Google as Nikhil More 54. Also, I am an active member of Pune Elixir and Erlang Group. We have a few members from the group present right over here. It is one of the most active community in India for Erlang and Elixir. So, let's start with FP versus OOP. We have a lot of debate that is always going on if FP is better or OOP is better. But really in my sense what I feel is OOP and FP are just two coins, two sides of the same coin. So, in my experience or to put in a simpler way, OOP and FP are two different tools and these two different tools are used to perform different tasks. So, it's like say you can't use a needle to cut a stack of hay, something like that. So, you have to select OOP or FP depending upon your own needs and requirements and the case as per it is. So, when we learned about OOP, we came across various characteristics. Some of these characteristics are OOP has class. Classes, when they are instantiated become objects. Classes have the following features. They have encapsulation. They have inheritance, polymorphism, abstraction. We did this in Java C++. So, when we try to compare FP with OOP or when we migrate from OOP to Elixir specifically, we have a notion in mind that modules are very much closely analogous to classes, but it's not. We seem to compare these two because they are collection of data, but they change mostly in one thing that in classes data is mostly private and you can access these private members only through public methods. But in modules, the data is not private. You can directly access the data and you don't need any specific setter methods or getter methods or any other methods to access or modify any of this data instances. So, modules are not classes. Then when we are working in FP, when we are working in Elixir, there are no objects created. We don't call objects to throw any methods. So, if we have a student, we don't initiate the student with student 1 and then call its get or set function by student 1.get in Elixir. The method over here does not bind to the data objects in Elixir or in any FP language. So, the functions are not bound to any class. So, you don't need to actually have to be in that class or in that environment where the class is instantiated and call it through that object. So, functions are not bound to any class. You can call a function that is in any module that is available in the environment and modules are not inheritable as classes are inherited by the children. So, as I have just spoken about the methods, the methods are not really called with reference to any object. They can be called by module.function and passing the parameters. And the code and functions in FP are detached. They are not tightly bound to each other. So, when we talk about functions in function in FP in Elixir, everything is immutable. When we create variables over here, the term variable is actually confusing in FP paradigm because they are not actually variables. They are sort of what we can say constants in Java. So, once you initiate a variable, it cannot be reassigned, the value. The value of a variable is not reassigned or overwritten. You in Erlang actually a new variable is a new memory space is allotted to the variable with the new value. The functions are idempotent and they always return the same value. So, here idempotency means that given a set of inputs to a function, they will always return the same value even if you try the function any number of times. And functions show referential transparency. So, each function will return a value and if we replace the value that is written by this function somewhere else where the function is used, it will always give the same results as if the function was executed in that place. So, now moving to object oriented and FP comparison, here I am taking an example of a simple account and with just a method to deposit some amount into that account. So, this would be something that can be a Java code for this account code, account class. So, we have a private integer account number. We create a private account balance for the account and we have show method and deposit method. We put our validation over there if the account goes down when we, sorry, if the deposit amount is greater than zero, is it positive or not and we add the balance and return it. And this balance is updated into the class. So, what we can see over here is that account balance is directly accessed through the deposit method and it updates this value within the body itself of the function. There is nothing written over here. The effect of this deposit function is that it actually accesses the memory location and overrides the value of account, account balance. So, everything is within the code. So, the class encapsulates the members, data members and the methods. So, when we convert this code into LXR code, we would do something like this. We would destruct with account number and say I have set the account balance to zero initially and then we have a function to deposit the account number. The same process goes over here. This is just a one-to-one mapping from Java code to LXR code. But what I would do is I would just put a check over here so that the type of account, the type structure account pattern matches with the account number so this data structure can be updated. If this data structure is not of the account type, it won't be updated over there. It would throw an exception. So, now we are moving to the next point that is inheritance. We have a separate class called saving accounts and we have a checking account. Both these have the same body, the same structure as the accounts. So, for inheritance, here is the checking account. Everything is the same. Just the class name changes. So, in Java, we create a super class account and then we try to create the children classes using saving account that extends this account and checking account also extends this account. So, this would be somewhat if we try to map one-to-one to LXR code. This would be saving account structure. A similar structure would be for checking accounts but here I try to reuse the code because in both the modules for saving accounts and checking accounts, we have the same function that would be repeated twice. So, I take this common function outside into a helper function and I can use this function anywhere in the code. So, it is not just for this account but I can have this deposit account for something else also. Now, due to lack of time, I have tried to compress the ideas of polymorphism and abstraction together into one but it would be a quick one. So, here it is polymorphism. We have class account that we have defined earlier. We also have saving account and checking account but now we have added a new class that is overdraft account but overdraft account has a separate function deposit for the deposit. The method in overdraft account is a bit different because when we deposit into this overdraft account, it would actually calculate the interest part and it would deposit the remaining principal part into the overdraft account. So, the java code would be something like this. It would show us we would have a separate deposit method that would overwrite the original deposit method that was in the account class. So, here we are having the same savings account and the same checking account. The depth module for an OD account is created over here and we would easily pattern match if the account is overdraft account, we would try a different method set of function to calculate the overdraft account deposit and we can actually utilize this pattern matching to overcome the to overwrite the already existing function because the parameter type for account is different. So, while we write a program in elixir, some points to be kept in mind is code dry and not wet. So, I usually try to separate out the reusable components into a separate class and use it as much as possible because when we write redundant code, what happens is that we may change when the business logic changes, we may change the code at one part and we may miss out some of the other codes due to oversight or maybe because we don't know because it was coded by somebody else. Then second part is I try to always split the task into smaller functions.  So, it does not mean that smaller means you have to break it down into smaller functions, but a function that can sufficiently describe a proper method should be going over here. You should name your functions descriptively. So, the function should speak out for itself. The function name should speak out for itself. If we have a feature for pipes in elixir, try to use it at maximum and you should document your code very well even though your functions are descriptive, but there might be some places where documentation and comments are required. So, your code should have this comment. If you have any questions, I think this was just for a basic overview. I hope I have tried to communicate very well about my thoughts to you. If you have any questions. Well, are there any questions for Nikhil? No questions? I actually had a question. Yes. Okay. What's your experience with the like the IDs and stuff like from Java is a pretty decent set of tooling like IntelliJ is pretty fully functional. There's a lot of stuff built into the IDs. I mean, I know it's not really relevant to your talk, but something that was curious about. I worked with Java on Eclipse. How is the tooling in elixir? Tooling, you can have add-ons in sublime or VS code. They are pretty much good because you don't have to add everything that is there into your ID. You can selectively add as what you want and you can compare and you can just use it. So, basically sublime goes well and VS code also goes well. Thanks. That's all. Any other questions? Thanks, everyone. Can we have a round of applause for Nikhil, please?