Dr. Irv Rubenstein, Author at MedFitNetwork

If You’re Using GLP-1 Meds for Weight Loss, Then You Gotta Do Weight Lifting (Part 2)

Dr. Irv Rubenstein/15 March 2025/ All MFN blog/

GLP-1’s are proving themselves as medical phenoms. They have been in existence for many years in the treatment of diabetes. They have demonstrated themselves as capable of reducing cardiac events, lowering blood pressure, cholesterol, heart failure symptoms, and even strokes. They have shown themselves effective in reducing the kidney problems that diabetes can cause in the long run. And there’s even proof that they might be useful for treating childhood obesity. Ultimately, they may prove valuable for medical conditions we haven’t yet explored. In light of the budding awareness of the strong correlations between our obesogenic diets that are high in fats, sugars, and calories and a variety of diseases ranging from some cancers to musculoskeletal ones, GLP-1’s may be the super-duper drugs that have exploded the weight loss market.

However, if weight loss is a goal and semaglutides and other similar hormone-affecting drugs is your method then, young or old, male or female, preserving muscle mass is critical. As a female, especially, whether pre- or post-menopausal, preserving muscle mass is even more critical as rapid and large amounts of weight loss includes bone density loss, too. Muscle mass training enhances bone mass accrual IF…, and this is a big IF, the weights you lift are heavy enough to be deemed ‘intense’.

The American College of Sports Medicine recommends that, for health, people should do some kind of RT should be done at least twice a week but could be done 3 or more if the program allows for sufficient recovery between sessions. A 2/wk program should consist of at least one exercise for each body part – legs, core, upper body/arms; ideally, you do 2-3 exercises per body part but they do not have to be the same exact exercises. For example, a heel raise gets the calf muscle, a squat and lunge also get the calf muscle, but they also get the upper leg and core.

If you choose to do 3 sessions/wk, be sure to space them out with at least 36-48 hours between sessions. For a more athletic program, it’s not unusual to do 4 or more sessions/wk but intelligent design must be applied to avoid overuse and overtraining, and injury.

What Constitutes a Viable Resistance Training Program

In the realm of RT, there are many models to consider, each with 4 variables: frequency, intensity, duration, and exercise type. Frequency we’ve already addressed. Duration is a function of how long you want to spend doing the exercises; some quick and dirty routines can last as short as 15 minutes or you can drag it out to an hour or more. But intensity and type are where special attention should be made when the training is being done to minimize loss of muscle and bone.

When discussing intensity, we’re talking about a percentage of your maximal ability. Most of us will never test our max so let’s use a common way of determining intensity: to volitional fatigue. That means that when you feel you can no longer do any more repetitions with good form and no compensations, you have reached volitional fatigue. It is very subjective and varies according to how you are feeling at the moment, including stressors outside the gym. Recognizing that many people with overweight and obesity have not been in the gym in a while or are not comfortable going to a gym, it may take a few sessions with modest weights to figure out what it really feels like to be fatigued at the end of a set of an exercise.

There’s no hard and fast rule but, if bone loss is one of your issues, either due to age, menstrual status, sedentary lifestyle, or poor diet, it is recommended that you try to fatigue in 10-12 repetitions; that corresponds to a heavy enough weight to provide a good stimulus for bone to accrue. With the understanding that most people who do not have RT experience won’t feel comfortable trying to achieve that kind of load/intensity, especially if they’d had any injuries or are prone to some, such as to the rotator cuffs in older adults, the process of ramping up to weights that can mitigate bone loss should be long, slow, and properly designed to reduce risks. See your local trainer….or call us at STEPS.

Exercise type, however, is where the message of RT in combination with drug-enhanced weight loss is most critical. While many people aspire to 6-pack abs (abdominals), that is an unreasonable goal, especially for those who have carried excess fat around their midsections or those who are older. Having a strong core – those muscles from the mid-thigh to the mid-thorax, front, sides, and back – is valuable but not essential for the average person. Having a functional core, on the other hand, is. A functional core is one where all the muscles know how to work together and have sufficient endurance and strength to allow you to perform activities of daily living, work, and recreation.

Exercise Selections and Options

Allow me to provide some specific exercise types that will strengthen muscles and bones that we all need in order to accomplish what a rapid weight loss system detracts from, especially for post-menopausal women.

Bone loss from the hips/upper femur, which contributes to falls and fractures in older people, can be countered with such exercises as a leg press machine, weighted squats, lunges, and step-ups.

Bone loss in the lumbar spine can be slowed with such exercises as weighted squats, lunges, step ups as well as deadlifts, bird dogs, and stability ball bridges or hip lifts. You can make the latter more demanding to achieve volitional fatigue by adding small arm and leg movements during the birddog and doing bridges with one leg rather than both.

Bone loss of the upper spine, which affects posture, especially potential dowagers humps in older adults – which is exacerbated in our texting and computer-based lifestyles –

Finally, wrist bones, which tend not to get much training beyond middle school for most females once PE coaches don’t make you do push-ups, are prone to breaking when falling. They are often the first markers of middle age women’s bone loss at the early stage of osteopenia should they experience a broken wrist from a fall. In fact, though, push-ups or some version of a chest press or bench press are some of the exercises that load the wrist and could help build bone IF loaded sufficiently. However, since the rotator cuff deteriorates with age, and is susceptible to injury from doing those very exercises that could help the wrist bones, it’s wise to train them with caution and avoid the volitional fatigue in 10-12 rep prescription. But it’s also wise to train the cuff muscles to minimize the risk of injury from any kind of RT even if you’re not intending to do these bone-enhancing exercises.

Note that each exercise for each segment of the body is done in a weight-bearing posture, even the chest/bench press. Even something as mundane as a plank in a push-up position constitutes a weight-bearing load capable of producing osteogenic forces that may build wrist bones’ strength.

While it is necessary to proceed with caution as you pursue a bone- and muscle-preserving workout regimen, to pre-condition the core and the rotator cuff muscles to avert injuries that might result from a RT program, within 4-6 weeks one will start to experience muscle mass changes. It could easily take a year or more to note any bone-building changes; first by some imaging technique or by falling and not breaking something, which we would recommend against trying. Ultimately, though, the effort to enhance lean tissue – bone and muscle – facilitates weight loss, fat loss, and quality of life. And, with the health upsides of GLP-1 meds, there’s a good chance that RT will even extend the health-years of your life.

Which is the main reason we all should be doing some RT in our lives.

