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Understanding and Conquering the Relative Insulin Resistance of Midlife – Beyond the Blood Tests

Carla DiGirolamo, MD, CF-L1, PN-1/3 January 2024/ All MFN blog/

One of the most common things my midlife clients struggle with is weight gain. “The things that worked before just don’t work anymore” is the mantra of so many during this phase of life. They visit their healthcare provider with concerns about “waking up in someone else’s body”. The doc runs some tests – thyroid levels, blood sugar studies, and insulin – and all the results come back in the normal range. “Great news!” says their doc. “There’s no problem. You’re just getting older”. End of story.

Many of you who have heard me on various podcasts know that I’m not a fan of the notion that hormone testing reflects the entirety of the Human experience as many “practitioners” would have you believe. The relative insulin resistance of midlife is a perfect example. One does not have to meet the criteria for “pre-diabetes” or metabolic syndrome for there to be real changes for which there are interventions. Isn’t the goal of medical care to prevent these things in the first place rather than just send you away until you actually become diabetic?

One does not need to meet the criteria for “pre-diabetes” or “metabolic syndrome” for there to be changes for which there are interventions. Isn’t the goal of medical care to prevent these things in the first place rather than just send you away until you actually become diabetic?

This is where understanding what’s happening inside your body during the various phases of hormonal life keeps you one step ahead of mainstream medicine. Today we will discuss the phenomenon of relative insulin resistance – the physiologic changes to energy utilization occurring in your body as a result of the normal hormonal changes of midlife – and how to mitigate the effects of these changes so that you can be your healthiest self.

Your Body on Carbs

In a nutshell, carbohydrate is consumed in the diet, digested and absorbed as glucose (among other simple carbohydrates), and utilized as fuel by the tissues in the body. Excess glucose that is not used is stored as glycogen in the liver and muscles, but also as fat. The hormone, “insulin”, is secreted by the pancreas in response to glucose entry into the bloodstream. Insulin drives glucose into the cells so that the cells can use the glucose as fuel to carry out their functions. The “efficiency” of insulin function is impacted by cycling estrogen and estrogen receptors on the surface of cells.

The two bodily systems that use the greatest amount of blood glucose are the brain and skeletal muscle – the voluntary muscles that move our bodies. During midlife, there is a decrease in cycling estrogen and estrogen receptor presence on the surface of skeletal muscle cells. As the ovarian hormonal cycles change and become irregular, there is less circulating estrogen. As a result, muscle mass, strength, and power decline along with the efficiency of the muscle’s ability to utilize blood glucose through insulin-mediated pathways.

A prominent player in cellular and insulin efficiency is an intracellular organelle called the mitochondria: the “batteries” that supply energy to cells. Below is an excerpt from my course Menopause Health and Fitness Specialist Course through MedFit Classroom that explains the science behind how skeletal muscle function is impacted by changes in estrogen and its receptors.

As we just mentioned, when blood glucose is not used as fuel, the excess is stored as fat. When the hormonal changes of midlife reduce the efficiency of glucose utilization by skeletal muscle, the result is a greater excess of unused glucose and increased storage of fat which results in changes in body composition.

Your End-Run Around Relative Insulin Resistance

There are three basic approaches to mitigating the impact of the hormonally-driven changes in how our bodies manage glucose. Resistance training (particularly weight training), nutrition, and neuroendocrine activation.

Resistance Training

If you want your muscles to use more glucose, then you need to increase the activity of those muscles. This looks different for different individuals. If you are sedentary, then starting with walking for 30 minutes 4-5 times per week is a great start! From there, add a weighted backpack, then maybe add some hills or even hiking trails. Simultaneously, engage a personal trainer for 6 weeks and become familiar with weight training. If you are an endurance athlete, make friends with the barbell. If you are a powerlifter, explore different ways to stimulate the muscles that add cardiovascular stimulation like combining running segments with heavy deadlifts. The point is, no matter what your fitness level or expertise, there are new and exciting ways to increase the functional capacity of your skeletal muscle.

Why does this work? The Human body is an amazing machine designed for survival. Mother Nature has programmed redundancies within our physiologic systems to promote longevity. We discussed the impact of our cycling reproductive hormones on how our muscles utilize blood glucose. Fortunately, other physiologic pathways facilitate glucose entry into the muscle cells that depend less on cycling hormones, most notably, the GLUT4 pathway. GLUT4 is a glucose transporter protein that works with muscle contraction to transport glucose into the cells. So when we stimulate muscle contraction through resistance training, this activates the GLUT4 pathway to facilitate the entry of glucose into the cells to be used as fuel, leaving less excess to be stored as fat.

GLUT4 is a glucose transporter protein that works with muscle contraction to transport glucose into the cells. So when we stimulate muscle contraction through resistance training, this activates the GLUT4 pathway to facilitate the entry of glucose into the cells to be used as fuel, leaving less excess to be stored as fat.

Nutrition

We have discussed how glucose enters the cells of our tissues through pathways involving insulin and GLUT4 and how unused, excess glucose is stored as fat. In this section, we will discuss the other important part of this equation, which is the load of glucose that enters the bloodstream by way of the foods we eat.

Glycemic Index – The glycemic index is a measure of how much a carbohydrate source will increase blood sugar over 2 hours from the time of consumption. There are low, medium, and high glycemic index foods with a great description in this resource from Healthline. A lower glycemic index reflects lower blood sugar following consumption and a higher index reflects greater increases in blood sugar. This is important because the glycemic index reflects the glucose “load” on the systems (such as insulin and GLUT4) that need to shuttle the glucose into the cells. When the glucose load is greater, the systems can become overloaded, leaving more excess to be stored as fat. When the load is less, insulin and GLUT4 can better “keep up” with transporting glucose into the cells for use as fuel leaving LESS excess to be stored as fat.

By focusing on carbohydrate sources with a lower glycemic index and minimizing those with a higher glycemic index, you can effectively decrease the glucose load that insulin and other glucose transport pathways see and thus more efficiently use carbohydrates as fuel and minimize the excess that is stored as fat.

