Thanks for giving Jessica Gouthro from Paleohacks such a warm reception last week. I’m glad you found her “13 Ways To Move More At Work” useful. She’s joining us again today to offer tips for those who are looking to ease joint pain. Enjoy!

It sounds counterintuitive, but it’s true: one of the best ways to ease joint pain is to exercise!

Whether you’re feeling aches and pains in your elbows or your lower back and hips, the key to managing and preventing joint and muscle pain is to exercise in the right way. If you have existing pain or joint discomfort, then you need to keep your workouts low-impact, but that doesn’t have to mean easy or ineffective.

You can keep reduce impact and lower your risk of injury by performing exercises that place less stress on the joints.

Some of the most popular low-impact workout options include:

  • Cycling
  • Swimming
  • Elliptical cardio
  • Incline walking
  • Controlled light-resistance weight training
  • Stretching and yoga

Aside from keeping your workouts low-impact, you can also start doing simple exercises to ease discomfort in specific parts of your body, like these 13 stretches for lower back pain or these 13 feel-good hip openers.

Try all 10 of the following exercises to relieve different forms of joint pain. You’ll need a chair, a small hand towel, a light dumbbell, and a resistance band for some of these moves. Remember your favorites and include them in your workouts anytime you feel discomfort in your joints.

1) “Wring the Towel” Wrist Stretch | 10 reps

Roll up a small towel and grab the ends with both hands.

Hold your arms out in front of you with palms facing down.

Slowly and with control, pretend you are wringing water out of the towel. Tilt one wrist up and the other wrist down at the same time, then alternate sides.

Continue wringing the towel in both directions for 10 full reps.

2) Dumbbell Wrist Curl | 10 reps per side

Sit on a chair or bench. Hold a light dumbbell in one hand and rest your elbow on your knee.

Keeping your arm still, exhale to flex your forearm and bend your wrist towards you to curl the dumbbell up.

Inhale to relax your wrist back to the starting position. .

Repeat for 10 slow and controlled reps, focusing on full range of motion with your wrist. Then switch sides.

3) Elbow Compression with Small Towel | 3 reps per side

Hold your arm out long. Roll up a small towel and place it right over your elbow.

Make a fist and curl your arm towards you, bending your elbow all the way closed on the towel. Aim to reach your knuckles to your shoulder.

Use your other hand to gently press inward on the back of your wrist to increase the compression. Breathe deeply as you hold for five seconds, then switch sides.

Complete three reps per side.

4) Narrow Grip Wall Press Tricep Extension | 10 reps

Place your palms flat on the wall at your chest height.

Step back a few feet so your body is at a slight angle. Ensure that your palms are flush against the wall.

Bend your elbows to lower your body towards the wall, keeping your elbows pointing straight down.

Stop when your elbows are about 3 inches from the wall and press back to straighten arms, flexing your elbows all the way.

Continue for 10 reps.

Tip: For a greater challenge, you can try this exercise with palms on a bench.

5) Hip and Low Back Compression Stretch | 3 reps per side

Lay flat on your back with your knees bent, feet flat on the ground.

Lift one knee towards your chest, using your hands to pull it in towards you. Actively work to ground your hips.

Take five deep breaths, then switch and do the same on the other side.

Continue alternating sides to complete three reps per side.

6) Pelvic Tilt | 10 reps

Stand with your feet shoulder-width apart.

Hinge at the hips and place your palms on your knees.

Lift your sitting bones and tilt your pelvis forward to create an arch in your lower back and stretch your hamstrings. Keep your neck in neutral and shoulders relaxed. Hold for a few breaths.

Next, round your lower spine and tuck your pelvis under to form a round shape. Hold for a few breaths.

Alternate between tilting forward and back for 10 reps, holding each pose as long as you like to relieve the pain and pressure in your low back and hips.

7) Single Leg Toe Touch | 10 reps per side

Stand on one foot and look down towards the ground to get balanced.

Hinge at the hips as you raise your back leg behind you, reaching your fingers toward the toes of the standing leg. Get as parallel to the ground as you can.

Slowly rise back up with control.

Repeat 10 reps on one side, then switch to the other side.

8) Glute Kicks | 10 reps

Kneel down on all fours and flex your right foot. Keep your left foot relaxed.

Lift your right leg up to form a straight line from your right knee to shoulders, with your right foot facing the ceiling.

Hold at the top for three seconds while engaging your glutes, then relax your knee back to the ground.

Repeat on the same side for 10 reps, then switch to the other side.

9) Resistance Band Knee Extension with a Chair | 10 reps per side

Loop a resistance band around one leg of a chair, and place the other end of the band behind one of your knees.

Grab the seat of the chair with your hands. Then step back until you feel a good amount of tension on the band.

Your banded leg should be directly below your hips.

Straighten your leg fully, resisting the tension on the band.

Then relax the knee. Keep your foot flat on the ground the entire time.

Repeat for 10 reps, then switch legs.

10) Isometric Quad Flex | 6 reps per side

Sit on the ground and place a rolled up bath towel under your right knee.

Place your hands on the ground behind you for support and sit up tall.

Flex your right leg to lift your heel off the ground. You should feel all the muscles surrounding your knee fire up.

Hold this flex for five full seconds, then relax.

Repeat six times on this side, then switch to the left leg.

Tip: For a challenge, increase the number of reps or increase each hold to eight seconds.

Revisit these helpful exercises anytime you feel joint pain or discomfort. As always, be smart about working through an injury. If your body is telling you to rest, do it. When the time is right, apply these gentle exercises to help you get stronger and feel better.

Thanks again to Jessica Gouthro for these tips and to Brad Gouthro for demonstrating them. Questions or comments about exercises or treatment for joint pain? Share them below, and thanks for stopping by.

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The post 10 Moves To Help Ease Joint Pain appeared first on Mark’s Daily Apple.

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I’ll start with the bad news: There are no vegetarian collagen sources. Every collagen supplement you see on the shelf came from a living organism. Though somewhere down the line someone will probably grow legitimate collagen in a lab setting, it’s not available today or for the foreseeable future.

Now, some good news: Vegans and vegetarians probably need less dietary collagen than the average meat eater or Primal eater because a major reason omnivores need collagen is to balance out all the muscle meat we eat. When we metabolize methionine, an amino acid found abundantly in muscle meat, we burn through glycine, an amino acid found abundantly in collagen. If you’re not eating muscle meat, you don’t need as much glycine to balance out your diet, but it’s still a dietary necessity.

Collagen isn’t just about “balancing out meat intake.” It’s the best source of a conditionally essential amino acid known as glycine. We only make about 3 grams of glycine a day. That’s not nearly enough. The human body requires at least 10 grams per day for basic metabolic processes, so we’re looking at an average daily deficit of 7 grams that we need to make up for through diet. And in disease states that disrupt glycine synthesis, like rheumatoid arthritis, we need even more.

What About Marine Collagen?

Okay, but eating a product made from a cuddly cow or an intelligent pig is off limits for most vegetarians. What about marine collagen—collagen derived from fish bones, scales, and skin?

Back about twenty years ago, “vegetarians” often ate fish. A number of them still exist out in the wild, people who for one reason or another avoid eating land animals (including birds) but do regularly consume marine animals. If it jibes with your ethics, marine collagen is a legitimate source of collagen for vegetarians. The constituent amino acids are nearly identical to the amino acids of mammalian collagen with very similar proportions and properties.

It’s highly bioavailable, with the collagen peptides often showing up intact in the body and ready to work their magic—just like bovine or porcine collagen. In fact, if you ask many marine collagen purveyors, it’s even more bioavailable than mammalian collagen owing to its lower molecular weight.

I’m not sure that’s actually accurate, though.

According to some sources, marine collagen comes in smaller particles and is thus more bioavailable than mammalian collagen, but I haven’t seen solid evidence.

There’s this paper, which mentions increased bioavailability in a bullet point off-hand, almost as an assumption or common knowledge.

This analysis found low molecular weights in collagen derived from fish waste. Mammalian collagen generally has higher molecular weights, so that appears to be correct.

However, a very recent pro-marine collagen paper that makes a strong case for the use of marine collagen in wound repair, oral supplementation, and other medical applications does not mention increased bioavailability. It may be slightly more bioavailable—the lower the molecular weight, the more true that is—but I don’t think the effect is very meaningful. Mammalian collagen is plenty bioavailable (most efficacious studies use collagen from cows or pigs), even if it’s a few dozen kilodaltons heavier.

But even if marine collagen isn’t particularly superior to mammal collagen, it is equally beneficial.

For skin health: Fish collagen improves hydration, elasticity, and wrinkling in humans who eat it. And again.

For metabolism: Fish collagen improves glucose and lipid metabolism in type 2 diabetics. HDL and insulin sensitivity go up, triglycerides and LDL go down.

And although fish collagen hasn’t been studied in the treatment of joint pain, if it’s anything like other types of collagen, it will help there too.

What Are Strict Vegetarian Options?

What if you absolutely won’t eat collagen from marine sources? Is there anything you can do as a vegetarian to make up for it?

Make Your Own

You could cobble together your own facsimile of collagen by making an amino acid mixture. Glycine, proline, and arginine don’t cover all the amino acids present in collagen, but they’re widely available and hit the major ones.

Still, eating the amino acids that make up collagen separately doesn’t have the same effect on those collagenous tissues as eating them together in a collagenous matrix. One reason is that the collagen matrix can survive digestion more or less intact, giving it different biological properties and effects.

In one study, rats with osteoporosis ate collagen hydrolysate that scientists had marked with a radioactive signature to allow them to track its course through the body. It survived the digestive tract intact, made it into the blood, and accumulate in the kidneys. By day 14, the rats’ thigh bones had gotten stronger and denser with more organic matter and less water content.

Another study found similar results, this time for cartilage of the knee. Mice who ate radioactive collagen hydrolysate showed increased radioactivity in the knee joint.