Originally printed on STEPS Fitness blog. Reprinted with permission.

Dr. Irv Rubenstein graduated Vanderbilt-Peabody in 1988 with a PhD in exercise science, having already co-founded STEPS Fitness, Inc. two years earlier — Tennessee’s first personal fitness training center. One of his goals was to foster the evolution of the then-fledgling field of personal training into a viable and mature profession, and has done so over the past 3 decades, teaching trainers across through country. As a writer and speaker, Dr. Irv has earned a national reputation as one who can answer the hard questions about exercise and fitness – not just the “how” but the “why”.

GLP-1 Receptor Agonists: The New, Improved, and Not-Fully-Understood Weight Loss Drugs (Part 1)

Dr. Irv Rubenstein/15 March 2025/ All MFN blog/

Super-duper weight loss drugs (originally they were designed to help those with Type 2 diabetes, or T2D) like Ozempic, Wegovy, Mounjaro, et al. have swamped the marketplace because of their unique pharmacologic actions compared to their predecessors. Earlier weight loss drugs and over-the-counter concoctions (like coffee and other caffeine-derivatives, as well as smoking cigarettes, for example) simply sped up metabolism and boost energy. These, then, provided (ab-)users an artificial mechanism by which to burn calories and even avoid consuming calories since energy levels didn’t require them.

What makes these modern drugs so unique is their effects on hunger and appetite hormones. Essentially, they alter or disrupt hormone signaling that tell the gut to stop demanding food and/or the brain to feel satisfied with the food you’ve consumed, presumably before you overeat. That is, those appetite and hunger messages lead people to eat less without – we hope – causing permanent and as-yet-unknown effects on the endocrine system as a whole.

Caveat: while some of these drugs have a relatively long history due to their use in managing diabetes, 5-10 years on the market may not be sufficient to declare with absolute certainty that long-term impacts are not going to crop up.

The past couple of decades have given scientists and pharmaceutical companies greater understanding about the gut-brain connection. Hormones, which are signaling proteins that course throughout the body, often have multiple outlets and receptors that allow one metabolic process to influence or be influenced by another part of the body. One of the most common hormones that most of us have some awareness and understanding of is insulin.

Insulin, cell receptors, and disease

Pumped out by the pancreas, insulin helps manage blood sugar, an essential substrate that feeds all of our organs, especially the brain. The digestive process breaks down carbohydrates into sugars that the blood stream then carries to organs for energy. Ever feel groggy or slower between meals? Well, that’s your brain saying ‘feed me…ideally, with sugars, or carbs’. Ever feel like your energy is waning on a long bike ride or hike? That’s your muscles demanding calories, especially sugar-based calories. The insulin signals drive both the sugar calories from those foods to their respective locales and even help pull stored glucose (a form of sugar) from glycogen stores (sugar formulations the body keeps around in case they’re needed like the liver) between feedings. When insulin is in short supply (as in Type 1 diabetes), sugar can’t enter cells.

However, without receptors on the surface and within the cells to allow insulin to do its job, it is neutered. These dysfunctional receptors are part of the process that leads to T2D: when insulin is unable to unlock the cells that have disabled receptors, the brain, heart, and other organs including muscles are deprived of energy.

A few digestive and appetite hormones have similar roles. Leptin, ghrelin, PYY, and the big kid on the block, glucagon-like peptide 1 (GLP-1) transmit signals of fullness, satiety, and hunger to and from the gut and brain. Without operative receptors, however, some of these signals get disrupted. Obesity itself, regardless of original causality, be it genetics, diet, or lifestyle, is one of those disruptors. With obesity, some of these hormones fail to signal when you are sated or over-signal that you continue to be hungry. GLP-1 works by messaging the digestive system that you are sated. Therefore, for those who cannot get that feeling, GLP-1 receptor agonists – these super-duper drugs – help reduce food intake by reducing appetite…and increasing weight loss.

All drugs have side effects

One of the oldest drugs which originally came from willow tree bark is aspirin. Well-known and long used to reduce fevers, manage headaches, and more recently thin blood for those folks at risk for potentially-fatal blood clots such as after lower-extremity surgery or certain cardiac conditions, can also lead to excessive bleeding in the event a closed-head injury or gastric ulcers due to its effect on the stomach lining.

Semaglutide and liraglutide, two of the main GLP-1 drugs out there, have been found to reduce food obsessions leading to calorie restriction but, oddly, have been correlated with reducing other addictive obsessions from gambling to sex to alcohol and other drugs. (1) Interestingly, in combination with bimagrumab, semaglutides “led to superior fat mass loss while simultaneously preserving lean mass despite reduced food intake”. (2)

However, a disconcerting unintended consequence of these weight loss meds is that “the potential health benefits of diet-induced weight loss are thought to be compromised by the weight-loss-associated loss of lean body mass, which could increase the risk of sarcopenia (low muscle mass and impaired muscle function)”. (3) Any time you diet, some of the weight you lose, after initial water weight, is lean tissue – muscle mass and, if rapid and extensive weight is lost, bone mass. A meta-analysis of 18 well-controlled studies that included over 1300 subjects confirmed that these kinds of drugs, which were originally designed to help those with T2D, contribute to loss of muscle mass; metformin, another T2D drug, on the other hand, does not. (4)

Some studies show that, “compared with persons with normal weight”, those with obesity have substantial muscle mass to support and transport their bodies, but poor muscle quality, that is more fatty infiltration generally from lack of a training stimuli. Somehow, though, the “diet-induced weight loss” reduction of muscle mass happens “without adversely affecting muscle strength”. This maintenance of muscle mass that accompanies weight loss improves overall physical function, likely due to the loss of fat mass which otherwise is a drag on performance. While it is recommended, and is very vogue, to encourage a high protein intake – of 1.2 – 2.0 grams/kg of body weight vs the RDA recommendation of 0.8 g/kg – to preserve lean body and muscle mass during weight loss, apparently this does not improve muscle strength; and it could have “adverse effects on metabolic function” if kidney problems are an issue or become one.