Neuroendocrine Adaptation

Adaptation is the ability of the body to adjust or “make familiar” movements or tasks that we undertake. This is a coordinated effort by the muscles, joints, metabolic, and endocrine processes all driven by the master puppeteer we know as the Nervous System!

Because Mother Nature designed Humans for survival, our ability to adapt to physical stimuli and physical tasks is powerful! When we stimulate the muscles repetitively in the same way for an extended period of time, the body doesn’t need to work as hard to manage the load or task and effectively switches into “Auto-pilot”. This is great for elite athletes where the tasks that their sports require become second nature through adaptation.

However, from the standpoint of muscle physiology, they crave something more! This is why we train differently in the off-season: to keep the muscles guessing and thus contantly adapting to become fitter, faster and stronger so that we can crush it on game day! To learn more about this incredible phenomenon, check out Neuroendocrine Adaptation: Your End-Run Around the Menopause Transition.

Key Points for Combatting Midlife Relative Insulin Resistance

Get moving! The first step to using more glucose as fuel and storing less as fat is to move those muscles. For the sedentary, walking, backpacking, and hiking are great ways to start.
If you have never trained with weights, another great place to start is a group “boot camp” style fitness class. Find one at your local gym and sign up with a friend! My favorite group class for getting started with weights is Les Mills BodyPump.
Any level of athlete can benefit from a 4-6 week training program with a trainer or strength coach to gain some basic skills and techniques from basic to more advanced movements depending on your fitness level/familiarity.
Incorporate resistance/weight training at least 2-3x per week.
No equipment, no problem! Push-ups and their many variations are fantastic for anyone of any fitness level to add mass, strength, and power to the muscles of the upper body.
Take an inventory of your carbohydrate intake and using the resources in this LINK, identify carbohydrate sources and potential substitutions that can move the needle toward lower glycemic index choices.
Nutrient timing is a strategy where carbohydrate intake is timed within an hour before training and within an hour after when the muscles are “looking” to fuel movement during the workout and then looking to replenish glycogen stores in the liver following a training session.
Most importantly, be consistent, but be patient! It’s about progress, not perfection. Every little bit you can do has benefits.

Fit Pros: Offer menopausal and perimenopausal women an individualized approach to training, nutrition and wellness as a Menopause Health and Fitness Specialist.

Dr. Carla DiGirolamo is a double Board-Certified Obstetrician/Gynecologist and Reproductive Endocrinologist who specializes in the care of reproductive age and mid-life women. Carla completed her residency training in Obstetrics and Gynecology at Brown University Medical School/Women and Infants’ Hospital and her Reproductive Endocrinology training at the Massachusetts General Hospital at Harvard Medical School.

Exercise and Prostate Cancer

Carol Michaels/22 December 2023/ All MFN blog/

The rising rate of prostate cancer necessitates developing better methods to prevent and treat prostate cancer. Prostate cancer is the third leading cause of cancer death among U.S. men, according to the American Cancer Society. The country’s 3.3 million prostate cancer survivors account for 21 percent of all cancer survivors.

There are many reasons why a cancer patient should stay as active as possible through cancer treatment and recovery. I will begin by pointing out a few studies that show how exercise can benefit cancer patients. These studies demonstrate how exercise can reduce certain side effects from treatment, increase energy, decrease stress, and improve quality of life.

There is evidence to support the use of exercise in prostate treatment. Exercise plays a role in the all-around improved physical and mental health and therefore should be considered in the treatment plan. We know that exercise can decrease recurrence for some cancers and the role it plays in weight control, which is correlated with some cancers. For prostate cancer specifically, data indicates that obesity increases the aggressiveness of prostate cancer, and thus mortality. Men receiving androgen deprivation therapy are at higher risk for depression. Exercise reduces depression.

Studies do have their limitations. Some use self-reported data about lifestyle and exercise. Moreover, there may be a low number of minority participants who may often have higher cancer rates. The following are a few of the published studies, which confirm that exercise should be included in the treatment plan for prostate cancer patients.

Studies have suggested that patients with high levels of physical activity had a lower rate of disease progression and also reduced mortality from prostate cancer. Ying Wang, PhD, a senior epidemiologist in the Epidemiology Research Program at the American Cancer Society in Atlanta, and colleagues analyzed data on 10,067 men diagnosed with non-metastatic prostate cancer between 1992 and 2011. Men with prostate cancer, which hasn’t spread may have longer survival the more they exercise. A study demonstrated that men who were the most physically active had a 34% lower risk of dying from prostate cancer when compared with men who were the least physically active. Men who either maintained or increased their exercise level also benefited. Prostate cancer patients who kept up a moderate to high level of physical activity also had better survival prognoses compared with their more sedentary counterparts. Those men who were more active before diagnosis were more likely to have lower-risk cancer tumors and a history of prostate screenings. They were also leaner, more likely to be nonsmokers and vitamin users and they ate more fish. Wang concludes, “Our results support evidence that prostate cancer survivors should adhere to physical activity guidelines, and suggest that physicians should consider promoting a physically active lifestyle to their prostate cancer patients.”

Androgen Deprivation Therapy leads to numerous side effects, which can be decreased through exercise. Side effects of ADT include loss of muscle, increase in fat mass and osteoporosis. Risk for diabetes and heart disease also increases. Brian Focht, reported at the November AICR convention, that functional ability increased dramatically as did quality of life for those that exercise, and side effects of ADT were reversed.

Exercise can decrease blood sugar levels, which lower insulin levels and also helps to lower inflammation. There does appear to be a positive association between insulin levels, inflammation and prostate cancer risk.

The evidence for physical activity in reducing anxiety and depression, while increasing general-well being is fairly substantial. Improving well-being can have a dramatic beneficial effect on sexual function. Consistent exercise will also help to lower insulin, blood sugar, and improve overall cardiovascular health, all of which have positive impact on erectile dysfunction and libido ().

In 2016, Rider and Wilson studied the connection between ejaculation and prostate cancer, which was published in European Urology. Men that reported higher ejaculatory frequency were less likely to be diagnosed with prostate cancer . This study showed a beneficial role of frequent ejaculation particularly for low-risk disease.