In both cases, the collagen remained more or less intact. A blend of the isolated amino acids would not. The fact is that collagen is more than glycine. When you feed people collagen derived from pork skin, chicken feet, and cartilage, many different collagenous peptides appear in the blood. You don’t get any of those from isolated glycine.

That’s not to say it’s pointless. Pure glycine can be a helpful supplement, used in several studies to improve multiple markers of sleep quality. Just don’t expect it to have the same effect as full-blown collagen.

Get Adequate Vitamin C

Acute scurvy, caused by absolute vitamin C deficiency, triggers the dissolution of your connective tissue throughout the body. Teeth fall out, no longer held in by gums. Wounds don’t heal, your body unable to lay down new collagen.

Vegetarians usually don’t have any issues getting adequate vitamin C.

Get Adequate Copper

Copper is a necessary cofactor in the production of collagen. Studies show that you can control the production of collagen simply by providing or withholding copper.

The best vegetarian source of copper is probably dark chocolate, the darker and more bitter the better.

Get Adequate Lysine

Lysine is another amino acid that’s necessary for the production of collagen.

The best sources of lysine are in meat of all kinds, but vegetarian options include hard cheeses like parmesan and pecorino romano, as well as eggs.

True vegetarian collagen doesn’t exist. Strict vegetarians will balk. But if you can bend the rules a bit, realize that making marine collagen out of fins and scales and bones is far less wasteful than just throwing it away, and look at the benefits with an objective eye, you’ll be pleasantly surprised. Even if you don’t end up using marine collagen, at least you have a few tools for getting many of the benefits with quick shortcuts and optimizing your own production of collagen.

Have you ever tried marine collagen? If you’re a vegetarian, would you consider it?

Thanks for reading, everyone. Take care and be well.

The post Does Vegetarian Collagen Exist? appeared first on Mark’s Daily Apple.

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Welcome to Friday’s For The Love of Food, Summer Tomato’s weekly link roundup. A few extra this week since I missed last week.

This week how to keep your heart 30 yrs younger, hunger induces risky eating behavior, and climate change makes oysters more dangerous.

Next week’s Mindful Meal Challenge will start again on Monday. Sign up now to join us!

Too busy to read them all? Try this awesome free speed reading app to read at 300+ wpm. So neat!

I also share links on Twitter @summertomato and the Summer Tomato Facebook page. I’m very active on all these sites and would love to connect with you.

Links of the week

What inspired you this week?

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The scientific literature is awash in correlations between a person’s health status and various biomarkers, personal characteristics, and measurements. As we hoard more and more data and develop increasingly sophisticated autonomous tools to analyze it, we’ll stumble across new connections between seemingly disparate variables. Some will be spurious, where the correlations are real but the variables don’t affect each other. Others will be useful, where the correlations indicate real causality, or at least a real relationship.

One of my favorite health markers—one that is both modifiable and a good barometer for the conditions it appears to predict—is grip strength.

The Benefits of Grip Strength

In middle-aged and elderly people, grip strength consistently predicts mortality risk from all causes, doing an even better job than blood pressure. In older disabled women, grip strength predicts all-cause mortality, even when controlling for disease status, inflammatory load, depression, nutritional status, and inactivity.

Poor grip strength is also an independent risk factor for type 2 diabetes across all ethnicities, and it can predict the presence of osteoarthritis in the knee. Among Korean adults, those with lower grip strength have a greater risk of clinical depression.

Even when hand grip strength fails to predict a disease, it still predicts the quality of life in people with the disease. The relative rate of grip strength reduction in healthy people is a good marker for the progression of general aging. Faster decline, faster aging. Slower (or no) decline, slower aging. Stronger people—as indicated by their grip strength—are simply better at navigating the physical world and maintaining independence on into old age.

Health and longevity aside, there are other real benefits to a stronger grip.

You command more respect. I don’t care how bad it sounds, because I agree. Historically, a person’s personal worth and legitimacy was judged by the quality of their handshake. Right or wrong, that’s how we’re wired. If you think you feel differently, let me know how you feel the next time you shake hands and the other person has a limp, moist hand. Who are you more likely to respect? To hire? To deem more capable? To befriend? To approach romantically? I’m not saying it’s right. I’m saying it’s simply how it is. We can’t avoid our guttural reaction to a strong—or weak—handshake. To me, that suggests we have a built-in sensitivity to grip for a very good reason.

So, how does one build grip?

10 Exercises To Build Grip Strength

Most people will get a strong-enough grip as long as they’re lifting heavy things on a consistent-enough basis.

1. Deadlifts

Deadlifts are proven grip builders. Wide grip deadlifts are also good and stress your grip across slightly different angles.

2. Pullups and 3. Chinups

Both require a good grip on the bar.

Any exercise where your grip supports either your weight or an external weight (like a barbell, dumbbell, or kettlebell) is going to improve your grip strength. But there are other, more targeted movements you can try to really turn your hand into a vise. Such as:

4. Bar Hangs

This is pretty simple. Just hang from a bar (or branch, or traffic light fixture) with both hands. It’s probably the purest expression of grip strength. As it happens, it’s also a great stretch for your lats, chest, shoulders, and thoracic spine.

Aim to hit one minute. Progress to one-hand hangs if two-handers get too easy. You can use a lower bar and keep one foot on the ground for support as you transition toward a full one-handed hang.

5. Sledgehammer Work

Grab the heaviest sledgehammer you can handle and use it in a variety of ways.

If you had to pick just one sledgehammer movement to target your grip, do the bottoms up. Hold the hammer hanging down pointing toward the ground in your hand, swing it up and catch it with the head of the hammer pointing upward, and hold it there. Handle parallel to your torso, wrist straight, don’t let it fall. The lower you grip the handle, the harder your forearms (and grip) will have to work.

6. Fingertip Pushups

Most people who try fingertip pushups do them one way. They do them with straight fingers, with the palm dipping toward the ground. Like this. Those are great, but there’s another technique as well: the claw.  For the claw, make a claw with your hand, like this, as if you’re trying to grab the ground. In fact, do try to grab the ground. This keeps your fingers more active, builds more strength and resilience, and prevents you from resting on your connective tissue.

These are hard for most people. They’re quite hard on the connective tissue, which often goes underutilized in the hands and forearms. Don’t just leap into full fingertip pushups—unless you know you’re able. Start on your knees, gradually pushing your knees further back to add resistance. Once they’re all the way back and you’re comfortable, then progress to full pushups.

7. Active Hands Pushups

These are similar to claw pushups, only with the palm down on the floor. Flat palm, active “claw” fingers. They are easier than fingertip pushups.

8. Farmer’s Walks

The average person these days is not carrying water pails and hay bales and feed bags back and forth across uneven ground like they did when over 30% of the population lived on farms, but the average person can quickly graduate past average by doing farmer’s walks a couple times each week. What is a farmer’s walk?

Grab two heavy weights, stand up, and walk around. They can be dumbbells, barbells, kettlebells, or trap bars. You can walk up hill, down hill, or around in circles. You can throw in some shrugs, or bookend your walks with deadlifts or swings. The point is to use your grip to carry something heavy in both hands.

9. Pinch Grips

Grasp and hold weight plates between your thumb and each finger.

10. Hammer Curls

Next time you do some curls, throw in a few sets of hammer curls. These are identical to normal bicep curls, except you hold the weights in a hammer grip, with palms facing toward each other—like how you hold and swing a hammer. Make sure to keep those wrists as straight as possible.

The thing about grip is it’s hard to work your grip without getting stronger, healthier, and faster all over. Deadlifting builds grip strength, and it also builds back, hip, glute, and torso strength. Fingertip pushups make your hands and forearms strong, but they also work your chest, triceps, abs, and shoulders. That’s why I suspect grip strength is such a good barometer for overall health, wellness, and longevity. Almost every meaningful piece of physical activity requires that you use your hands to manipulate significant amounts of weight and undergo significant amounts of stress.

For that reason, the best way to train your grip is with normal movements. Heavy deadlifts and farmer’s walks are probably more effective than spending half an hour pinch gripping with every possible thumb/finger permutation, because they offer more full-body benefits. But if you have a few extra minutes throughout your workout, throw in some of the dedicated grip training.

Your grip can handle it. The grip muscles in the hands and forearm are mostly slow-twitch fiber dominant, meaning they’re designed to go for long periods of exertion. They’re also gross movers, meaning you use them all the time for all sorts of tasks, and have been doing so for decades. To make them adapt, you need to stress the heck out of them with high weight. Train grip with high reps, heavy weights, and long durations. This is why deadlifts and farmer’s walks are so good for your grip—they force you to maintain that grip on a heavy bar or dumbbell for the entire duration of the set with little to no rest.

Oh, and pick up some Fat Gripz. These attach to dumbbells and barbells and increase the diameter of the bar, giving you less leverage when grabbing and forcing you to adapt to the new grip conditions by getting stronger.

Now, will all this grip training actually protect you from aging, type 2 diabetes, osteoarthritis, and early all-cause mortality? Maybe, maybe not.

But it—and the muscle and fitness you gain doing all these exercises—certainly doesn’t hurt.

How’s your grip? How’s your handshake? How long can you hang from a bar without letting go?

Thanks for reading, everyone. Take care, be well, and go pick up and hold some heavy stuff.

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References:

Sasaki H, Kasagi F, Yamada M, Fujita S. Grip strength predicts cause-specific mortality in middle-aged and elderly persons. Am J Med. 2007;120(4):337-42.

Leong DP, Teo KK, Rangarajan S, et al. Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet. 2015;386(9990):266-73.

Rantanen T, Volpato S, Ferrucci L, Heikkinen E, Fried LP, Guralnik JM. Handgrip strength and cause-specific and total mortality in older disabled women: exploring the mechanism. J Am Geriatr Soc. 2003;51(5):636-41.

Van der kooi AL, Snijder MB, Peters RJ, Van valkengoed IG. The Association of Handgrip Strength and Type 2 Diabetes Mellitus in Six Ethnic Groups: An Analysis of the HELIUS Study. PLoS ONE. 2015;10(9):e0137739.