Finally, while both endurance exercise, if performed at pretty high intensities such as stair climbing or cycling with high resistances, and resistance training (RT) at moderate to heavy loads “help preserve” lean tissue during a weight loss regimen, only intensive and consistent RT improves muscle strength. This is why researchers are so heavily promoting RT as a way to prevent the inevitable loss of muscle and to restore the low-quality muscle that people with obesity have to a more functional variety. (3)

The mechanisms for these drugs’ effects on lean tissue are under investigation. One group of researchers has determined that the combination of these drugs actually protects against muscle atrophy. The biochemistry is irrelevant here. What might be more relevant is the customary fact that rarely are these drugs prescribed together. So, while they might prevent this adverse effect, it will require more study before they are co-prescribed. (5) There is evidence that shows that oral semaglutide, when prescribed for T2D patients, does help with weight loss and, even alone, does not lead to substantial loss of muscle mass. (6)

Weight loss vs Muscle loss: Inevitable or Preventable?

As we discussed above, any significant amount of weight loss is accompanied by muscle and even bone loss, especially if done quickly over a short period of time. This could be diet-related, disease- or medical treatment-related (think: during chemo or radiation for cancer), or even, shockingly, exercise-related. Yes, if someone engages in intensive and long-duration cardio training such as running or biking, and weight loss occurs, so, too, does muscle loss. (Real News, Nov 2024)

Why? It’s pretty simple: unless sufficient calories are consumed to compensate for the excess energy output, the body becomes very efficient by discarding muscles that are not used in the training (REAL News – Dec. 2024) or simply allowing unused muscle fibers, like the bigger, stronger, more powerful fast-twitch fibers, to atrophy since neural stimulation is withheld. Even young athletes on a hypo-caloric diet designed for weight loss lose muscle mass unless they’re on a significantly-elevated protein intake diet. (7) Sadly, too, weight loss of 5% or more is accompanied by bone density loss! (REAL News – December 2018)

With studies showing that GLP-1’s can lead to 15 – 24% weight loss, they can be accompanied by 10%, or ~6 kg, of muscle mass loss. (8) Sergeant et al (2019) found in over half of the studies included in their meta-analysis of the same year, the proportion of muscle loss was somewhere between 20% and an astounding 50% of the total weight lost! (9) A more recent study by Bikou et al. confirmed that, while extremely effective for fat loss, these meds can cause up to 40% of the weight lost being lean mass. (10)

All of these researchers concluded that, with intensive RT, not only can patients reduce the muscle loss, they can maintain muscle mass to reduce weight re-gain should they stop taking the medications.

Takahashi et al (11) demonstrated that vitamin D supplementation, and possibly vitamin B12, but not vitamins A, B6, C, and E, might correlate with with the loss of lean tissue in older adults with T2D. Thus, in addition to a vigorous RT program, getting in extra D could reduce the atrophy that accompanies weight loss.

Nunn et al., in a study of diet-induced mouse obesity, found that blocking a particular muscle cell receptor that is known to interfere with muscle growth – ActRII – while being treated with a semaglutide medication preserves muscle mass. It actually induced an almost 10% increase in lean mass!However, this is what you might call a proof of concept study and has not yet been approved for humans taking a GLP-1 drug. (12)

Some studies have found that muscle mass loss does not deteriorate as much in patients with T2D as one might expect. (6) The Japanese subjects experienced substantial health benefits over the 24 months they used a combination of liraglutide and semaglutide, affirming Klausen et al.’s (1) finding. Too, Gurjar et al. found that “drug repositioning” with liraglutide might be the answer to weight-loss-induced muscle loss, at least in mice. (13)

There is a new kid on the block in Phase 3 studies – a combination drug of Amylin + two GLP-1 drugs – semaglutide and cagrilintide – that offers comparable weight loss while helping to “preserve the reduction in energy expenditure” which could help maintain weight loss in the long run. (14) This could be the game-changer what with all these super-duper drugs that are helping people lose weight, especially for those who are older, more likely to have blood sugar control issues such as T2D, and may already have suffered age-related sarcopenia. However, for all patients who are taking these GLP-1’s, the basic prescription still holds, whether or not it totally reverses years of sedentary living or age-related muscle loss, and that’s RT using loads greater than body weight.

Check out part 2, If You’re Using GLP-1 Meds for Weight Loss, Then You Gotta Do Weight Lifting

Originally printed on STEPS Fitness blog. Reprinted with permission.

References

1. Mette Kruse Klausen et al. The role of glucagon‐like peptide 1 (GLP‐1) in addictive disorders. Br J Pharmacol. 2022 Feb; 179(4): 625–641. Published online 2022 Feb 2. doi: 10.1111/bph.15677)

2. Nunn et al. Antibody blockade of activin type II receptors preserves skeletal muscle mass and enhances fat loss during GLP-1 receptor agonism. Mol Metab. 2024 Feb:80:101880. doi: 10.1016/j.molmet.2024.101880. Epub 2024 Jan 11.

3. Cava et al. Preserving Healthy Muscle during Weight Loss. Adv Nutr. 2017 May 15;8(3):511-519. doi: 10.3945/an.116.014506. Print 2017 May.

4. Ida et al. Effects of Antidiabetic Drugs on Muscle Mass in Type 2 Diabetes Mellitus. Curr Diabetes Rev. 2021;17(3):293-303. doi: 10.2174/1573399816666200705210006.

5. Xiang et al. GLP-1RA Liraglutide and Semaglutide Improves Obesity-Induced Muscle Atrophy via SIRT1 Pathway. Diabetes Metab Syndr Obes. 2023 Aug 15:16:2433-2446. doi: 10.2147/DMSO.S425642. eCollection 2023.

6. Uchiyama et al. Oral Semaglutide Induces Loss of Body Fat Mass Without Affecting Muscle Mass in Patients With Type 2 Diabetes. J Clin Med Res. 2023 Jul;15(7):377-383. doi: 10.14740/jocmr4987. Epub 2023 Jul 31.

7. Mettler et al., Increased Protein Intake Reduces Lean Body Mass Loss during Weight Loss in Athletes. Medicine & Science in Sports & Exercise 42(2):p 326-337, February 2010. DOI: 10.1249/MSS.0b013e3181b2ef8e

8. Locatelli et al. Incretin-Based Weight Loss Pharmacotherapy: Can Resistance Exercise Optimize Changes in Body Composition? Diabetes Care. 2024 Apr 30:dci230100. doi: 10.2337/dci23-0100.

9. Sergeant et al. A Review of the Effects of Glucagon-Like Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors on Lean Body Mass in Humans. Endocrinol Metab (Seoul). 2019 Sep;34(3): 247-262. doi: 10.3803/EnM.2019.34.3.247.

10. Bikou et al. A systematic review of the effect of semaglutide on lean mass: insights from clinical trials. Expert Opin Pharmacother. 2024 Apr;25(5):611-619. doi: 10.1080/14656566.2024.2343092. Epub 2024 Apr 18.