Some doctors have traditionally told patients to rest during this time but Favil Singh’s research confirms the importance of getting fit prior to surgery. Singh’s research published in the journal Integrative Cancer Therapies has shown that a regular dose of physical activity prior to surgery helps the recovery process. This reduces time in the hospital.

Singh stated “This is the first time we’ve been able to demonstrate the benefits of ‘pre-habilitation’ for prostate cancer patients. It is safe, side effect-free and can be done while undergoing chemo or radiotherapy. Just two sessions a week of resistance and exercise training for six weeks can make a difference to recovery.”

Often, there is a waiting period in between diagnosis and surgery. If fitness level can be improved before surgery the patient, then the patient goes into the surgery stronger and may have a better recovery.

The American Cancer Society and American College of Sports Medicine recommends at least 150 minutes of moderate physical activity or 75 minutes of vigorous exercise each week. This advice is a good goal for those who have been inactive. Unfortunately, in my view this is insufficient for a significant number of cancer patients. Having worked with cancer patients for over 20 years, I believe that this recommendation needs to be changed. It is impossible to include aerobic exercise, strength training, and other exercise methods in the current recommended time frame.

Carol J. Michaels is the founder and creator of Recovery Fitness® LLC, located in Short Hills, New Jersey. Her programs are designed to help cancer survivors in recovery through exercise programs. Carol, an award winning fitness and exercise specialist, has over 17 years of experience as a fitness professional and as a cancer exercise specialist. Visit her website, carolmichaelsfitness.com

References

Steven C. Moore PhD, et al, Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med. 2016; 176(6): 816-825.

Lynch B.M., Dunstan D.W., Vallance J.K., Owen N. Don’t take cancer sitting down: A new survivorship research agenda. Cancer. 2013, Jun 1; 119(11): 1928-35 Medicine

Kristina H. Karvinen, Kerry S. Courneya, Scott North and Peter Venner, Associations between Exercise and Quality of Life in Bladder Cancer Survivors: A Population-Based Study, Cancer Epidemiology and Biomarkers Prevention May 2007, 10.1158/1055-9965

Gopalakrishna et al, Lifestyle factors and health-related quality of life in bladder cancer survivors: a systematic review. Journal of Cancer Survivorship, 2016 (5): 874-82

Vallance, J., Spark, L., & Eakin, E.. Exercise behavior, motivation, and maintenance among cancer survivors. In Exercise, Energy Balance, and Cancer (2013) (pp. 215-231). Springer

Cannioto et al., The association of lifetime physical inactivity with bladder and renal cancer risk: A hospital-based case-control analysis, Cancer Epidemiology, Volume 49 August 2017

Cramp F, Byron-Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev. 2012; 14(11): CD006145.

Booth FW, et al., Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2012 Apr; 2(2): 1143-211.

Stephanie Cash et al, Recreational physical activity and risk of papillary thyroid cancer among women in the California Teachers Study. Cancer Epidemiology, Feb 2013,37(1): 46-53

Hwang, Yunji MS; Lee, Kyu Eun MD, PhD; Park, Young Joo MD, PhD; et al, Annual Average Changes in Adult Obesity as a Risk Factor for Papillary Thyroid Cancer: A Large-Scale Case-Control Study, Medicine, March 2016, Mar; 95(9): e2893

Cao Y, Ma J. Body mass index, prostate cancer-specific mortality, and biochemical recurrence: a systematic review and meta-analysis. Cancer Prev Res (Phila). 2011; 4: 486-501.

Galvao, et al. 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 Jan 10; 28(2): 340-7.

Galvao, et al. Exercise can prevent and even reverse adverse effects of androgen suppression treatment in men with prostate cancer. Prostate Cancer Prostatic Dis. 2007; 10(4):340-6.

Winters-Stone KM, et al. Resistance training reduces disability in prostate cancer survivors on androgen deprivation therapy: evidence from a randomized controlled trial. Arch Phys Med Rehabil. 2015 Jan; 96(1): 7-14.

Giovannucci EL, Liu Y, Leitzmann MF, Stampfer MJ, Willett WC. A prospective study of physical activity and incident and fatal prostate cancer. Arch Intern Med. 2005; 165: 1005-1010.

Storer TW, Miciek R, Travison TG. Muscle function, physical performance and body composition changes in men with prostate cancer undergoing androgen deprivation therapy. Asian J Androl. 2012, Mar; 14(2): 204-21.

Focht, Brian C.; Lucas, Alexander R.; Grainger, Elizabeth; Simpson, Christina; Fairman, Ciaran M.; Thomas-Ahner, Jennifer; Clinton, Steven K., Effects of a Combined Exercise and Dietary Intervention on Mobility Performance in Prostate Cancer, Medicine & Science in Sports & Exercise. May 2016:48(5S): 515.

Rider J, Wilson K.et al. Ejaculation Frequency and Risk of Prostate Cancer: Updated Results with an Additional Decade of Follow up, European Urology. December 2016, volume 70, issue 6

Singh F. et al. Feasibility of Presurgical Exercise in Men With Prostate Cancer Undergoing Prostatectomy, Integrative Cancer Therapies (2016). DOI: 10.1177/1534735416666373

Wang et al, Recreational Physical Activity in Relation to Prostate Cancer–specific Mortality Among Men with Nonmetastatic Prostate Cancer. European Urology July 2017 online bit.ly/2tXMK6Y

Fueling Tips for Single and Double Workouts

Nancy Clark, RD/20 December 2023/ All MFN blog/

As one coach aptly stated, “Too many athletes show up for training, but they don’t show up for meals. They might as well not show up for training.” So true! Pre-exercise fueling makes a big difference in terms of how well athletes can enhance their performance. Food eaten within the hour before exercise does get put to good use, helping athletes train harder and longer. (It also helps curb the post-exercise hunger and sugar cravings that can easily end up as overeating.)

You can only perform at your best if you are well-fueled on a daily basis. Yet too many athletes wonder what (and if) they should eat before exercise. Rowers want to know what to grab (if anything) as they roll out of bed and head to the boathouse. Triathletes ask about how to fuel for their second workout of the day. Runners want a pre-exercise snack that will not cause intestinal distress.

No one pre-exercise food is best for all athletes. Hence, you want to experiment to learn which foods settle best in your body. Here is some guidance for planning effective pre-exercise fueling.