Wen L, Shin MH, Kang JH, et al. Association between grip strength and hand and knee radiographic osteoarthritis in Korean adults: Data from the Dong-gu study. PLoS ONE. 2017;12(11):e0185343.

Lee MR, Jung SM, Bang H, Kim HS, Kim YB. The association between muscular strength and depression in Korean adults: a cross-sectional analysis of the sixth Korea National Health and Nutrition Examination Survey (KNHANES VI) 2014. BMC Public Health. 2018;18(1):1123.

Lee SH, Kim SJ, Han Y, Ryu YJ, Lee JH, Chang JH. Hand grip strength and chronic obstructive pulmonary disease in Korea: an analysis in KNHANES VI. Int J Chron Obstruct Pulmon Dis. 2017;12:2313-2321.

Iconaru EI, Ciucurel MM, Georgescu L, Ciucurel C. Hand grip strength as a physical biomarker of aging from the perspective of a Fibonacci mathematical modeling. BMC Geriatr. 2018;18(1):296.

The post Why Grip Strength Matters—and 10 Ways to Build It appeared first on Mark’s Daily Apple.

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Most people chalk urinary incontinence and excessive urgency up to age. We get old, stuff stops working, we wake up to wet sheets. Cue jokes about adult diapers and investing in “Depends” futures. It’s not entirely out of line. Aging matters. There’s just more to it. Like other aspects of “aging,” incontinence and unreasonable urgency don’t just “happen.” Aging may hasten or accompany the decline, but it’s by no means inevitable, unavoidable, or unmitigated.

There are surgical treatments available, many of which involve the implantation of balloons and slings and rings and hammocks. Those are beyond the scope of this post, which will focus on exercises and other less invasive interventions and preventive measures.

What’s the Deal With Urinary Incontinence?

The most well-known type is stress incontinence. When you do anything intense enough to create pressure, such as a sneeze, a particularly boisterous laugh, a trampoline session, a power clean, or a box jump, the pressure escapes through the weakest point of your body—your slack pelvic floor muscles which support and enable bladder function. The result is inadvertent leakage.

The most common type is urgency incontinence. That’s when you can control your bladder well enough, but you feel like you have to go more frequently than you’d like. This can disrupt sleep and place you in uncomfortable situations.

There’s also prostate-related urinary incontinence. If men have incontinence, it’s usually because of prostate issues or prostate surgery altering the normal flow and function of their urinary tract. Today’s post won’t deal with this explicitly, although many of the exercises I’ll discuss that help women treat incontinence can also help men treat prostate-related incontinence. For more info on this, revisit my post on prostate health from a few weeks back.

Both stress incontinence and urgency incontinence usually have the same cause: pelvic floor dysfunction. The pelvic floor acts as a taut, supple sling of muscle and connective tissue running between the pelvis and the sacrum that supports the pelvic apparatus, including organs, joints, sex organs, bladders, bowels, and various sphincters. We use it to control our urination, our bowel movements, even our sexual functions. It’s very important.

What Goes Wrong?

It gets weak and tight and pulls the sacrum inward (the tail gets pulled toward the front of the body), interfering with urination and urinary control.

What causes pelvic floor dysfunction?

Childbirth is one potential cause, but it’s not a foregone conclusion. Women who have vaginal deliveries are more likely to display more pelvic floor dysfunction than women who have cesareans, while a more recent study found that tool-assisted vaginal delivery and episiotomy were the biggest risk factors for vaginal delivery-associated incontinence, not vaginal delivery alone. Allowing passive descent in the second stage of labor, rather than active pushing from the get-go, might also reduce the association.

Muscular atrophy of the pelvic floor muscles. The pelvis is where the magic happens. It’s where we generate power, walk, run, procreate, dance, and move. To keep it happy, healthy, and strong, we have to move. And then keep moving. Through all the various ranges of space and time and possible permutations of limbs and joints. That’s what all our muscles expect from the environment. It’s what they need. When that doesn’t happen, they atrophy—just like the other muscles.

Who Develops Incontinence?

Stress incontinence is more common among women than men. And most women with stress incontinence are older, although childbirth can increase the incidence.

Signs of Poor Pelvic Floor Function

Besides urinary incontinence and urgency incontinence—which are pretty tough to miss—what are some warning signs of poor pelvic floor function?

Low-to-no glute activity when walking. According to expert Katy Bowman, the glutes play a crucial role in pelvic floor function and incontinence prevention.

Lack of lower back curvature. This suggests your pelvis is being pulled inward due to poor glute activity and/or overly tight pelvic floor musculature.

Muscle atrophy elsewhere. If the muscle’s disappearing from your arms and legs, what do you think is happening in other areas?

What Can You Do?

Work On Your Squat

If you can’t sit in a full squat, with shins fairly vertical and heels down on the ground, you need to work on your form.

I suggest reading this old post by Kelly Starrett describing optimal squat form. He focuses on performance and strength training, but the technique applies equally to basic bodyweight squatting for pelvic floor health.

One thing to emphasize: go as low as you can without reaching “butt wink” threshold. The butt wink is when the pelvis begins rotating backward underneath the body. If you’re butt winking all over the place, you’re shortchanging your glutes and preventing them from balancing out the pelvic floor situation. Stop short of the butt wink.

Squat a Lot

You don’t have to load up the bar, although that’s a great way to build glute strength. In fact, I’d refrain from heavy squatting if you’re currently suffering from urinary incontinence, as the stress placed on that region of the body during a heavy squat can make the problem worse and cause, well, leakage.

I’m mainly talking about everyday squatting: while playing with the kids, picking up dog poop, unloading the dishwasher, brushing your teeth, cleaning the house, gardening. If you can incorporate squatting while using the bathroom, perhaps with a Squatty Potty or similar product, that’s even better. Katy Bowman recommends women squat to pee in the shower as an integral part of her therapy for pelvic floor disorder.

Squat To Use the Toilet (or At Least Get Your Feet Up)

I wrote an entire post almost ten years ago exploring the virtues of squatting to poop. Not only does it improve symptoms in hemorrhoid sufferers, reduce straining, and alleviate constipation, but squatting to poop turns out to relieve a lot of excessive pressure on the pelvic floor musculature.

Not everyone’s going to hoist themselves up over the toilet standing on a stack of thick books, or go all out and build a Southeast Asian-style squat toilet in their bathroom, or even get the Squatty Potty. It’s probably the best way to do it—and it’s certainly the most evolutionarily concordant way to poop—but it’s not totally necessary. What matters most is getting those feet up and those knees above your hips. If you can achieve this by placing your feet on a stool (not that kind of stool) as you sit on the toilet, it should do the trick.

Take a Walk and Feel Yourself Up

Next time you walk, rest your palms on the upper swell of your butt cheeks. Every time you step through, you should feel your glutes contract. If they contract, awesome. You’re unconsciously using your glutes to propel yourself forward. If they don’t, you’ll have to train them to contract when you walk.

Do this by going for a ten minute walk (minimum) every single day while feeling your glutes. Consciously contract them enough and feel yourself up enough and the resultant biofeedback will make glute activation a passive behavior, like breathing. Eventually you’ll start doing it without thinking. That’s the goal.

Do Kegels—Differently

The classic therapy for pelvic floor disorder is to train the pelvic floor muscles directly using kegels. This is the muscle you contract to stop yourself from peeing midstream. “Doing kegels” means contracting and releasing that muscle for sets and reps. A common recommendation is to hold for ten seconds, release for ten seconds, repeated throughout the day. Waiting in line? Kegels. Eating dinner? Do some kegels. Remember that man at the DMV last week who would randomly tense up and start sweating as you both waited for your number? He was probably doing kegels.

It’s definitely part of the story—studies show kegels work in men, women, and seniors—but it’s not enough.

Consider  Katy Bowman’s take on the subject. She thinks kegels by themselves make the problem worse by creating a tight but ultimately weakened pelvic floor muscle that pulls the sacrum further inward. Combine that with weak or underactive glutes that should be balancing the anterior pull on the sacrum but don’t and you end up with rising pelvic floor dysfunction and incontinence.  She recommends doing kegels while in the squat position to ensure that the glutes are engaged and all the other contributing muscles are in balance.

Do More Than Kegels

The bad news is that we don’t have controlled trials of Katy Bowman’s protocols with deep squats and frequent daily movement and going barefoot over varied surfaces and squat toilets. We mostly just have basic “pelvic floor exercises,” which usually just mean “kegels.” The good news is that even these suboptimal exercise therapies seem to work on anyone with incontinence, whether they’re just coming off a pregnancy, a 70th birthday, or a prostate procedure. Young, old, middle-aged, male, female—exercise works.

Actually, we do have one small study that suggests kegels will work much better if you balance them out with exercises that target the glutes and hips. In the study, women suffering from urinary incontinence were split into two treatment groups. One group did pelvic floor muscle exercises (kegels). The other group did pelvic floor muscle exercises, plus exercises to strengthen the hip adductors, the glute medius, and glute maximus. Both groups improved symptoms, but the group that did the combo exercises had better results.

For hip adduction, you can use that hip adduction machine where you straddle the chair with legs spread and bring your knees together against resistance. Another option is to use resistance bands. Attach one end of the band to a secure structure and the other to your ankle. Stand with legs spread, then bring the banded leg inward toward the unbanded leg; you should feel it in your inner thigh. Do this for both legs.

For glutes, you have many options. Glute bridges, hip thrusts, squats, deadlifts, lunges, resistance band glute kickbacks.

If you want to get deep into this subject and really learn the optimal exercises for pelvic floor dysfunction, I’d pick up a copy of Katy’s Down There For Women.

Get Strong and Stay Strong

One of the strongest predictors of urinary incontinence is physical frailty. The more frail—weak, fragile, prone to falling, unable to handle stairs, unsteady on one’s feet—the man or woman, the more likely they are to suffer from urinary incontinence. This mostly comes down to muscle atrophy; the frail tend to have low muscle mass all over, including the pelvic floor.

Studies show that strength training improves urinary control in both men coming off prostate procedures and women.