11. Takahashi et al. Vitamin Intake and Loss of Muscle Mass in Older People with Type 2 Diabetes: A Prospective Study of the KAMOGAWA-DM Cohort. Nutrients. 2021 Jul 8;13(7):2335. doi: 10.3390/nu13072335

12. Nunn et al. Antibody blockade of activin type II receptors preserves skeletal muscle mass and enhances fat loss during GLP-1 receptor agonism. Mol Metab. 2024 Feb:80:101880. doi: 10.1016/j.molmet.2024.101880. Epub 2024 Jan 11.

13. Gurjar et al. Long-acting GLP-1 analog liraglutide ameliorates skeletal muscle atrophy in rodents. Metabolism. 2020 Feb:103:154044. doi: 10.1016/j.metabol.2019.154044. Epub 2019 Dec 5.

14. From online lecture on Medscape: https://www.medscape.org/viewarticle/1001688_4

Don’t Let Arthritis Stop You: Move On

Dr. Irv Rubenstein/20 February 2025/ All MFN blog/

Arthritis comes in many forms and has many manifestations, affecting almost every joint in the body. We generally speak in terms of the two most-known if not popular forms of arthritis: rheumatoid (RA) and osteo-arthritis (OA.) The essential difference is in the root cause. RA is an auto-immune disease whereby the body, for unknown reasons, attacks itself, particularly in the joints. OA, on the other hand, is often considered the downstream effect of wear and tear, over-use, prior injury, or, as we’re seeing more of as society gets more sedentary, from lack of use. In OA, typically, some insult to the joint disrupts the natural repair processes and further deterioration occurs subsequently.

Due to their differing causes, there are obviously differing treatments; but the basics of medical management are essentially the same. I am not qualified to address the specifics of the treatments available but, in lay terms, treatment usually entails some version of anti-inflammation and pain-reduction drugs, precautionary movement or positional guidance (don’t do’s, for example), physical therapy to manage pain and inflammation, and therapeutic exercises to support the structures affected as the disease itself causes not just inflammation and pain but damage to the structures that support the joints. Typically we identify arthritis as something that damages cartilage and, in truth, that is often what the standard ‘films’ – X-ray, possibly MRI (magnetic resonance imaging) – show. We now know that the synovial sacs around the joint are also affected and that these and other chemical disturbances affect the muscles and tendons that move and support the joint. In almost all cases of arthritis, pain, inflammation, reduced strength and range of motion (ROM) ensue, diminishing quality of life in many ways and, because some of the drugs used to treat it, potentially reducing quantity of life. (Gastrointestinal bleeding from non-steroidal anti-inflammatories (NSAIDs) or bone loss (osteoporosis) from corticosteroids can lead to fatal outcomes (such as spontaneous fractures leading to falls from osteoporosis) if not treated with other medications.)

When someone is potentially afflicted or actually diagnosed with a form of arthritis, the medical community goes into hyper-drive, encouraging changing one’s habits, be they the types of activities one engages in recreational, competitively, or professionally; or the types of non-activities one currently does, in particular, being inactive.

In some cases, dietary advice is offered as we are learning more about foods that are pro-inflammatory and others that have anti-inflammatory benefits. In the former category, we are learning that excessive sugar or simple carbohydrates, including processed wheat products, may exacerbate inflammation while others, such as salmon, dark, green veggies, and certain oils (e.g., olive oil) are capable of reducing the inflammatory elements circulating throughout our bodies and our joints. Furthermore, in more extreme cases, when arthritis becomes very painful and debilitating, over-the-counter and/or prescription-fitted braces may be offered to defer some of the more end-line procedures such as surgery to fuse the joint or replace it with a prosthetic device.

The most common non-pharmaceutical and non-surgical treatment for arthritis of any sort: exercise.

Note that there are several legitimate ways to integrate exercise through resistance training programs that have proven quite effective in arthritis management. Yoga, Pilates (floor or machine based), Tai Chi, Qigong and water-based, or aqua, exercise are all beneficial to many aspects of the overall arthritis program of strength, ROM, proprioception and ultimately function. Since many of these are quite technical and are often done in class formats, one should ask the instructor(s) as to their experience working with arthritis clients.

As with any form of exercise, by whatever professional instruction, you should be totally aware of your pain levels as going “through” the pain is not recommended; thus, you must assert control over the exercise sessions. There will be some exercises, however, that are not destructive and may be somewhat painful but must be done in order to maintain reasonable levels of function and independence. So long as the pain subsides within a couple of hours – preferably as soon as you stop – and there is no exacerbation of inflammation the next day, you can assume that the exercise was just enough. If symptoms flare up over the next 24 hours, however, assume you did more than you should have and alert your trainer or instructor so that he/she can avoid doing the aggravating exercise(s) as much or as hard next time. For these reasons, along with all the other recommendations so far as exercise interventions are concerned, it is best to seek the counsel and assistance of a fitness professional with a background in medical fitness. This could be someone with a more advanced academic degree, someone with a license to practice rehabilitation exercise (physical therapist, athletic trainer, etc.), or someone who’s taken several educational programs to have a greater understanding of the variety of disorders and diseases that may benefit from exercise interventions.

UPCOMING WEBINAR

Walking Off the Plank or Getting to the Core of the Matter

Dr. Irv Rubenstein/5 May 2021/ All MFN blog/

The ubiquity of planks in gyms and exercise videos has denigrated it to the level of a ‘fad’.

Once the newcomer to fitness – about 20 years ago – it is now so common as both an exercise of choice for almost all kinds of athletes and people and as a standard of achievement for those with too much time on their hand that it has lost its sheen so far as I’m concerned.

Now don’t get me wrong: the plank, both the front plank and the lateral or side plank, is a valuable tool in the hands of a competent personal trainer or fitness instructor… or therapist. But a little history might put it in perspective as I go on with my thesis here.

For the uninitiated, low back pain vs 6-pack abs has been the main driver of abdominal muscle training. Prior to the early 1950s, most people who did ab work – for it was not yet understood as the ‘core’ – were athletes, particularly boxers and soldiers. The latter group did them both to fulfill some concept of total body strength (in addition to push-ups, pull-ups, and other calisthenics) and to torture recruits. The former did them to protect against the pounding of their opponents in the ring.