First, take steps to train your gut (not just your heart, lungs, and muscles).

I’ve talked to many athletes (particularly in running sports) who purposefully choose to not eat within hours of exercise as a means to avoid gastro-intestinal (GI) upset. While this may seem like a good idea for the short term, it’s a bad idea if you want to optimize performance for the long run.

The intestinal tract is trainable and can digest food during exercise that lasts >30 minutes. (The gut shuts down during short, intense bouts, so plan to eat 2 to 4 hours in advance of those workouts!) To train your gut, start by nibbling on 50 to 100 calories of crackers, pretzels, or any simple-to-digest carb within the hour pre-exercise. Once your GI tract tolerates that snack, titrate the calories up to 200 to 300—maybe a packet of oatmeal, a granola bar, or an English muffin (with some peanut butter on it for longer-lasting energy). Experiment with a variety of fruits (applesauce), vegetables (sweet potato), and grains (leftover pasta) to learn what works best for your body. You are an experiment of one.

For some athletes, GI distress can be caused by the inability to thoroughly digest specific types of carbohydrates called FODMAPS (Fermentable Oligo-, Di-, Mono-saccharides And Polyols). Common sources of FODMAPs include garlic and onion (found in the spaghetti sauce & garlic bread often enjoyed the night before a big work-out), as well as apples and raspberries. For more in-depth FODMAP information, visit www.KateScarlata.com.

Meal timing matters. When you eat matters as much as what you eat.

Too many athletes eat backwards. That is, they undereat during the active part of their day, only to consume a huge meal before going to bed. Two standard excuses for skimpy daytime fueling include:

#1: “I look forward to a big dinner. That’s when I finally have time to relax and reward myself for having survived yet-another busy day.”
#2: “I want to lose weight. I can stick to my diet at breakfast & lunch, but I blow it at night. Evening eating is my downfall.”
If either scenario sounds familiar, think again. You are going to consume the calories eventually, so you might as well plan to eat them when they can be put to good use.

Morning exercisers want to eat part of their breakfast (granola bar & latte) before they workout and then the rest of their breakfast afterwards (oatmeal, banana & PB). They then want to plan an early hearty lunch at 11:00ish and a second lunch/hearty snack at 3:00ish. The goal of the second lunch is to both fuel the upcoming workout and curb the appetite for dinner so they can then be content to eat a lighter dinner—and likely better sleep than if they had stuffed themselves with a big meal.

Athletes who do double workouts really want to eat a hearty early lunch to refuel from the morning session and prepare for the second (afternoon) session. They’ll have 4 to 5 hours to readily digest lunch before they train again.

**You might need to plan time to eat.**

Busy athletes who juggle work and/or school plus double workouts often complain they have no time to eat. Sometimes that is true and sometimes they choose to sleep a few more minutes (leaving no time for breakfast) or keep working on a project (leaving no time for lunch). Those are both choices. They could have chosen to make fueling more of a priority.

If you struggle with finding time to eat, plan ahead and schedule lunch time in your daily calendar, or set an alarm for snack-time before your 4:00 pm workout. Maybe you can convert your afternoon coffee into a latte, grab a banana, or eat an energy bar while driving to the gym or reading email? Anything is better than nothing.

If you go from work (or school) to afternoon workout, the extra-large lunch will offer fuel for an energetic afternoon workout. Alternatively, plan to have a 3:00 Second Lunch readily available (apple + cheese+ crackers; half or whole PB & J sandwich; yogurt + granola + banana).

Any fuel—even cookies or candy—is better than exercising on empty. You’ll even perform better after having enjoyed a sweet treat as opposed to having eaten nothing. (Research suggests sugar/candy eaten within 15-minutes pre-exercise can actually boost performance and not simply contribute to a sugar “crash.”)

Final thoughts

For athletes, every meal has a purpose. You are either fueling up to prepare for exercise, or you are refueling afterwards to both recover from the work-out and prepare for your next session. Fueling properly takes time and energy. You need to be responsible! Do not brush off meals and snacks as if they are optional inconveniences in your busy day.

Proper fueling requires time-management skills, particularly for students and athletes doing double sessions. You want to schedule time (rest days? weekends?) to food shop and batch-cook so you can have the right foods in the right places at the right times. You (almost) always find time to exercise; you must also find time to fuel properly.

Nancy Clark MS RD CSSD counsels both fitness exercisers and competitive athletes in the Boston-area (Newton; 617-795-1875). Her best-selling Sports Nutrition Guidebook is a popular resource, as is her online workshop. Visit NancyClarkRD.com for info.

Gratitude: The Gift of Being Present

Cate Reade, MS/18 December 2023/ All MFN blog/

The holiday season can be a wonderful time for gathering and celebrating with family and friends, but it can also be a source of much added stress. You may be fretting about any number of circumstances like: how to manage your weight or chronic condition like diabetes during all the “feastivities”; choosing the perfect gifts and worried if you can afford them; missing a loved one who can’t be with you or who has passed away; or perhaps you feel unwell or someone close has been diagnosed with a disease.

Whatever personal challenges you are experiencing, research shows that grateful people are happier and healthier; can make better decisions; and are more joyful⁽¹⁾. It’s a skill anyone can learn and benefit from and best of all, it’s free!

How it Works

An attitude of gratitude bolsters the feel-good neurotransmitters (brain chemicals) dopamine and serotonin. Feeling thankful and appreciative also boosts the love hormone oxytocin so we feel more connected while it decreases the stress hormone cortisol⁽²⁾.

Our day-to-day lives are so busy that we often rush from one task to the next one without being mindful. Living in the fast lane thrusts us into a chronic state of stress, consistently raising cortisol levels that end up damaging our body cells, organs and systems. This is a major reason why stress is the silent killer that we all talk about but don’t take seriously enough.

Slowing down, taking a few deep breaths and being grateful moves us out of the sympathetic state or fight or flight mode and into the parasympathetic state of rest, digest, heal and repair. This is where our body and mind can relax and rejuvenate so we can sleep better and experience more energy and vitality. And who doesn’t want more healthy energy?!