The best option is to never get frail in the first place. If you’re younger and in shape, keep training and moving. Don’t lose it. If you’re younger and trending frail, get training and moving. Don’t squander the time you have. It goes quickly. If you’re older and frail, you have to start today. Fixing this doesn’t happen overnight. Being frail makes it harder to do the things necessary to get strong, but that doesn’t absolve you of the responsibility.

The Bottom Line

None of this stuff is a guarantee against incontinence. Guarantees don’t really exist in life. But I’d definitely argue that anyone who employs all the tips and advice mentioned in today’s post will have a better shot at maintaining bladder control than their doppelganger in some parallel universe who never tries anything—the earlier the better.

If you have any experience with urinary incontinence, let us know in the comments down below. What worked? What didn’t? What worked for a while, then stopped?

Thanks for reading—and sharing here. Happy Halloween, everybody.

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References:

Bernstein IT. The pelvic floor muscles: muscle thickness in healthy and urinary-incontinent women measured by perineal ultrasonography with reference to the effect of pelvic floor training. Estrogen receptor studies. Neurourol Urodyn. 1997;16(4):237-75.

De araujo CC, Coelho SA, Stahlschmidt P, Juliato CRT. Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review. Int Urogynecol J. 2018;29(5):639-645.

Kokabi R, Yazdanpanah D. Effects of delivery mode and sociodemographic factors on postpartum stress urinary incontinency in primipara women: A prospective cohort study. J Chin Med Assoc. 2017;

Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol. 1996;88(3):470-8.

Dokuzlar O, Soysal P, Isik AT. Association between serum vitamin B12 level and frailty in older adults. North Clin Istanb. 2017;4(1):22-28.

The post Urinary Urgency and Incontinence: Why It’s Not Just Age appeared first on Mark’s Daily Apple.

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I’m 65, and though I’ve been able to stave off the worst of what normally passes for the “aging process”—as can almost anyone by paying attention to how you eat, sleep, train, move, and live—the fact remains that I’m not training like I used to.

It’s not so much that I’m “losing” a step, although it happens to the best of us. It’s that I’ve totally transcended the need or desire to train hard for the sake of training hard. There are no more competitions. My ego is content on the training front. I’m not wrapped up in pounds lifted or miles run.

I get regular questions about what I do for workouts and how they’ve changed over time. Today I thought I’d answer this.

Miami has a fantastic gym culture with impressive facilities to support it. I almost have to go the gym. It’s something I still enjoy. I just make it count.

I’ve managed to compress my time in the gym with “super-sets” for each exercise.

These aren’t always super-sets where you’re bouncing between the squat rack and the bench press every other set. The kind of super-set I’m talking about is a rest-pause super-set. I try to hit between 12-20 total reps—that’s my goal—in three mini-sets with minimal rest. The super-set is broken up into three subsets with very short rest periods.

An example: Deadlift, 9 reps. Rest 30 seconds. Deadlift, 6 reps. Rest 30 seconds. Deadlift, 4 reps. You’re done. That’s a total of 19 reps. Once I hit 20, I’m adding weight.

Why I like this method:

  • Over fast. I get in, get a great workout, and get out.
  • No meandering and wasting time between sets. There are hard rules (30-second rests) that I must follow.
  • Hard to go heavy enough to hurt yourself. If you’re doing 15-20 reps with little rest, by necessity the weight you use needs to be manageable.
  • But heavy and intense enough to produce benefits. I know, I know, feeling sore the next day isn’t a good barometer of how effective the workout was. That’s what they say, but everyone secretly loves and craves the feeling of DOMS. Really makes you feel like you did something worthwhile.

I’ve fallen in love with the trap bar.

At this point in the game, I don’t need to hit PRs on the straight bar deadlift. Trap bars just feel safer, more natural, more versatile. Some great possibilities (many of which I throw in) include:

  • Trap Bar Deadlift With Squat Bias—Deadlifts with more knee flexion, almost a half squat.
  • Trap Bar Romanian Deadlift—Knees soft but mostly straight, almost a straight leg deadlift with or without touching the floor in between reps.
  • Trap Bar Power Shrug—Deadlift at a pretty good clip, explode upward and shrug the bar. Almost like you’re jumping without leaving the ground.
  • Trap Bar Squat—Squat down, grasp bar, stand up, repeat. Stack some weights and stand on them for added range of motion/squat depth.
  • Trap Bar Split Squat—Stand inside the hexagon, place foot on elevated surface (1.5 ft, about) behind you, perform a split squat, wake up sore.
  • Trap Bar Row—Stand inside the hexagon, bend over at the waist, row that bar up toward your belly.

The average person can get 90-95% of the benefits using a trap bar instead of a straight bar. Maybe higher, even.

I lift for a different purpose now.

As for the weights I use, now that my PR days are behind me, I lift to avoid injury now more than anything. That means knowing what “heavy” really is and backing down a hair. I’ll do one or two upper body days, and one leg day each week. That’s it. Two, maximum three strength sessions.

I base my workouts around standup paddling and Ultimate Frisbee games.

Both of these are stressful enough (in a good way) that I want to be rested for (and from) those activities before I engage in a lifting session. Just to be clear, I play Ultimate all-out for up to two hours, so it’s become my sprint day.

The Miami Ultimate Frisbee scene is very high-level. I’ve fallen in with a regular pickup squad, and the level of competition rivals Malibu’s. So, that aspect of my activity hasn’t changed. I’m still getting my one day of Ultimate a week.

If I’m feeling up to it, Miami beaches are fantastic for sprints. You don’t go as fast because the sand is so powdery, but it makes you work even harder.

Miami has also really changed how I spend time with my favorite activity, standup paddling.

In Malibu, it was a bit wilder. I’d head out past the breakers and paddle in any direction. It was huge, free, open, and infinite.

In Miami, you have the ocean side which is great and much calmer than Malibu, but you also have these inland waterways, like huge canals running through Miami. I’ve been spending a ton of time exploring them, checking out the beautiful homes and boats and even the occasional manatee popping up. And because it’s so calm, I can really go hard without worrying about waves. While paddling is fun, I go pretty hard for at least an hour and up to 90 minutes, so it’s a serious aerobic day for me.

I walk more.

I can walk so much more in Miami. In Malibu, I had to drive somewhere to walk, whether it was a trail head for a hike, down to the beach for a stroll, or to Venice or Santa Monica to just wander. In Miami, Carrie and I can walk out the door and go the market, the water, the book store, the cafe, or just wander. It’s integrated into our day, not something we have to schedule. People don’t really think of Miami as a ‘walking city,” and it’s certainly no New York or San Francisco, but it beats the pants off Southern California.

Trap bar, rest-pause sets, and environment aside, what I train hasn’t changed all that much. I’m still lifting heavy things, running really fast, moving frequently at a slow pace, and doing activities I love. But somehow I’m doing a better job of seamlessly integrating them into my daily existence. I’ve minimized the amount of time I spend lifting without compromising my results. I’m using my compressed training to fuel the activities I love doing, giving me more time that’s also higher quality.

A lot of this could be the simple result of moving somewhere new after living in the same city for twenty years, sort of a honeymoon phase. We’ll see. My workouts here are even more a part of my general lifestyle. They’re, for the most part, parts of my life rather than interruptions to it, which is the ancestral model at its modern best maybe. That’s how I choose to see it.

Thanks for stopping by today, folks. I’d love to read your feedback and questions and hear what new routines you’re trying out. Take care.

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The post Mid-60s Check-in: 5 Ways My Workout Has Changed appeared first on Mark’s Daily Apple.

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Yesterday, I linked to a study showing that the beneficial effects of high levels of cardiorespiratory fitness—the kind you build with cardio/endurance training, HIIT, and sprints—have no upper limit. At first glance, this study appears to bust the “myth” of chronic cardio and the U-shaped curve of endurance training and prove that the more you train, the longer you’ll live. This appears to run counter to some of my central claims—that too much mid-to-high intensity endurance exercise leads to burnout, health issues, and diminishing returns.

A commenter wrote a great comment that got me wondering:

As far as “the more exercise the better” study I wonder if folks who had to drop out of long distance cardio training due to injuries or cortisol driven exhaustion are considered in the equation? In other words, if you can tolerate chronic cardio you may live longer, otherwise it might break you down. Everyone has a sweet spot for exercising is my gut feeling and you have to “listen to your body”. I still like the primal mantra along the lines of (if I may be so presumptuous as to paraphrase Mark) “walk a lot, do sprints once a week, lift heavy things once or twice a week, spend time outdoors, take part in sports or recreational activities that are fun for you”.

What do I think is going on? How do the results of this paper jibe with my take on Chronic Cardio?

First off, we have to acknowledge the basic structure of the study.

This study didn’t actually measure “hours spent training.” They gave subjects treadmill tests (stress tests) to determine their cardiovascular fitness, then divided everyone into different tiers of fitness based on the results. In fact, the authors of the study criticized the shortcomings of previous studies which used self-reported training data instead of objective measurements of cardiorespiratory fitness like the treadmill test. This makes the study far more accurate and useful. It also means you can’t make any ironclad proclamations about the connections between hours spent training and longevity. You can certainly make inferences—people who had better cardio fitness probably spent more time training to get it—but there are other interpretations. All you can say for certain is that higher levels of cardio fitness predict greater longevity.

I don’t see how anyone could argue with that. Of course being fitter is better.

But my criticism of chronic cardio isn’t a criticism of cardiovascular fitness. It’s a criticism of how most people go around obtaining that fitness—by destroying their bodies.

That doesn’t have to happen anymore. Tons of top guys these days are finally figuring out that you don’t have to log as many laps/miles/etc as possible to maximize your performance, but that wasn’t always the case. I grew up convinced that the more miles I ran, the healthier I’d be. That’s how I did it back in my marathon and triathlon days, and it almost destroyed me and an entire generation of my peers.

You can train twice as much as the next guy yet have worse fitness, either because you’re not training intelligently, you’re overtraining and hampering the adaptive process, or you’re not sleeping. That’s chronic cardio. You can train less and get better results, if you’re optimizing your recovery, nutrition, and sleep. That’s Primal Endurance.