But in the early 50s, two docs, Williams and Kraus, came up with an ab routine to help those with what was then and would still be called non-specific back pain (NSBP). They determined that the sedentary world of office workers was the cause of so many new chronic complaints of low back pain (LBP). Thus they developed what came to be called the Williams flexion exercises: sit-ups (crunches had yet to be developed), oblique sit-ups, and knee-to-chest and other hamstring stretches among some other exercises.

As our understanding of LBP improved over the decades, with better diagnostic tools available to physicians, it became more specific rather than non-specific. Thus, disk problems were better understood and new therapies evolved. Hence was born the McKenzie protocol. These exercises were extension-based, with the yoga cobra stretch designed to push the disk forward away from the spinal nerves and supermans, bird dogs, and the elimination of all flexion exercises until further notice becoming the new, vogue protocol.

While these did little for the abs, they worked the back muscles and introduced, although the term had yet to be applied, the core.

In the mid-1990s, some physiotherapists came up with an exercise designed to help those with a very specific LBP, that is, spondylolisthesis, and spondylolysis-related pain. The researchers qua therapists had determined that the small, intrinsic muscles of the mid-section – the transverse abdominis (deep within the abdominal wall), the multifidi (which span 3 vertabrae) and the rotatores (which span 2 vertabrae) – tended to be atrophied in those with spondylo issues. These muscles also did not respond to voluntary movement in a timely fashion. Thus they created what has become known as the navel drawing-in maneuver, a technical procedure that takes time to learn but had proven itself quite useful for patients.

So, while these exercises did little for the larger, external muscles we can see in the mirror, they did what they were supposed to do for those deeper – what are called the local – muscles that stabilize an inherently unstable spine: try to stabilize it.

Why am I going through this history of ‘core’? Because in the late 1990s, Dr. Stuart McGill started touting the planks, front and side, as ways to strengthen the global – the large external, visible – muscles that lock the spine in position. His research is compelling but, more than that, it’s exciting. Doing the navel drawing in maneuver of spondylo problems is worthwhile for those problems, but you can’t incorporate them as easily into a hard-core group or individual exercise program… and you can’t measure improvement as easily as you can with a timed plank.

Which brings me to the topic at hand: how long do you have to be able to hold a plank to derive benefits?

A Runner’s World article addressed this not so much from a scientific standpoint as from a practical and pragmatic one. Whereas many in the fitness world brag about helping clients get to, or themselves doing, 60 second or longer planks as if that’s a big deal, this article questions such valuations.

First, we should ask, why plank? If it’s for ab strength, cool — but the longer you do it, the more it’s about endurance, not strength. If it’s for ab look, or definition, cool — but then nearly anything would work as well, although one should cut one’s food intake enough to shed fat overall. That way the muscles you have – and you all have them – are more noticeable.

If it’s for core strength and function, cool – but how much of our daily lives occur in a prone position hovering off the floor a few inches? (Caveat: planks are generally non-functional, like crunches, because of their positioning, but it’s possible that a vigorous and healthy sex life is improved with both front and side plank capabilities!)

Nonetheless, for whatever reasons you’ve incorporated planks into your life, or workout styles, the ultimate benefit of the plank is for spinal stability. In other words, they were designed and studied and promoted to help those with LBP issues. They may help in almost any and all types of LBP but they may need modification according to one’s abilities and pain instigators.

Studies have shown a benefit to young athletes at the college level if you can hold a front or side plank for 100-120 seconds. While these are pretty substantial numbers, they alone won’t confer complete security against low back issues. In other words, the data is correlative, not predictive. Planks can be corrective but doing them longer does not mean you are even more secure against LBP.

As the article mentioned above notes, doing shorter planks (10-30 second) but more of them may be sufficient for both pain and injury prevention as well as function even if you operate standing or seated in your sport or daily life. These shorter planks may give you that six-pack and side torso look you seek, assuming you have a lean midsection overall.

And they may even be useful in such injury prevention programs for athletes whose knees and ankles are at risk as well as in the elderly when it comes to fall prevention.

My model for them, as a side note, is to do them briefly but quickly. That is, to ‘pop’ up into the plank position but hold for 5-10 seconds. The idea is to be able to quickly engage these powerful support muscles as they would be needed for real life – in a coordinated and rapid firing to support the spine as it goes through its often large and dangerous positions in life and sport.

This is what I gleaned from a study Dr. McGill reported years ago at an ACSM meeting in Nashville. Comparing the muscles that fired in the hips and torso of a football player and an exercise science Master’s Degree student, he found the former engaged all the correct stabilizing muscles simultaneously and at the right time during a plyometric push-up. The grad student fired off the same muscles but not in a coordinated manner, suggesting that maybe his spine was not quite as rigid during this vigorous endeavor.

So now, after reading all this, I hope you understand that I’m not discouraging planks. I’m simply reinforcing their value by making them effectively, easier.

Short and sudden planks will give you good tone, good muscle strength and endurance… but also good power and better function, with which to manage and prevent low back pain.

Article originally printed on stepsfitness.com. Reprinted with permission. Images courtesy of STEPS Fitness.

Core Exercise, Part 2: Training The Abs To Do Their Job

Dr. Irv Rubenstein/19 March 2021/ All MFN blog/

In a previous blog, Core Exercise, Part 1: Fad, Fashion or Fundamental?, I proposed that core exercise is not just about training the abs since the core is a more integrated, comprehensive functional unit that simply includes the abs as one element. In Part 2, I want to stress how the abs actually function – not based on EMGs or ultrasounds – in doing movements we train with in the gym that correspond to real life.

Motivated by an article in Women’s Health, “17 Back Exercises Every Woman Should Add to Her Workout ASAP“, I was pleasantly pleased to see exercises listed with a by-line that said “It’s not all about the abs, you guys”. The thrust of the article and exercises was that the back is important, too. I’d add that the back is MOST important and that anything you do to strengthen the back, especially with some of the unilateral exercises described, is even BETTER for the abs than crunches.

While some of the exercises were simply simple adaptations of traditional exercises, such as the overhand and underhand bent over row, or were clearly aimed at the anterior core – the abs – they highlight the message I often bring to my sessions with clients.

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AS A PERSONAL FITNESS TRAINER, IT’S MY GOAL TO PROVIDE SAFE AND EFFECTIVE EXERCISES THAT ENHANCE A PERSON’S HEALTH, WELLNESS, AND FUNCTION.

With this mission statement, first and foremost in my mind when I approach a training session with whomever at whatever stage of health or fitness they are in, my goal is to train them to move and perform ADLs or recreational activities with less strain and stress to their bodies. Especially their spines!