Count Your Blessings

When we focus on what we have instead of what we don’t have, it puts us in a positive frame of mind. We become more content, satisfied and fulfilled. The ability to notice, appreciate and savor life’s moving parts grows gratitude for better physical and psychological well-being^(1,3).

Grateful people count their blessings and look at their lives and experiences as gifts^(1,3). We can shift our perspective and explore: “What is this difficult situation trying to teach me?” “What am I grateful for in this moment?”

When my family and I were recovering from chronic Lyme, we were all thankful for each other, the support of family and friends and for having the resources to pay for exorbitant out-of-pocket medical expenses. Gratitude played a starring role in our healing.

Mindfulness

Practicing mindfulness is an effective way to plug into the feeling of gratitude. Dr. Jon Kabat-Zinn defines mindfulness as “paying attention on purpose in the present moment, non-judgmentally…as if your life depended on it”⁽⁴⁾.

When you think about it, all we really have is the present moment. Unfortunately, we spend a lot of time and waste precious energy worrying about the future or commiserating over the past. Focusing on the present moment helps us connect to each other, our thoughts and our own lives so we can become the best version of ourselves. Each day we have the opportunity to do and be better.

Cultivate Gratitude

When we are mindful we can be amazed by the power of breath, the body’s ability to heal itself from an infection or injury, the beauty of the blue sky, a pink sunrise or sunset, the miracle of a baby being born, the unconditional love of a pet, the plants and trees that clean the air and provide oxygen, the water that runs out of a faucet or down a cool Rocky Mountain stream… the possibilities are limitless.

Better Health

Scientific studies show that being thankful and appreciative is associated with less physical illness, fewer aches and pains; lower levels of stress, anxiety, and depression^{(3, 5)}; and fostering new and lasting relationships^(6).

Being grateful also expands our scope of cognition so we can be more flexible and creative with our thinking and make better decisions. This makes it easier to cope with stress and adversity⁽¹⁾.

Unwrapping the Gift

When we are grateful and thankful, we tend to be kinder and more generous. Gratitude makes us feel good, so we want to do it again and again. The best part is that it’s easy to get started and can feel the benefits quickly. Research shows that you can start feeling better in as little as 2 weeks by writing in a Gratitude Journal⁽¹⁾.

Here’s How

Grab a notebook, pad or smart phone and each evening before bed, write 3 things you are grateful for. Write novel blessings, trying not to repeat the same ones, because the possibilities are endless. Practice this for 2 weeks and see what happens.

The best time to get started is now, in the present moment. Today, tell someone how grateful you are for them. You will be sharing a great gift.

Cate Reade, MS, RD is a Registered Dietitian, Exercise Physiologist and Functional Medicine Practitioner candidate on a mission to improve functional mobility and health span utilizing the power of lifestyle medicine. She has been teaching, writing and prescribing healthy eating and exercise programs for over 25 years. Today, as CEO of Resistance Dynamics and inventor of the MoveMor™ Mobility Trainer, she develops exercise products and programs that target joint flexibility, strength and balance deficits to help older adults fall less and live more.

References

Emmons, R & McCullough, M (2003). Counting Blessings Versus Burdens: An Experimental Investigation of Gratitude and Subjective Well-Being in Daily Life. Journal of Personality & Social Psychology. www.greatergood.berkeley.edu.
Gottfried, S (2016). www.saragottfriedmd.com/thanksgiving-what-gratitude-does-to-your-brain/
Hill, PL et al (2013). Examining the Pathways between Gratitude and Self-Rated Physical Health across Adulthood. Pers Individ Dif. www.ncbi.nlm.nih.gov/pubmed/23139438
Jon Kabat-Zinn, Ph.D. www.psychalive.org | videos
Cheng, S et al. (2015) Improving mental health in health care practitioners: Randomized controlled trial of a gratitude intervention.” Journal of Consulting and Clinical Psychology. https://www.ncbi.nlm.nih.gov/pubmed/25222798
Williams, L & Bartlett M (2015). Warm thanks: gratitude expression facilitates social affiliation in new relationships via perceived warmth. Emotion. www.ncbi.nlm.nih.gov/pubmed/25111881

The Protein Demands of Aging

Gerry Morton/15 December 2023/ All MFN blog, Conditions/

Remarkable changes in body composition occur as people get older. For example, physiologic proteins are reduced, including proteins that make up blood components, immune bodies, or organ tissue. This can lead to poor wound healing, poor immune function, or loss of skin elasticity.

The Walking Games

Jonathan Ross/13 December 2023/ All MFN blog/

Walking is the most readily available form of physical activity that most people can do regularly. As the days turn darker and the temperatures drop, the innate enjoyment of walking outdoors can make regular walking harder as we spend more time indoors.

The solution? Walking Games.

These are strategies to bring enjoyment and engagement to indoor physical activity. Further, these strategies also sneak in some added of brain health benefit with added cognitive challenge and an emotionally enhanced experience beyond what people expect from “walking.”

Brain games alone are not enough. They can provide some cognitive benefit, but for most of human history, we solved intensely meaningful problems directly related to survival while moving, not sitting on a couch playing a low-stakes brain game or working on a crossword puzzle.

Likewise, any exercise is good for brain health. But when you add cognitive challenge to exercise, the benefits multiply. Conceptually, it’s as simple as considering the difference between the treadmill and a trail for walking. The latter requires using sensory information to consciously choose where and how to take each step.

The strategies below are designed to create a “think and move” experience, all while enhancing the emotional response to movement.

Walking Game 1: Alphabet Walk

Mark off a rectangular or oval space with cones, water bottles, shoes, pillows, or anything else readily available.
Within the space, walk to trace letters on the floor with your feet. Use names of favorite movies, books, musical artists or names of friends, family, or pets or perhaps names of travel destinations.

The highly variable direction of movement makes the walking more beneficial and the use of letters of cherished names adds cognitive benefit and enhances the emotional state while walking by keeping favorite pop culture offerings or loved ones front-of-mind while moving.

Walking Game 2: Balloon Tap Walk

Blow up a balloon and gently tap it as you walk to keep it up by “air dribbling.”

The need to track the unpredictable action of the balloon will result in variable walking speeds and co-coordination of eye-hand movements.