As for these subjects, there is some serious genetic confounding occurring. Those dudes with elite fitness levels well into their 70s are often a different breed. They’re hard to kill. They’re tough. They can withstand the discomfort of grueling mile after mile. What other types of discomfort can they bear and even grow from? They’re just more robust than the average 70-year-old. It may not be the elite training itself that’s making them resist death. It’s just as likely they have the genetic capacity to excel in endurance training, and even if they didn’t exercise they’d still live longer than average.

There’s also the healthy user bias. The kind of lifestyle regular exercisers follow emphasizes sleep, plenty of rest and recuperation, smart supplementation and nutrition, and all sorts of other things that are also linked to longer, better health.

This paper makes a strong case for using something like Primal Endurance to build great cardiorespiratory fitness without risking chronic cardio territory.

Thanks for writing and reading, folks. Take care!

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The post Dear Mark: Is There No Upper Limit to Endurance Training? appeared first on Mark’s Daily Apple.

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As many of you know, Brad is my longtime writing partner, host of the Primal Endurance podcast and host of the weekly keto show on the Primal Blueprint podcast. Our relationship goes back 30 years to when I was Brad’s coach during his career on the professional triathlon circuit. The start of Brad’s chronic plantar fasciitis ordeal dates back nearly that long, until he was completely cured in a matter of weeks back in 2011. Hence, the subject of today’s post! If you are a sufferer, pay close attention because we dove deep into this topic and are giving you the tools to never suffer again.

Indeed, as Brad will detail shortly, miracle cures are possible, even for extreme sufferers. About three years ago, Brad was over at my place on a Monday and noticed me spending a lot of time rubbing and stretching my chronically tight Achilles tendon; it had taken its weekly beating the previous day at Ultimate Frisbee. I tried the prolonged stretches he details in the article and experienced immediate relief. (Around the same time, I also started to experiment with the early supplemental collagen products on the market, which also helped my foot issues and other joint aches and pains clear up.). 

Enjoy today’s article, and let us know your thoughts on this treatment protocol. 

Plantar fasciitis—it’s painful to even pronounce, and if you contract this condition you’re in for a long, frustrating, painful ordeal. It’s characterized by a burning sensation around the rim and/or bottom of your heel, and assorted peripheral pains such as a sore or burning arch, sensitive nerve endings along your arch, inflamed bursa sacs in your heel bone that make the heel sensitive to touch and applied weight, a bumpy, lumpy sensation on the bottom of your heel that are often called bone spurs, and general stiffness, tightness, and pain in the foot, arch, Achilles tendon, and calf muscles.

Symptoms are typically worse first thing in the morning or after prolonged periods of sitting or standing. If you have a mild case, you can get some range of motion and blood flow going upon awakening and the pain will typically subside and not compromise your exercise. In advanced stages, you will have a hard time getting mobility going and even walking will be painful. When you do get sufficiently warmed up and into a workout, the burning pain will often continue during and after exercise. The condition can worsen over time until you are sidelined by the lack of mobility and subsequent chronic pain.

Explaining Plantar Fasciitis: Anatomy and Causes Behind It

The plantar fascia is a super-strong ligament that runs the length of the bottom of your foot. On one end, the plantar fascia attaches to the metatarsal bones of each of your toes. It then fans out wide, like a sheet covering the length of the bottom of your foot. It subsequently tapers to attach into your calcaneus (heel bone). The plantar fascia acts as a prominent shock absorber when you walk, run, or jump. Consequently, it gets put under a lot of stress and can easily become inflamed when the muscles, ligaments, and tendons in your lower extremities are dysfunctional or overstressed.

Plantar fasciitis is extremely common among not only runners and competitive athletes but also folks who work on their feet all day like nurses, laborers and even standup desk user. Then there are people who have strong sedentary patterns (commute, desk job, insufficient exercise); people with arthritis, obesity, poor muscle tone, flexibility, mobility or generally poor physical fitness; and people who wear crappy modern shoes with stiff construction, encased toe compartments, and elevated heels. Does that pretty much cover the entire population of the developed world?

Indeed, no one is immune to the risk of plantar fasciitis, because the condition often comes about when there is any sort of weakness, overuse, inflammation, or dysfunction in the muscles, tendons, and ligaments in the lower extremities. For example, if your calf muscles or Achilles tendons become stiff and inflamed from doing chronic cardio or consuming an inflammation-boosting high-carb, allergenic-loaded, SAD diet, these dysfunctions may manifest most painfully as plantar fasciitis.

I don’t know many serious runners who haven’t had this condition at one point or another in their lives. I had the condition for the better part of 15 years—ranging from a mild lingering annoyance that vanished with some quick morning exercises that increased blood flow and mobility, to so debilitating that I couldn’t walk in the morning. Indeed, for several years in the midst of my professional triathlon career, I had to exit bed onto one leg, hop out the door into the backyard, then drop my right leg into my backyard spa. Only after a few minutes of working through ankle and calf range of motion with hot jets blasting could I apply pressure to the foot and walk normally. Then, I’d lace up my shoes and head out for a run of five, ten, or even twenty miles!

That’s a strange juxtaposition from cripple to endurance machine in a few minutes, but it generates an important reflection: plantar fasciitis almost never gets better with rest alone. On the contrary, it quite often gets worse when an injured athlete stops running or a nurse takes a leave from the ER floor for a desk position. For example, during one off season of my professional career, I decided (in consultation with my coach Mark Sisson) to take a six-week break from running in order to focus on swimming and cycling and allow the painful plantar fasciitis injury to heal once and for all. Upon my return to light jogging, you can guess what happened: the injury was more painful than ever!

Interventions That Address the Symptoms, Not the Cause

Before we get to the prescribed treatment protocol, let’s look at what interventions are commonly suggested but generally don’t work well at actually treating the condition. (See how many look familiar.) As you might expect, athletes and active folks have tried all sorts of treatment modalities and remedies, most of them landing somewhere on the spectrum from ineffective but harmless to outright disastrous.

Rest

Well intentioned as it may be, rest is usually ineffective with plantar fasciitis. Getting off your feet or out of your exercise groove results in atrophy of both the large muscles and small stabilizer muscles in your legs as well as reduced range of motion, increased stiffness, shortened muscle, and—often—more pain when you try to return to your normal activities.

Orthotics, Arch Supports, Arch Taping

These approaches work like a Band-Aid works to stop the bleeding. If you have plantar fasciitis and have to perform for your country in the Olympics, a professional taping job is a great idea to keep the pain at bay and allow you to qualify out of your heat for the quarter-final. Alas, these support measures fail to address the cause, however.

Furthermore, they can very often compromise healing if you insist on using them long-term instead of making a sincere commitment to addressing and healing the underlying causes. Specifically, using artificial aids and supports will cause weakening and atrophy of the lower extremities over time. You make things easy for your feet, so they can wither away inside a cushy protective cocoon instead of be challenged to grow stronger every moment that you ambulate.

That said, remember that staying active is essential to ultimate healing of plantar fasciitis, and so using support measures to help you stay active by any means necessary can be warranted over the short term.

Ice, Heat, Electrical Stimulation, Ultrasound

These and other feel-good techniques are generally focused on relieving painful symptoms—symptoms that are bound to return again and again over time until you address the cause. As previously stated, complementary therapies are fine to the extent that they help keep you active. Ice massage can also be helpful in the aftermath of performing some aggressive healing exercises, as we will discuss shortly.

Massage Therapy

This can be highly effective to undo some of the damage caused by chronic injury and facilitate healing. In particular, Active Release Technique (ART) and deep tissue techniques go a long way toward increasing the mobility and fluidity of muscles and connective tissue.

The caveat here is that deep massage and ART treatments set you up for success, but you have to do the healing work described shortly to make the effects stick. Otherwise, you will undo damage with the bodywork, then create the damage all over again by exercising on dysfunctional legs.

Cortisone Injection

Can you say “rupture”? Not rapture, but rupture. Yes, ouch! Generally, cortisone injections provide immediate and amazing relief from pain symptoms, often at extreme risk to your long-term health. When you override your body’s natural inflammatory processes and pain signaling with a powerful drug, you gain instant relief, but increase injury risk because you no longer are governed by natural tightness and pain that is attempting to protect you from the damage of performing with a dysfunctional appendage. Furthermore, anti-inflammatory treatments (including chronic use of seemingly innocent NSAIDS before workouts) weaken your natural ability to regulate inflammation over time.

There are a tiny fraction of injury cases where a cortisone injection may provide enough relief to facilitate an aggressive rehabilitation process that results in healing, but I urge extreme caution here. I say “extreme” because you may face enthusiastic health care professionals who will pretty much beg you to accept an injection. I know someone whose decades long nursing career ended in large part due to a cortisone injection that preceded a rupture, multiple surgeries, and ultimately a downward spiral that ended in permanent disability status.

The Plantar Fasciitis Cure: An Extended Stretching Regimen For Fast Healing

When you address the causes of plantar fasciitis, you’ll experience relief from the painful symptoms surprisingly quickly. To correct the cause, you must lengthen your calf muscles, increase mobility throughout the lower extremities, and start a methodical progression to a more minimalist/barefoot lifestyle. Commit to the following protocol every single day for just a couple weeks and it’s quite likely that even a severe and debilitating long-term condition will clear up to the extent that you will be pain-free and fully functional in a matter of weeks.

Lengthen Your Calf Muscles

“Do the wall stretches several times a day. Hold each stretch for two minutes. You’ll be healed in a few weeks.” This brief quip was all I needed to cure 15 years of consistent pain and suffering from plantar fasciitis. The message was delivered to me in 2011 by a podiatrist in a booth at the race expo of the Sacramento, CA, Urban Cow Half-Marathon and 5k—where I am the announcer annually. I have tried in vain to figure out who the guy was, but I’ll extend my deepest gratitude to the mystery healer right here and now.