Recognizing that many come in wishing to do something about their guts, I comply with some abs-specific exercises when they are ready for them. But first I aim to train the core as I defined it in the Part 1 blog.

Let’s, for now, leave out of consideration the person with a low back issue such as a ruptured disk or chronic low back pain (LBP). These kinds of issues require gentle step-by-step approaches akin to physical therapy-type exercises before venturing into real-life functional exercises just to get the core working. Which leads me to my framework for working the core, but really any muscle.

There are 5 layers to muscle function:

activation
endurance
strength
power
speed

Activation is a neuromuscular bioelectrical event whereby an exercise causes muscles to engage – that is, to fire – so that they learn or re-learn how to do what they were supposed to do. Imagine a stroke victim unable to move a toe. It is the essence of core stabilization. If therapists can get the person’s focus on moving the toe, and the toe actually moves again, that means nerve signals went from the brain down the spine and into the legs all the way to the toe. When the muscle receives those signals, even though it’s been weakened by the stroke itself, it starts to twitch. When the twitch becomes large enough, it fires enough fibers to make the toe move… even a little.

When it comes to core exercise, first we want the muscles to get engaged, to fire, but not to generate movement – that is, to first do an isometric hold. So, for example, taking the bent over row as a case in point, by bending over, with both feet on the floor and one hand supported on a bench or chair, the other holding a weight, the core engages to prevent rotation toward the side that holds the weight. In other words, almost every muscle of the core is activated even as you focus on bringing the weight toward the ribs. Take the support arm away and now the core is super-activated as it now has to support the upper torso plus the weight(s). It’s not a back exercise anymore, it’s a total core exercise as even the abs engage to stiffen the spine against the pulls of gravity and of the lumbar erectors.

Endurance is the next phase of training. This doesn’t mean simply running for miles on end. It means that a muscle can be activated and engaged for longer periods of time than simply to make any particular movement. This entails multiple repetitions (reps) and sets and even exercises that target that muscle. This is initially done with lower resistances so that the exercise is learned properly and all moving parts and stabilizing parts are able to do their jobs properly.

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When it comes to core endurance, we often do high reps of crunches or bridges and call it a day. But the reality is our core works even while sitting, especially while standing and most importantly while moving. Thus an exercise that engages core muscles in functional positions or patterns of movement is more functional than one that isolates one section at the expense of others.

For example, taking the alternating bent over reverse fly (#14 of the article above), we see a long lever arm moving outward to the side as the trainee tries to stay parallel to the floor. Each subsequent movement by each arm applies a torque to the core that tries to bend and twist it. Doing multiple reps actually trains the core to stabilize for a long period of time, more so than if you do both arms at the same time. For one thing, the anti-rotation component doesn’t exist to the same degree in the bilateral move as it does in the unilateral. For another, assuming you can do the same number of reps with a particular weight whether bilateral or unilateral, the time under tension is longer for the alternating reverse fly; almost double if not more. (One could argue that you could even use a higher load as you have more rest between reps doing one arm at a time.)

Strength is the ability to apply force… or resist load. This entails lifting heavier weights in order to optimize one’s ability to apply a lot of force. Usually, this is measured as a function of %RM, or percentage of maximal repetition. That is, if you can curl 30# one time, that is your 1RM; if you can do it 10 times, it’s your 10RM. Thus, if you do 15# curls, you are training at 50% of your 1RM.

The other way to look at it is by how many reps you are able to do. If you can do more than 12, you are essentially training endurance as you are now working below 50% 1RM. It is recommended you lift at loads that actually fatigue you anywhere from 8 to 12 reps to get strong.

AT THE LOWER END OF REPS, YOU ARE GETTING STRONGER WHILE AT THE UPPER END YOU’RE CLOSING IN ON ENDURANCE.

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For the core, even though it’s just another muscle, the break point could endanger the spine so it’s usually not recommended to hit with high loads. That said, many exercises we do in the gym do actually involve the core at extremely high loads and never require isolating it. For example, a low-rep, high-load squat or power lift engages the core at extremely high load even though we tend to observe the legs or arm movements. But we could also do a standing cable row with a very heavy resistance which would fatigue the upper body in 8-12 reps but recognize that the core is also heavily challenged, making this an effective strength exercise for the core itself.

Power is the ability to produce lots of force quickly; it’s a function of speed but does not require actual speed. When the body tries to move quickly but the resistance prevents it, you’re engaging muscles, especially fast twitch, white fiber muscles, to produce speed, but the weight slows you down. Watch a powerlifter and you’ll note that he/she is hardly moving fast but is trying to do so with great effort. Now that’s power!

For core power, something as simple and basic as a squat and curl on the way up, assuming the resistance is greater than you could lift if you were simply standing or sitting down, would engage the core muscles rapidly in order to stiffen the spine. Likewise, a push-press, which is a shoulder overhead press performed off a partial squat, with speed, would constitute core power. The muscles that stabilize the lumbopelvic region would have to engage rapidly to propel the weights upward from the shoulder, then would have to contract isometrically very quickly to stabilize the spine against any backward bending resulting from the momentum of the weights from in front of the center line to on or behind it. If done with one arm, now you have to resist a lateral bending force on the core, too.

Finally, there’s speed, the ability to produce a high velocity movement. We know speed when we see it, in running, biking, etc. but in resistance training, we are often put off by it. The ability to move a light load very fast actually puts the joint in a dangerous position. Going back to the article, there are two exercises that should not be done fast: #4, the Good Morning, and #15, the Stability Ball Back Extension. I prefer to think of these as endurance exercises, maybe shifting into strength, but not power or speed.

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But how could we do a core exercise to simulate speed? My preference is for the tubing torso rotation, especially with a controlled stopping point. As this video shows, with a modest resistance, you can move quickly. However, I would suggest stopping at 45 degrees past the mid-point as the resistance declines rapidly beyond that; thus there’s no counterforce applied by the tubing as the spine approaches the terminus of the tissues themselves. Nonetheless, you can see how, with slightly more resistance and with a controlled end point, core speed could be trained here.

Which brings me to the end.

In sum, core training is not muscle-specific. It involves, includes, entails and integrates many of the muscles we associate with the core. It takes into account the various elements of muscle training, from activation to high speeds, from endurance to power. Core training does not require, in fact, I’d say it actually is violated, by isolation exercises except where the person’s initial status requires it.