Walking Game 3: Balloon Wall Dribble

Blow up a balloon and face a wall.
Tap the balloon into the wall and keep tapping it into the wall, adjusting body position slightly side-to-side to move with the balloon.

Optional add-on for balloon exercises: Use a light-colored balloon and a dark-colored marker. Write letters or numbers on the balloon. Use it to perform any of the following (in increasing order of difficulty):

Call out the letter or number most visible when tapping the balloon.
Call out words in the same categories introduced above in “Alphabet Walk”
Using the numbers, designate a left and right hand for even and odd numbers, then tap the balloon with the corresponding hand. Or, perform simple math like addition or subtraction.
Combine use of letters and numbers. For example, call out favorite musical artists for letters and use the left-right/even-odd hand tap for numbers.

Walking Game 4: Bounce, Catch…or Fetch

This can be done strolling slowly through any indoor space or standing still. Use a ball, a pet’s toy, a pillow, or any object which you can bounce and/or toss and catch. Bonus brain points for using something without an “easy” shape as it requires more manual dexterity to catch. And if you drop the object, you get some extra essential life skill movement by fetching it from the floor.

Wrap Up

The reason people become less active when spending more time indoors is that the usual ways of moving more indoors are boring – no one is realistically going to take a walk around their house. However, moving consistently is important to our physiology and our brain health regardless of the weather or season.

Using these and other similar strategies that you think of can make staying active when spending more time inside more appealing, and that is the key to making it happen more regularly. You can be an inspired leader to the people you serve when you make things enjoyable, more engaging, and as a result easier to do (so they no longer have to force themselves to do them.)

Brain Health Education for Fit Pros

All physical activity is good for the brain, but the inclusion of specific elements such as coordination, reactivity, partner interaction, attention and memory challenges integrated with physical activity make it even more beneficial. MedFit Classroom’s Alzheimer’s Disease Fitness Specialist course blends current science with common sense to present cutting-edge ideas to optimize the impact that fitness can have in the lives of those you serve who are concerned about or diagnosed with Alzheimer’s.

Article originally printed in canfitpro magazine.

His “800 Pounds of Parents” directly inspired Jonathan’s prolific fitness career. He is a multiple Personal Trainer of the Year Award-Winner (ACE, IDEA, and PFP Magazine), master trainer for the American Council on Exercise (ACE), creator of Funtensity, brain fitness visionary, blogger, international speaker and author. He is the author of MedFit’s Alzheimer’s Disease Fitness Specialist online course.

Surviving the Holiday Season

Kristy Richardson/11 December 2023/ All MFN blog/

The hardest time of year for weight management is from Halloween until Valentine’s Day – temptations are everywhere from home to the workplace and everywhere else you go, people wear more clothes and are more covered up because of the weather, and people tend to exercise less because they are stressed, exhausted, it is cold, and they have very little time.

Here are some tips to manage weight during the holiday season…

Plan ahead

Eat something before you go out so that you are not inclined to eat everything or anything in sight.
Stock your home, office, and/or car with healthy snacks such as fruit in your home, almonds in your office, and a nutrition bar in your car.
Plan on making healthy choices for your meals such as mustard instead of mayonnaise or light Italian rather than ranch dressing.

Manage stress

Make a list of stress relieving activities that do not include food or eating such as getting a massage, exercising, listening to music, or talking on the phone.

Party responsibly

If you are attending a pot-luck party, bring something healthy so you know there will be at least one healthy choice at the party.
Eat small portions of your favorite sweets at parties.
Try to fill your plate with mostly fruits and veggies at parties.
If you want to try new dishes, only take a taster size portion so that you are not tempted to eat more than you should. Then go back and get more of what you like if you are still hungry.
Drink a glass of water after each glass of soda or alcoholic beverage in order to cut beverage calories in half.
Focus on socializing with other guests rather than eating the food available.

Keep moving

If you know you will not have time to exercise, try to fit other small activities into your day such as parking farther away, taking the stairs, and putting the shopping cart away instead of putting it to the side.
If you have a stationary bicycle or a treadmill that you haven’t used for a while, take it out and put it in front of the TV, so you can watch TV when you work out.
Take a walk alone or with your spouse, kids, or other family and friends after dinner.

Kristy Richardson is a dietitian and exercise physiologist, specializing in sports nutrition and weight management, She is the founder of OC Nutrition and also works as a nutrition professor at Fullerton College.

References

Cleveland Clinic. (2009). 8 Steps to Surviving the Holiday Weight Gain. Retrieved December 22, 2009 from: http://my.clevelandclinic.org/heart/prevention/nutrition/holidayeating12_01.aspx

Zamora, Dulce. (2007). Holiday weight management; Surviving the Feasting Season. Retrieved December 22, 2009 from: http://www.medicinenet.com/holiday_weight_management/article.html

The Habits of Successful Weight Losers

Jason Karp, PhD/8 December 2023/ All MFN blog/

In a national television interview with Barbara Walters in 2014, Oprah Winfrey confessed that not being able to maintain her weight loss was her biggest regret. In that interview, Walters asked Winfrey to finish the sentence, “Before I leave this Earth, I will not be satisfied until I…”

“Until I make peace with the whole weight thing,” Oprah replied. Losing weight is hard; keeping it off is even harder. What is unique about those who succeed? The answer is buried deep in the archives at the Weight Control and Diabetes Research Center in Providence, Rhode Island: The National Weight Control Registry (NWCR), the largest database ever assembled on individuals successful at long-term maintenance of weight loss. Founded in 1994, the NWCR includes more than 10,000 individuals who complete annual questionnaires about their current weight, diet and exercise habits, and behavioral strategies for weight loss maintenance.

Habit #1: Live with Intention

Living with intention eliminates the random approach to weight loss maintenance in favor of the systematic and methodical one that leads to results. The NWCR has shown that, when intention is behind weight loss maintenance, 21 percent of overweight people are successful weight losers. [1]

The longer people keep their weight off, the fewer strategies they need to continue keeping weight off. [2] In other words, weight maintenance gets easier. The longer your clients persist in their intention and behave in accord with that intention, the easier it is for that behavior to “stick” and turn into a habit.