Here is what happened on that fateful day: I typically walk the grounds and meet the exhibitors, so I can give them a little plug over the P.A. I remember from that day a booth with signs about healing foot pain and exam tables set up for interested runners. An enthusiastic podiatrist greeted me at the booth and started talking about how he could easily and quickly cure conditions like plantar fasciitis.

I challenged his assertion, informing him that I’d had the condition for 15 years and had tried everything: morning Jacuzzi hopping, a heel lift in my right foot, removing the heel lift, returning the heel lift, expensive rigid orthotics custom molded from my footprint, expensive soft “dynamic” orthotics made of silicone gel, obsessive icing and stretching, wearing giant pillow cushion shoes from Nike, switching over to Vibram Five Fingers and other minimalist options, switching back to pillow shoes—basically everything short of the dreaded cortisone injection.

I eventually agreed to try the prolonged stretches, obviously with huge reservations but a sincere commitment. In a few weeks, my symptoms were completely gone for the first time in 15 years. I’d call it a miracle, but it was so incredibly simple I’m not sure you can call it a miracle.

Extended Wall Stretch

Hopefully, you’re familiar with the wall stretch that is the runner’s bread and butter? You extend one leg behind you, lean into the wall at a 45-degree angle, and push against it like you are trying to push it over. With your rear leg straightened and heel grounded, the stretch focuses on the soleus, the narrow muscle running along either side of your leg and merging at the bottom into your Achilles tendon. When you bend your rear leg and lift your heel off the ground, you redirect the emphasis to the gastrocnemius, the ball-shaped muscle that gives you that sexy rock-hard definition on the upper part of your leg.

Holding each of the aforementioned four stretches (left leg straight, left leg bent, right leg straight, right leg bent) for two minutes is the secret to healing. In case you’ve never timed your stretches, holding a single position for two minutes will likely seem like an eternity. I’d speculate that the most devoted stretching enthusiasts might never hold a single stretch for than 10-20 seconds. Even the most deliberate of yoga classes won’t hold you in a single position for that long. As I mentioned, I had devotedly stretched my lower legs and feet in assorted ways for years in the tug-of-war against my condition, but never held any single stretch for so long.

Why Two Minutes?

When you hold a stretch for two minutes, you are sending a powerful message to your musculoskeletal and central nervous systems to lengthen the relevant muscle fibers. Witness ballerina dancers stretching for hours every day in order to maintain optimal muscle function for their demanding efforts—constantly reinforcing the message to brain and tissue that they need to by hyper-flexible.

This process of lengthening a muscle is complex but important to understand. If you listen to or read the Nutritious Movement commentary from noted biomechanist and author Katy Bowman, you may be familiar with the term proprioceptors. These are the nerve endings that help your muscles communicate with your central nervous system. When your proprioceptors detect a muscle fiber being stretched, something called the stretch reflex is triggered. This reflex causes a stretched muscle to contract—an excellent safeguard against injury during assorted day-to-day activities, including fitness activities and sports.

After a workout in which muscles have repeatedly contracted or absorbed impact, holding a few stretches for twenty seconds will send a nice little message to the fibers to relax and loosen up a bit as you transition from a state of exertion to relaxation. Then the stretch reflex kicks in, you experience a little discomfort, and end the stretch. When you go big time, work through the possibly uncomfortable stretch reflex sensation, and hold the muscle in a stretched position, you start to make some real progress. Here the proprioceptors in the stretched muscle, known as the muscle spindles, become habituated to the new length of the muscle such that the stretch reflex is muted. Instead, when specific thresholds of stretching frequency, intensity and duration are exceeded, a lengthening reaction occurs in the muscle. Here the muscles relax and allow you to deepen into the stretch. If you have ever been to a yoga class and noticed you can take stretches much deeper after you are warmed up and habituated with repeated stretches, you may know what this lengthening reaction feels like.

When your muscles relax due to the lengthening reaction, another key player on your healing team jumps into action: the golgi tendon organ. This is located in the tendon near the end of a muscle. It sends a message to your central nervous system, essentially: “Hey, this dude is sick of suffering with plantar fasciitis for 17 years. He wants some longer calf muscles for Christmas, so please comply.” Enjoy this much more detailed and scientific discussion of the science of muscle stretching.

Tips For Adopting the Healing Protocol

If you want to heal quickly, strive to quickly work up to doing the wall stretch protocol several times a day (shoot for five times or more). As described previously, this will take all of eight minutes per session: two stretches on two legs for two minutes each. An aggressive stretching regimen will, in a matter of days, greatly relieve the stress on your arch and heel caused in large part by shortened muscles that don’t absorb impact optimally.

Because of the high degree of difficulty with two-minute stretches, you can expect some next day soreness. Take care to stretch only the point of mild discomfort instead of actual pain. This may mean you have to back off a bit during your wall push to survive until the two-minute bell. You will also likely discover that you will be able to hold a much deeper stretch in the evening than in the morning, and more easily reach the two-minute bell. Alas, doing these stretches first thing in the morning when your muscles are the shortest is critical to your progress. So is doing them as many times per day as you are willing. Remember, we are trying to work beyond the stretch reflex and achieve a lengthening reaction.

You may even consider getting the legendary Strassburg sock to assist your healing process. This device, a sock with a strap attached, places your ankle in a flexed position all night, putting the plantar fascia under tension so that it does not contract and cause the painful morning stiffness. Instead, you wake up with an elongated plantar fascia much like the afternoon version that feels much better to walk on than the morning version. Again, the sock is best used in conjunction with an aggressive healing protocol.

Please keep in mind this prolonged stretching protocol is designed for injury prevention/healing, and is not advisable right before a workout. You may have heard prominent accounts of how static stretching can temporarily weaken a muscle for up to 30 minutes, and this is a valid concept. After all, you are about to demand intense contractions from your muscles for the workout, so aggressive pre-workout stretching is not the best way to prime them for action. Instead, do a simple warmup—increasing body temperature and respiration to the extent that you break a little sweat.

Watch this video where I describe the power of the wall stretch to heal plantar fasciitis and direct you to do the stretches correctly.

Mobilizing Lower Extremities

Concurrent with your commitment to prolonged calf stretches is a commitment to achieve increased mobility and flexibility in the foot and leg, via a series of special movements and treatment modalities with colorful nicknames. If you’re in the Crossfit scene or otherwise a fan of Dr. Kelly Starrett, aka “K-Starr,” you might be familiar with some of the unique and colorful terminology—terms like bashing, tacking and mobilizing—that have become his custom lexicon and spread like wildfire into the fitness community. K-Starr is a former elite level whitewater kayak athlete, proprietor of San Francisco CrossFit, creator of the popular MobilityWOD.com website, and author of Becoming a Supple Leopard—perhaps the most comprehensive volume on mobility, flexibility, functionality, healing and prevention for athletic folks ever in the history of the world. Visit MobilityWOD.com to get a free 10-day dose of Kelly and his highly engaging, informal, and humorous style with which he conveys his unique and effective approach.

K-Starr is a big fan of using toys like massage balls, golf balls, lacrosse balls, foam rollers, voodoo straps (try this Voodoo Floss treatment for plantar fasciitis) and even elbows in an aggressive and focused manner to increase blood flow, improve range of motion, and facilitate healing in muscles and connective tissue. Once your mobility improves, you then have a fighting chance at exhibiting correct functional movement during exercise and daily life (e.g., running with a balanced center of gravity over your feet and an efficient dorsiflexion of the foot on each stride), such that you won’t be doomed to a lifetime of repeating injuries, both acute and overuse.

Regarding plantar fasciitis, Starrett recommends attacking the cause by working to increase mobility, flexibility, and functionality throughout the lower extremities. You can check out his full suggested regimen on YouTube.

Complete the prolonged stretching plus mobility work protocol several times a day until the pain and stiffness are nearly when you awaken in the morning. Then you can shift into maintenance mode where you might do the stretches once or twice a day instead of five to seven times a day. And you might do your bashing, tacking and mobilizing only in the aftermath of tough workouts when you experience next-day stiffness.

Your main objective is to prevent the shortening and lost mobility that laid the foundation for plantar fasciitis in the first place. 

Look for Brad’s follow-up post on preventing plantar fasciitis from setting in (or re-occurring) later in just a couple weeks. In the meantime, give your focus to the treatment, and let these stretches do their magic. Thanks again to my friend, Brad Kearns, for stopping in and sharing his experience today.

Again, you can follow Brad on his new podcast, Get Over Yourself, where he gets to unleash his lively personality and cover broader topics including health, fitness, peak performance, personal growth, relationships, happiness, and longevity, always with humor and a little spice.

Thanks, everybody. Be sure to share your thoughts and questions on plantar fasciitis below. Have a great end to your week.

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Resources/References:

Dr. Phil Maffetone and Dr. Mark Cucuzella, How to Treat Plantar Fasciitis Naturally (pdf booklet)
Hal Walter, How to Treat Your Plantar Fasciitis Naturally

Phil Maffetone and Dr. Frykman, barefoot running podcast

Dr. Kelly Starrett Plantar Fasciitis

Plantar Fasciitis, Fix Your Feet

The Physiology of Stretching

Stretching: The Truth

Strassburg Sock

Voodoo Floss ankle and calf

The post How To Cure Plantar Fasciitis appeared first on Mark’s Daily Apple.

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For today’s edition of Dear Mark, I’m answering two questions from readers. First, is it possible to become deficient in omega-6 fats as an adult? What would that even look like, and is there anything that might make omega-6 more important?

Second is a question related to last week’s feature on prostate health. Is saw palmetto an effective supplement for prostate issues? It depends on the issue.

Let’s go:

I have a question for “Dear Mark”
Here it is:

I am completely and totally primal for 10 years now. Can I become O6 deficient ? Since 90% of my fat intake is saturated or O3.