CORE TRAINING IS NOT A FAD, NOR IS IT A SEPARATE PART OF A WORKOUT SESSION. IT CAN BE PART AND PARCEL TO ANY IF NOT ALL EXERCISES SIMPLY BY DOING THINGS ON ONE LEG, WITH ONE ARM, WITH RESISTANCES COMING FROM VARIOUS DIRECTIONS (GRAVITY-DOWN, CABLE OR TUBE -HORIZONTALLY OR DIAGONALLY).

Core is neither a fad nor a fashion, it is fundamental, and now you know why and what-for to take your training to the next level.

Originally printed on stepsfitness.com. Reprinted with permission. Images courtesy of STEPS Fitness.

Core Exercise, Part 1: Fad, Fashion or Fundamental?

Dr. Irv Rubenstein/12 March 2021/ All MFN blog/

What’s all the fuss about “core”? Too many articles in the lay literature address core as if somehow it’s a brand new thing in fitness. Yet, those articles fail to appreciate the full measure of what core exercise is all about. In fact, they tend to further the image of core by emphasizing the abdominals, praising stars and models for their core work based on how they look with bare midriffs.

This is not to say the trainers for these media stars, or even the stars themselves, or the authors who write about them don’t know a core from an ab. But it is disturbing to me and my colleagues that the two phrases often get juxtaposed as if you can’t have one without the other.

THE REALITY IS A STRONG, CUT ANTERIOR ABDOMINAL WALL DOES NOT MEAN YOU HAVE A STRONG CORE, BUT A STRONG CORE DOES MEAN YOU HAVE A VIABLE AND STRONG ANTERIOR ABDOMINAL WALL.

Let me explain.

First of all, the core is the complex of muscles of the spine, pelvis and lower extremities that contribute to the stability and safety of the spine itself. I have addressed this on my website, here, here, here, here and especially here as it relates to athletic injuries. Thus core muscles act on the spine, directly or indirectly, to enable forces from the lower extremities and/or upper extremities to yield movement patterns from walking to kicking, throwing to shaking hands.

WHEREAS ANY MOVEMENT OF ANY PART OF THE BODY REQUIRES SOME STABILITY IN SOME AREAS IN ORDER TO BE FLUID AND CORRECT OR ON TARGET, THE CORE IS THE CENTRAL REGULATOR, DISSIPATOR AND CAPACITOR FOR ALL HUMAN MOVEMENT.

Without going into excessive scientific detail and rationalization, for the sake of simplicity for all to understand, the core partially consists of the anterior abdominal wall which is made up of the rectus abdominis (RA, or 6- or 8-pack) on the front and the external (EO) and internal obliques (IO) on the sides. The EO has fibers that run from the lateral lower rib cage toward the midline downward; the IO start more toward the lower back (attaching to the thoracolumbar fascia and anterolateral pelvis) and run upward toward the midline attaching on the lower anterior ribcage. If you can imagine it, the EO fibers run diagonally away from the midline and therefore pull the trunk toward the opposite side of the body; the IO pull the trunk toward the pelvis on the same side. Together they bend the spine laterally toward the side they’re on.

If the RA and both sides of the EO/IO complex contract at the same time, the chest moves toward the pelvis or, if the chest is held steady, the pelvis moves toward the chest (as in a reverse crunch). If the RA and the EO on the right and IO on the left contract, the torso rotates toward the left, as in a twisting crunch or throwing motion.

But the anterior abdominal wall, which is what people associate with a strong core, isn’t the whole picture, visually or functionally.

The posterior core consists of the quadratus lumborum (a low back muscle that bends the spine to either side), erector spinae (the thick, multi-muscle group of the lumbar spine which extends the spine backwards), and the gluteals, especially the big muscle, the gluteus maximus, your butt muscle.

But the core goes even deeper and further afield. For example, any muscles that attach to the pelvis, to which the spine is attached, are technically core muscles. In that they help to control the position of the pelvis relative to leg movements, they help to control the spine.

Thus, we should include the hamstrings on the back of the thigh and the quadriceps on the front; the adductors on the inner thigh and the abductors on the outer thigh such as the TFL (tensor fascia lata), sartorius and, above all, the gluteus medius and its baby brother, gluteus minimus. All these are what some have called the ‘global’ muscles of the core in addition to the abs and low back/gluteals above.

However, where there’s an outer or global core, there must be an inner or local core. These are the muscles that make up the ‘inner tube’ or ‘cylinder’ that support the spine. The front of the inner tube is made up of the transversus abdominis (TrA or TvA). The posterior wall is made by the psoas, which combines with the iliacus to form the iliopsoas. This under-acknowledged and under-appreciated muscle is worthy of more attention by spine docs and fitness professionals despite or maybe because of the lack of use it suffers in modern society.

Like any cylinder, there’s a top and a bottom. The top of the inner core is the diaphragm – yes, you read that right: the dome-shaped muscle that we always associate with breath and breathing. Again, out of respect for your time, I won’t delve too deeply into the role of the diaphragm but suffice it to say that, prior to any major body effort, that little breath-hold you take – the Valsalva maneuver – requires a functioning diaphragm to inhale and hold the air.

And the bottom is what we call the pelvic floor, the complex of small muscles in the bowl of the pelvis that help control urination, defecation and stabilization of the pelvic organs. You mostly know it when it’s not working right, such as with incontinence, but it’s a critical set of muscles most of us never have to think about when it comes to activity let alone spinal stabilization. According to some, though it may be a little too scientific for this discussion, its valuable role comes into play when stiffening the spine against heavy exertions.

To conclude Part 1, the core is the center of the body with branches upward, downward, and side to side that help stabilize the spine so that forces can be transmitted along the kinetic chain. These muscles link with each other in and around the pelvic-lumbar spine regions to direct our legs and feet, shoulders and hands in the directions and in the manners which we expect. They align our head and neck to enable us to see our world. They require a new way of thinking when it comes to training in the gym or on the field of play or work. Their integration is more important, unless there’s a known or notable weakness or dysfunction, than the strength or look of any one or more of them.

In Part 2, in a subsequent post, I will address the fundamental principles of authentic core training and will point out how to judge truly core exercises from tone-and-fit ones.

Originally printed on stepsfitness.com. Reprinted with permission.