What makes one individual persist at a specific behavior while another individual doesn’t? For starters, the persistent individual has a conscientious personality. In the most recent NWCR study published in 2020, conscientiousness was compared between successful weight losers from the NWCR and non-NWCR weight regainers. [3] The successful weight losers were found to be more conscientious than the weight regainers and scored higher on measures of order, virtue, responsibility, and industriousness. The scientists suggest that being conscientious may help individuals maintain their weight loss by improving adherence to specific behaviors.

In a review of 56 studies that contained 58 health behaviors, researchers at Université Laval in Quebec, Canada and the University of Limburg in The Netherlands found that intention remained the most important predictor of health behavior, explaining 66 percent of the variance. [4] In half of the reviewed studies, perceived behavioral control (believing that you have control over your behavior) significantly added to the prediction.

Habit #2: Control Yourself

Being a successful weight loser requires a lot of self-control, delaying gratification now (e.g., dessert) for the more desirable reward later (e.g., a slimmer waistline, better health, enhanced self-esteem, and happiness).

Compared to typical unsuccessful dieters, successful weight losers are better able to resist temptation, control themselves, and push back against the environment. They restrict certain foods, [5] weigh themselves regularly, [6, 7] and use digital health technology. [8]

One of the key factors of self-control is disinhibition, which literally means not being inhibited. Some inhibition is good, because it prevents people from not giving into temptation and eating whatever and how much they want. High levels of disinhibition are bad, because it leads to risky behavior. Disinhibited eating is a failure to maintain control over eating. The opposite of disinhibited eating is dietary restraint. Several NWCR studies have found that increased disinhibition leads to regaining lost weight. [9, 10, 11, 12, 13] Other studies have found strong relationships between a lack of self-control—impulsivity—and obesity. [14, 15, 16]

Habit #3: Control Calories

Successful weight losers consume fewer daily calories than the general population. Table 1 shows the number of calories the NWCR members consume per day, from the several studies that have reported it, along with the amount of weight they lost at the time they entered the NWCR.

Table 1 – Caloric Intake of Successful Weight Losers

	Calories Per Day	Pounds Lost
	1,381 ^{[17, 18]} 1,297 (women) 1,725 (men)	66 63 (women) 78 (men)
	1,306 (women) ^[19] 1,685 (men)	63 (women) 77 (men)
	1,390 ^[20]	69
	1,462 ^[21]	124
	1,400 ^[22]	62
	1,399 ^[23]	73
Average Women Men	1,406 1,302 1,705	79 63 78

Successful weight losers consume a low-calorie diet of about 1,400 calories per day, with women consuming about 1,300 and men consuming about 1,700 calories per day. By comparison, the U.S. adult population consumes an average of 2,120 calories per day (women consume about 1,820 calories per day and men consume about 2,480 calories per day). [24, 25]

Successful weight losers control calories several ways, including limiting how often they eat out at restaurants, [26] rarely eating fast food, [27] and limiting how many calories they drink. [28] They are also more likely than normal-weight individuals to have plans to be extremely strict in maintaining their caloric intake, even during times of the year when it’s easy to consume calories, like during holidays. [29]

Want to learn about more of the habits of successful weight losers? Check out Dr. Karp’s book, Lose It Forever: The 6 Habits of Successful Weight Losers from the National Weight Control Registry

A competitive runner since sixth grade, Dr. Jason Karp pursues his passion every day as a run coach, exercise physiologist, bestselling author of 10 books and 400+ articles, speaker, and educator. He is the 2011 IDEA Personal Trainer of the Year and two-time recipient of the President’s Council on Sports, Fitness & Nutrition Community Leadership award. His REVO₂LUTION RUNNING™ certification has been obtained by fitness professionals and coaches in 23 countries. His new book, “Lose It Forever: The Habits of Successful Weight Losers from the National Weight Control Registry” is available on Amazon.

References

[1] Wing, R.R. and Hill, J.O. Successful weight loss maintenance. Annual Review of Nutrition, 21:323-341, 2001.

[2] Klem, M.L., Wing, R.R., Lang, W., McGuire, M.T., and Hill, J.O. Does weight loss maintenance become easier over time? Obesity Research, 8:438-444, 2000.

[3] Gold, J.M., Carr, L.J., Thomas, J.G., Burrus, J., O’Leary, K.C., Wing, R., and Bond, D.S. Conscientiousness in weight loss maintainers and regainers. Health Psychology, 2020.

[4] Godin, G. and Kok, G. The theory of planned behavior: a review of its applications to health-related behaviors. American Journal of Health Promotion, 11(2):87-98, 1996.

[5] Wing, R.R. and Phelan, S. Long-term weight loss maintenance. American Journal of Clinical Nutrition, 82:222S-225S, 2005.

[6] Wing, R.R. and Hill, J.O. Successful weight loss maintenance. Annual Review of Nutrition, 21: 323-341, 2001.

[7] Butryn, M.L., Phelan, S., Hill, J.O., and Wing, R.R. Consistent self-monitoring of weight: A key component of successful weight loss maintenance. Obesity, 15:3091-3096, 2007.

[8] Goldstein, C.M., Thomas, J.G., Wing, R.R., and Bond, D.S. Successful weight loss maintainers use health-tracking smartphone applications more than a nationally representative sample: comparison of the National Weight Control Registry to Pew Tracking for Health. Obesity Science and Practice, 3(2):117-126, 2017.

[9] McGuire, M.T., Wing, R.R., Klem, M.L., Lang, W. and Hill, J.O. What predicts weight regain among a group of successful weight losers? Journal of Consulting and Clinical Psychology, 67:177-185, 1999.

[10] Niemeier, H.M., Phelan, S., Fava, J.L., and Wing, R.R. Internal disinhibition predicts weight regain following weight loss and weight loss maintenance. Obesity, 15:2485-2494, 2007.

[11] Butryn, M.L., Phelan, S., Hill, J.O., and Wing, R.R. Consistent self-monitoring of weight: A key component of successful weight loss maintenance. Obesity, 15:3091-3096, 2007.

[12] Thomas, J.G., Bond, D.S., Phelan, S., Hill, J.O., and Wing, R.R. Weight-loss maintenance for 10 years in the National Weight Control Registry. American Journal of Preventive Medicine, 46(1):17-23, 2014.