It’s technically possible to become deficient in omega-6 fatty acids. The early rat studies that discovered the essentiality of Omega-6s found that their complete removal made the subjects consume more food (without gaining weight), drink more water (without peeing more than rats on a normal diet), develop scaly skin, lose fur, urinate blood, go infertile, grow weird tails, and die early. All this despite eating an otherwise nutrient-dense diet with all the fat-soluble vitamins (they even removed the fat from cod liver oil and gave the vitamins), B vitamins, and other nutrients a rat could ever want. The only thing missing was a source of omega-6 fats.

Once they discovered the issue—a lack of omega-6—how’d they fix it?

Coconut oil didn’t work, for obvious reasons. It’s almost pure saturated fat.

Butter worked, but you had to use a lot. The omega-6 fraction of butter is quite low.

Cod liver oil worked, but it didn’t fully cure the deficiency disease.

Lard worked well, as did corn oil, liver, flax oil, and olive oil. All of those fat sources fully resolved the issue and eliminated the symptoms. They were all good to decent sources of omega-6 fatty acids.

They also tried pure linoleic acid (the shorter-chained omega-6 PUFA found in nuts and seeds and the animals that eat them) and arachidonic acid (the long-chain omega-6 PUFA found in animal foods). Both worked, but AA worked best.

Throughout all these trials, exactly how much omega-6 fat did the rats require in their diets to cure deficiency symptoms?

When they used lard to cure it, the rats got 0.4% of calories from omega-6 PUFA. If the numbers hold true for humans, and you’re eating 2500 calories a day, that’s just 10 calories of omega-6, or about a gram and a half of pure arachidonic acid to avoid deficiency.

When they used liver to cure it, the rats got 0.1% of calories from omega-6 PUFA. If the numbers hold true for humans, and you’re eating 2500 calories a day, that’s just 2.5 calories of omega-6, or about a third of a gram of arachidonic acid to avoid deficiency.

The truth is that omega-6 deficiency is extremely hard to produce, even when you’re trying your hardest. Way back in the 1930s, the early omega-6 researchers tried to induce deficiency in an adult by giving him a 2 grams fat/day diet for months. Nearly all fat was removed, particularly the omega-6 fats, and the rest of the diet was fat-free milk, fat-free cottage cheese, orange juice, potato starch, sugar, and a vitamin/mineral supplement. Maybe not the ideal Primal diet, but better than some.

He ended up improving his health, not hurting it. There was no sign of deficiency.

Omega-6 fats are everywhere in the food environment, even if you’re actively avoiding concentrated sources of them. No one is developing a deficiency these days. However, certain conditions might increase the tolerable or beneficial upper limits of omega-6 intake.

If you’re strength training with the intent to gain lean mass, a little extra arachidonic acid can improve your results. The dose used was 1.5 grams per day. Average intake through food runs about 250-500 mg, though Primal eaters heavy on the animal foods are probably eating more.

If you’re recovering from injury or healing a wound, a little extra arachidonic acid can speed it up. AA is an important co-factor in the inflammatory response necessary for tissue healing.

Well done, Mark. My doc just prescribed saw palmetto to reduce multiple nighttime visits to the bathroom, though the research I’m looking at says there’s no clinical evidence to support saw palmetto for prostate problems. Your take?

It depends on the problem.

Large observational trials have found no connection between saw palmetto supplementation and prostate cancer risk. It neither helps nor harms.

Saw palmetto does seem to help benign prostatic hyperplasia, a non-cancerous growth of the prostate. This won’t cause serious health issues directly, but it can impede the flow of urine and lead to multiple nighttime bathroom visits. Saw palmetto is quite effective at reducing nighttime urination. If that’s what your doc is trying to help, I’d say give it a shot.

You might ask about combining saw palmetto with astaxanthin. It’s been shown to reduce the conversion of testosterone into estradiol that can sometimes result from plain old saw palmetto supplementation.

That’s it for today, folks. Take care and be well. Chime in down below if you have any questions or comments.

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References:

Mitchell CJ, D’souza RF, Figueiredo VC, et al. Effect of dietary arachidonic acid supplementation on acute muscle adaptive responses to resistance exercise in trained men: a randomized controlled trial. J Appl Physiol. 2018;124(4):1080-1091.

Oh SY, Lee SJ, Jung YH, Lee HJ, Han HJ. Arachidonic acid promotes skin wound healing through induction of human MSC migration by MT3-MMP-mediated fibronectin degradation. Cell Death Dis. 2015;6:e1750.

Bonnar-pizzorno RM, Littman AJ, Kestin M, White E. Saw palmetto supplement use and prostate cancer risk. Nutr Cancer. 2006;55(1):21-7.

Saidi S, Stavridis S, Stankov O, Dohcev S, Panov S. Effects of Serenoa repens Alcohol Extract on Benign Prostate Hyperplasia. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2017;38(2):123-129.

Vela-navarrete R, Alcaraz A, Rodríguez-antolín A, et al. Efficacy and safety of a hexanic extract of Serenoa repens (Permixon ) for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH): systematic review and meta-analysis of randomised controlled trials and observational studies. BJU Int. 2018;

Angwafor F, Anderson ML. An open label, dose response study to determine the effect of a dietary supplement on dihydrotestosterone, testosterone and estradiol levels in healthy males. J Int Soc Sports Nutr. 2008;5:12.

The post Dear Mark: Omega-6 Deficiency and Saw Palmetto appeared first on Mark’s Daily Apple.

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Many of you have asked about prostate health in a Primal context. Men are interested because they know men have a decent chance of getting prostate cancer. Women are interested because they’re worried about the men in their lives getting prostate cancer. Today, I’m going to delve deep into the topic, exploring the utility (or lack thereof) of standard testing, the common types of treatment and their potential efficacy, as well as preventive and unconventional ways of reducing your risk and mitigating the danger of prostate cancer.

Let’s go.

First, what does the prostate do, anyway? Most people only think about it in terms of prostate cancer.

It’s a gland about the size of a small apricot that manufactures a fluid called prostatic fluid that combines with sperm cells and other compounds to form semen. Prostatic fluid protects sperm against degradation, improves sperm motility, and preserves sperm genetic stability.

What Goes Wrong With the Prostate?

There are a few things that can happen.

Prostatitis

Inflammation of the prostate, usually chronic and non-bacterial. A history of prostatitis is a risk factor for prostate cancer.

Benign Prostatic Hyperplasia

Non-cancerous enlargement of the prostate. As men age, the prostate usually grows in size. This isn’t always cancer but can cause similar symptoms.

Prostate Cancer

What most of us are interested in when we talk about prostate health… After skin cancer, prostate cancer is the most common cancer among men and the sixth most common cause of cancer death among men worldwide. Yet, most men diagnosed with prostate cancer do not die from it; they die with it. The 5-year survival rate in the US is 98%.

That said, there is no monolithic “prostate cancer.” Like all other cancers, there are different grades and stages of prostate cancer. Each grade and stage has a different mortality risk:

  • Low-grade prostate cancer grows more slowly and is less likely to spread to other tissues.
  • High-grade prostate cancer grows more quickly and is more likely to spread to other tissues.
  • Local prostate cancer is confined to the prostate. The 5-year relative survival rate (survival compared to men without prostate cancer) for local prostate cancer is almost 100%.
  • Regional prostate cancer has spread to nearby tissues. The 5-year relative survival rate for regional prostate cancer is almost 100%.
  • Distant prostate cancer has spread to tissues throughout the body. The 5-year relative survival rate for distant prostate is 29%. Distant prostate cancer explains most of the prostate-related mortality.

What Are Symptoms of Prostate Cancer?

The primary symptom is problems with urination. When the prostate gland grows, it has the potential to obstruct the flow of urine out of the bladder, causing difficulty urinating, weak urine flow, painful urination, or frequent urination. This can also be caused by benign prostatic hyperplasia, a non-cancerous enlargement of the prostate.

What Causes Prostate Cancer?

A big chunk is genetic. People with “knockout” alleles for BRCA, which codes for tumor suppression, have an elevated risk of some forms of prostate cancer. That’s the same one that confers added risks for breast cancer.

Ethnicity matters, too. Men of Sub-Saharan African descent, whether African-Americans in the U.S. or Caribbean men in the U.K., have the highest risk in the world for prostate cancer—about 60% greater than other ethnic groups. White men have moderate risks; South Asian, East Asian, and Pacific Islander men have lower risks.

Testosterone has a confusing relationship with prostate cancer. Conventional wisdom tends to hold that testosterone stimulates prostate cancer growth, and there’s certainly some evidence of a relationship, but it’s not that simple.

In one study, men with low free testosterone levels were less likely to have low-grade (less risk of spreading) prostate cancer but more likely to have high-grade (higher risk of spreading) prostate cancer.

In another, testosterone deficiency predicted higher aggressiveness in localized prostate cancers.

In Chinese men, those who went into treatment with low testosterone were more likely to present with higher-grade localized prostate cancers.

Other studies have arrived at similar results, finding that “hypogonadism represents bad prognosis in prostate cancer.”

Many prostate cancer treatments involve testosterone deprivation, a hormonal reduction of testosterone synthesis. This can reduce symptoms and slow growth of prostate tumors during the metastatic phase, but prostate cancer tends to be highly plastic, with the ability to adapt to changing hormonal environments. These patients often see the cancer return in a form that doesn’t require testosterone to progress.

What About Testing?

If you have a prostate, should you get tested starting at age 40?

Not necessarily. The value of early testing hasn’t been established. Some researchers even question whether early testing is more harmful than ignoring it, and most of the research finds middling to nonexistent evidence in favor of broad testing for everyone. Early testing has a small effect on mortality from prostate cancer, but no effect on all-cause mortality.

PSA testing can also be inaccurate. PSA is prostate specific antigen, a protein produced by the prostate. It’s normal to have low levels of PSA present in the body, and while high levels of PSA are a good sign of prostate cancer—even years before it shows up in imaging or digital probes—they can also represent a false positive. Those two other common yet relatively benign prostate issues—benign hyperplasia and prostatitis—can also raise PSA levels well past the “cancer threshold.”

Other causes of high levels of PSA include:

  • Urinary tract infections
  • Recent sex or ejaculation
  • Recent, vigorous exercise
  • Certain medications.