Alzheimer’s Disease, Fitness and Exercise

Dr. Irv Rubenstein/23 January 2020/ All MFN blog/

Alzheimer’s Disease (AD) is a neurodegenerative disease that strikes fear and terror into those who are getting on in years and family members who are in line to care for them. According to the Alzheimer’s Disease Foundation, in 2015 it is estimated that 5.3 million Americans have the disease. It is the 6th leading cause of death behind heart disease, strokes, and cancer but it is the only one that cannot be prevented (1) although some experts now estimate that it may be the third highest (2).

If You Can’t Beat It, Use It: An Exercise Guide to Post-Joint Replacement Wellness

Dr. Irv Rubenstein/23 July 2019/ All MFN blog/

It all started over 40 years ago, when I chose as my sport – some would say, my life – the Korean martial art of Tae Kwon Do. I was young, fit, pretty strong and, unbeknownst to me, very flexible – perfect for the art of kicking high and hard. Once I got hooked on it, I was in the gym a few hours a day, 6-7 days a week…for the next almost 20 years. That did not include the running I did to get my cardiovascular conditioning primed for the art and sport I was practicing at high levels of both skill and competition. I knew then, at age 19, that I was going to pay for the training and abuse I was putting my body through, but not until I was older, say, 40 or so.

The Role of Exercise in the Treatment of Diabetes

Dr. Irv Rubenstein/21 June 2019/ All MFN blog/

Diabetes Word Cloud Concept

According to the American College of Sports Medicine’s flagship journal, Medicine and Science in Sports and Exercise (1), there are more than 21 million Americans with Type 2 Diabetes as of 2010 with an estimated 7 million undiagnosed. If these numbers don’t mean much, let’s give it some perspective: in 1958 there were only 1.5 million. (Granted, the US population has increased, but only from about 180 million to 310 million, not 15-fold as in the numbers of T2D.) Furthermore, due to the now-defined pre-diabetes – or sub-clinical diabetes where the precursors to diabetes are lurking if lifestyle does not change dramatically – it is estimated that 80 million Americans are at risk. Thus, some public health officials are predicting that 21-33% of Americans will have diabetes by the year 2050. The healthcare burden this portends will bankrupt the nation. To make matters worse, the preponderance of both pre-diabetes and T2D is increasing in children and adolescents as sedentary behavior, poor diet and obesity abounds.

While prevention is optimal and much is being done in the way of public health messaging, one of the best means by which to regulate blood sugar in either healthy, pre-diabetes or T2D patients is through physical exercise. Recall above where we discussed how muscles use the sugar in the blood for fuel. The more muscles you have and the more regularly they work at some critical level of effort, the easier it is to control blood sugar. In fact, one’s levels of physical activity (PA) may be a better predictor of risk for diabetes than one’s BMI (body mass index, a ratio of height to weight.)

For the sake of discussion, we should break down physical activity into three main types – activities of daily living (ADL), aerobic exercise (AE) and resistance (or strength) exercise (RE). The MSSE article reviewed the data on all these for their impact on blood sugar, insulin control and T2D risk. Not unremarkably, the evidence strongly suggests that the more active you are, the lower your post-meal and long-term blood sugar is, the better your muscles are able to use the sugar in the blood (glucose tolerance or insulin sensitivity), the lower or lesser your insulin response is to food intake, and the lower your risk for diabetes is. What is remarkable, however, is how little physical activity is required in order to affect many of these changes and benefits.

As far as ADLs is concerned, the general prescription is to ambulate (walk, run, bike, etc) for 30-60 minutes a day or close to 10,000 steps/day, or almost 4 miles/day. This does not mean you have to take walks that last that long; it means you should move around more often throughout the day and sit less often. In fact, some studies show that simply standing up for 2 minute bouts of walking every 20 minutes of sitting lowered post-meal blood sugar and insulin response to eating. (2) While walking is effective, new studies (3) demonstrate that high intensity interval training (HIIT), or sprinting, may be an even better regulator of blood sugar. Comparing training programs in two groups of sedentary women, one doing intervals of moderate intensity, the other at high intensity, the authors found that the HIIT group had slightly greater fat oxidation in the muscles, a roundabout indicator of improved glucose control. HIIT might also be more time efficient.

Between the two studies referenced here, and many more that have looked at HIIT programs compared to traditional long, slower/lower intensity programs, the general belief is that the more muscles that are contracting and the harder they contract, the better the short-term and long-term blood sugar control. The only caveat here is that large muscle groups or bigger body movements are necessary to see these effects; single joint/small muscle contractions will not elicit the disease-modifying effects one might be seeking. For these reasons, RT has been getting more looks when it comes to modifying risk factors for T2D. In fact, the preponderance of evidence shows that RT, at sufficiently high enough intensities to build muscle mass, improves blood sugar control both by using sugar to fuel contractions and by improving the insulin sensitivity of those muscles even after the workouts.

Overall, physical activity has been shown to be an effective, efficient and low-risk/low side-effects treatment and preventive for T2D. A single bout of exercise is sufficient to regulate blood sugar for the next 16-24 hours.

As such, it is recommended that exercise be partaken nearly every day for at least 30 minutes; if obesity is a factor in a patient’s disease, then 60-90 minutes of accumulated physical activity is strongly suggested. Furthermore, a combination exercise prescription of cardiovascular and RT exercise – either same or alternating days – is deemed optimal.

To conclude, physical activity of all sorts has been found to enhance blood sugar uptake by muscles during the session and for several hours thereafter. Thus, it is one of the best, least invasive means by which to prevent, regulate and, for early stage T2D, even reverse diabetes and its downstream effects on the heart, kidneys, nerves (especially of the lower extremities), and eyes. Besides its collateral benefits on the cardiovascular system, it may help reduce weight though it is essential in maintaining weight loss. And PA clearly improves quality of life, not just through its physical benefits but its effects on the brain and psyche, reducing the risk of depression which may be a factor in both the sequence of events leading to weight gain, the challenges of both weight loss and disease management, and the reduction in one’s ability to enjoy various aspects of life due to immobility, neuropathy, visual impairment, and dialysis.

For more information about diabetes, exercise, pharmaceutical management and research, please visit the American Diabetes Association site at diabetes.org

References

1. Roberts et al, Modification of Insulin Sensitivity and Glycemic Control by Activity and Exercise. MSSE, Vol. 2013: 45(10):1868-1877
2. Dunstan et al., Breaking up prolonged sitting reduces glucose and insulin responses. Diabetes Care, 2012:35(5): 976-983
3. Astorino et al., Effect of Two Doses of Interval Training on Maximal Fat Oxidation in Sedentary Women. MSSE, Vol. 45(10), pp.1878-1886, 2013