In fact, if you have a PSA reading of 4 (the usual threshold), there’s still just a 30% chance it actually indicates cancer.

What About Treatment?

Let’s say you do have prostate cancer, confirmed by PSA and a biopsy (or two, or three, as needle biopsies often miss cancers). What next? Should you definitely treat it?

It’s unclear whether treatment improves survival outcomes. One study took men aged 50-69 with prostate cancer diagnosed via PSA testing, divided them among three treatment groups, and followed them for ten years. One group got active monitoring—they continued to test and monitor the status of the cancer. One group received radiotherapy—radiation therapy to destroy the tumor. And the last group had the cancer surgically removed.  After ten years, there was no difference among the groups for all-cause mortality, even though the active-monitoring group saw higher rates of prostate cancer-specific deaths (8 deaths—in a group of 535 men— vs 5 in the surgery group and 4 in the radiotherapy group), cancer progression, and metastasis.

In another study of men with localized prostate cancer, removing the prostate only improved all-cause mortality rates among men with very high PSAs (more than 10). In men with lower PSAs, “waiting and seeing” produced similar outcomes as surgery.

Prostate removal also carries many unwanted side effects, like incontinence and sexual dysfunction. No one wants prostate cancer, but it’s no small thing to have problems with urination and sex for the rest of your life. Those are major aspects of anyone’s quality of life.

Before you make any decisions, talk to your doctor about your options, the relative mortality risk of your particular cancer’s stage and grade, and how the treatments might affect your quality of life.

How Can You Reduce the Risk of Prostate Cancer?

1. Inflammation is definitely an issue.

For one, there’s the relationship between prostatitis, or inflammation of the prostate, and prostate cancer that I already mentioned above.

Two, there’s the string of evidence linking anti-inflammatory compounds to reductions in prostate cancer incidence. For example, aspirin cuts prostate cancer risk. Low-dose aspirin (under 100 mg) reduces both the incidence of regular old prostate cancer and the risk of metastatic prostate cancer. It’s also associated with longer survival in patients with prostate cancer; other non-steroidal anti-inflammatories are not.

Third, anti-inflammatory omega-3 fatty acids (found in seafood and fish oil) are generally linked to lower rates of prostatic inflammation and a less carcinogenic environment; omega-6 fatty acids can trigger disease progression. A 2001 study of over 6,000 Swedish men found that the folks eating the most fish had drastically lower rates of prostate cancer than those eating the least. Another study from New Zealand found that men with the highest DHA (an omega-3 found in fish) markers slashed their prostate cancer risk by 38% compared to the men with the lowest DHA levels.

2. The phytonutrients you consume make a difference.

A series of studies on phytonutrient intake and prostate cancer incidence in Sicilian men gives a nice glimpse into the potential relationships:

The more polyphenols they ate, the less prostate cancer they got.

The more phytoestrogens they ate, the more prostate cancer they got. Except for genistein, an isoflavone found in soy and fava beans, which was linked to lower rates of prostate cancer. The Sicilians are eating more fava than soy, I’d imagine.

How about coffee, the richest source of polyphenols in many people’s daily diets? It doesn’t appear to reduce the incidence of prostate cancer, but it does predict a lower rate of fatal prostate cancer.

3. Your circadian rhythm and your sleep are important.

Like everything else in life, tumor suppression follows a circadian pattern. Nighttime melatonin—which is suppressed if your sleep hygiene is bad and optimal if your sleep hygiene is great—inhibits the growth of prostate cancer cells and reduces their ability to utilize glucose. One way to enhance nighttime melatonin is by getting plenty of natural, blue light during the day; this actually makes nighttime melatonin more effective at prostate cancer inhibition. On the other hand, getting that blue light at night is a major risk factor for prostate cancer.

4. Get a handle on your fasting blood sugar and insulin.

In one study, having untreated diabetic-level fasting blood sugar was a strong risk factor for prostate cancer. Another study found that insulin-lowering metformin reduced the risk, while an anti-diabetic drug that raised insulin increased the risk of prostate cancer. Metformin actually lowers PSA levels, which, taken together with the previous study, indicates a causal effect.

5. Keep moving, keep playing, keep lifting.

This has a number of pro-prostate effects:

It keeps you insulin sensitive, so neither fasting insulin, nor fasting glucose get into the danger zone.

If you’re doing testosterone suppression treatment, exercise can maintain (and even increase) your muscle mass, improve your quality of life, and increase your bone mineral density.

Oh, and do some deadlifts. Men with prostate cancer who trained post-surgery had better control over their bodily functions, as long as they improved their hip extensor strength. If you don’t know, hip extension is the act of standing up straight, of moving from hip flexion (hip hinging, bending over) to standing tall. It involves hamstrings, glutes, and the entire posterior chain. Deadlifts are the best way to train that movement pattern.

The prostate cancer issue is frightening because it’s so common. Almost all of us probably know someone who has or had it, even unknowingly. But the good news is that most prostate cancers aren’t rapidly lethal. Many aren’t lethal at all. So whatever you do, don’t rush into serious treatments or procedures without discussing the full range of options in a frank, honest discussion with your doctor.

That’s it for today, folks. Thanks for reading. If you have any questions, comments, or concerns about prostate cancer, feel free to chime in down below. I’d love to hear from you.

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References:

Perletti G, Monti E, Magri V, et al. The association between prostatitis and prostate cancer. Systematic review and meta-analysis. Arch Ital Urol Androl. 2017;89(4):259-265.

Ilic D, Djulbegovic M, Jung JH, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis. BMJ. 2018;362:k3519.

Brawer MK, Chetner MP, Beatie J, Buchner DM, Vessella RL, Lange PH. Screening for prostatic carcinoma with prostate specific antigen. J Urol. 1992;147(3 Pt 2):841-5.

Castro E, Eeles R. The role of BRCA1 and BRCA2 in prostate cancer. Asian J Androl. 2012;14(3):409-14.

Watts EL, Appleby PN, Perez-cornago A, et al. Low Free Testosterone and Prostate Cancer Risk: A Collaborative Analysis of 20 Prospective Studies. Eur Urol. 2018;

Neuzillet Y, Raynaud JP, Dreyfus JF, et al. Aggressiveness of Localized Prostate Cancer: the Key Value of Testosterone Deficiency Evaluated by Both Total and Bioavailable Testosterone: AndroCan Study Results. Horm Cancer. 2018;

Dai B, Qu Y, Kong Y, et al. Low pretreatment serum total testosterone is associated with a high incidence of Gleason score 8-10 disease in prostatectomy specimens: data from ethnic Chinese patients with localized prostate cancer. BJU Int. 2012;110(11 Pt B):E667-72.

Teloken C, Da ros CT, Caraver F, Weber FA, Cavalheiro AP, Graziottin TM. Low serum testosterone levels are associated with positive surgical margins in radical retropubic prostatectomy: hypogonadism represents bad prognosis in prostate cancer. J Urol. 2005;174(6):2178-80.

Banerjee PP, Banerjee S, Brown TR, Zirkin BR. Androgen action in prostate function and disease. Am J Clin Exp Urol. 2018;6(2):62-77.

Zhou CK, Daugherty SE, Liao LM, et al. Do Aspirin and Other NSAIDs Confer a Survival Benefit in Men Diagnosed with Prostate Cancer? A Pooled Analysis of NIH-AARP and PLCO Cohorts. Cancer Prev Res (Phila). 2017;10(7):410-420.

Russo GI, Campisi D, Di mauro M, et al. Dietary Consumption of Phenolic Acids and Prostate Cancer: A Case-Control Study in Sicily, Southern Italy. Molecules. 2017;22(12)

Russo GI, Di mauro M, Regis F, et al. Association between dietary phytoestrogens intakes and prostate cancer risk in Sicily. Aging Male. 2018;21(1):48-54.

Discacciati A, Orsini N, Wolk A. Coffee consumption and risk of nonaggressive, aggressive and fatal prostate cancer–a dose-response meta-analysis. Ann Oncol. 2014;25(3):584-91.

Dauchy RT, Hoffman AE, Wren-dail MA, et al. Daytime Blue Light Enhances the Nighttime Circadian Melatonin Inhibition of Human Prostate Cancer Growth. Comp Med. 2015;65(6):473-85.

Kim KY, Lee E, Kim YJ, Kim J. The association between artificial light at night and prostate cancer in Gwangju City and South Jeolla Province of South Korea. Chronobiol Int. 2017;34(2):203-211.

Murtola TJ, Vihervuori VJ, Lahtela J, et al. Fasting blood glucose, glycaemic control and prostate cancer risk in the Finnish Randomized Study of Screening for Prostate Cancer. Br J Cancer. 2018;118(9):1248-1254.

Haring A, Murtola TJ, Talala K, Taari K, Tammela TL, Auvinen A. Antidiabetic drug use and prostate cancer risk in the Finnish Randomized Study of Screening for Prostate Cancer. Scand J Urol. 2017;51(1):5-12.

Park JS, Lee KS, Ham WS, Chung BH, Koo KC. Impact of metformin on serum prostate-specific antigen levels: Data from the national health and nutrition examination survey 2007 to 2008. Medicine (Baltimore). 2017;96(51):e9427.

Galvão DA, Taaffe DR, Spry N, Joseph D, Newton RU. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: a randomized controlled trial. J Clin Oncol. 2010;28(2):340-7.

Ying M, Zhao R, Jiang D, Gu S, Li M. Lifestyle interventions to alleviate side effects on prostate cancer patients receiving androgen deprivation therapy: a meta-analysis. Jpn J Clin Oncol. 2018;48(9):827-834.

Uth J, Fristrup B, Haahr RD, et al. Football training over 5 years is associated with preserved femoral bone mineral density in men with prostate cancer. Scand J Med Sci Sports. 2018;28 Suppl 1:61-73.

Park J, Yoon DH, Yoo S, et al. Effects of Progressive Resistance Training on Post-Surgery Incontinence in Men with Prostate Cancer. J Clin Med. 2018;7(9)

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