[13] Lillis, J., Thomas, J.G., Niemeier, H., and Wing, R.R. Internal disinhibition predicts 5-year weight regain in the National Weight Control Registry (NWCR). Obesity Science and Practice, 2(1):83-87, 2016.

[14] Chamberlain, S.R., Derbyshire, K.L., Leppink, E., and Grant, J.E. Obesity and dissociable forms of impulsivity in young adults. CNS Spectrums, 20(5):500-507, 2015.

[15] Fields, S.A., Sabet, M., and Reynolds, B. Dimensions of impulsive behavior in obese, overweight, and healthy-weight adolescents. Appetite, 70:60-66, 2013.

[16] Amlung, M., Petker, T., Jackson, J., Balodis, I., MacKillop, J. Steep discounting of delayed monetary and food rewards in obesity: a meta-analysis. Psychological Medicine, 46(11):2423-2434, 2016.

[17] Klem, M.L., Wing, R.R., McGuire, M.T., Seagle, H.M., and Hill, J.O. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. American Journal of Clinical Nutrition, 66:239-246, 1997.

[18] Wing, R.R. and Hill, J.O. Successful weight loss maintenance. Annual Review of Nutrition, 21:323-341, 2001.

[19] Shick, S.M., Wing, R.R., Klem, M.L., McGuire, M.T., Hill, J.O., and Seagle, H.M. Persons successful at long-term weight loss and maintenance continue to consume a low calorie, low fat diet. Journal of the American Dietetic Association, 98:408-413, 1998.

[20] McGuire, M.T., Wing, R.R., Klem, M.L., Seagle, H.M., and Hill, J.O. Long-term maintenance of weight loss: Do people who lose weight through various weight loss methods use different behaviors to maintain their weight? International Journal of Obesity, 22:572-577, 1998.

[21] Klem, M.L., Wing, R.R., Chang, C.H., Lang, W., McGuire, M.T., Sugerman, H.J., Hutchison, S.L., Makovich, A.L., and Hill, J.O. A case-control study of successful maintenance of a substantial weight loss: Individuals who lost weight through surgery versus those who lost weight through non-surgical means. International Journal of Obesity, 24:573-579, 2000.

[22] Klem, M.L., Wing, R.R., Lang, W., McGuire, M.T., and Hill, J.O. Does weight loss maintenance become easier over time? Obesity Research, 8:438-444, 2000.

[23] Ogden, L.G., Stroebele, N., Wyatt, H.R., Catenacci, V.A., Peters, J.C., Stuht, J., Wing, R.R., and Hill, J.O. Cluster analysis of the National Weight Control Registry to identify distinct subgroups maintaining successful weight loss. Obesity, 20(10):2039-2047, 2012.

[24] Wright J.D., Wang, C.Y., Kennedy-Stephenson, J., Ervin, R.B. Dietary intake of ten key nutrients for public health, United States: 1999-2000. Advance Data From Vital and Health Statistics, 334:1-4, 2003.

[25] U.S. Department of Agriculture, Agricultural Research Service. Energy intakes: percentages of energy from protein, carbohydrate, fat, and alcohol, by gender and age. What We Eat in America, NHANES 2015-2016, 2018.

[26] Wing, R.R. and Hill, J.O. Successful weight loss maintenance. Annual Review of Nutrition, 21:323-341, 2001.

[27] Thomas, J.G. and Wing, R.R. Maintenance of long-term weight loss. Medicine & Health Rhode Island, 92(2):56-57, 2009.

[28] Catenacci, V.A., Pan, Z., Thomas, J.G., Ogden, L.G., Roberts, S.A., Wyatt, H.R., Wing, R.R., and Hill, J.O. Low/no calorie sweetened beverage consumption in the National Weight Control Registry. Obesity, 22(10):2244-2251, 2014.

[29] Phelan, S., Wing, R.R., Raynor, H.A., Dibello, J., Nedeau, K., and Peng, W. Holiday weight management by successful weight losers and normal weight individuals. Journal of Consulting and Clinical Psychology, 76(3):442-448, 2008.

Proprioception Training: An integral aspect of joint replacement fitness

Pat Marques/6 December 2023/ All MFN blog/

Proprioception refers to the conscious and unconscious perception of postural balance, muscles sense, and joint position and stability. Basically, it is your sense of where you are in time and space for movement. We have found over the years that the best way to explain proprioception to clients comes from Dr. Eric Cobb at Z-Health Performance Solutions:

“Proprioception is the body’s 3D map of itself in time and space. AKA our movement and awareness map”.

The detail and definition of this “proprioceptive map” comes from several specialized mechanoreceptors (i.e. nerve endings) in the muscles, tendons, joint capsules, fascia, and skin. As fitness trainers as we are usually taught about muscle spindles and Golgi tendon organs when we learn about flexibility training, but there is a lot more to proprioceptive input. You are affecting the proprioceptive input to the brain when you use a neoprene knee sleeve (pressure), kinesiology tape (skin stretch), heat or ice packs (temperature), TENS units (electric), etc.

Why understanding and training proprioception is important for joint replacement clients

Several conditions can alter proprioception, thus “clouding” the map and degrading movement sense and capability, including pain, trauma, effusion, and fatigue. A joint replacement client also likely had poor motor control of the joint in the first place that resulted in compensatory movement patterns and overuse injury over time. Complicating the matter further, although it may have been necessary, the surgery itself is an “insult” to the musculoskeletal and nervous systems.

To move a joint well, you must be able to feel the joint and surrounding tissue well. An extreme example of what can happen without the sense of touch or joint position is the story of Ian Waterman. A rare neurological illness resulted in his losing all touch and joint position sensation, effectively paralyzing him from the neck down even though the motor control area of his brain and the descending pathways to send movement information to his musculature were fine!

Varied stimulus drives improved mapping

We can improve proprioception in several ways:

Reduce causes of proprioceptive “inhibition” (i.e., pain, fatigue, and effusion) – Therefore we need to only move in pain-free ranges of motion, and build muscular endurance.
Augment sensory information – We can do this by providing novel sensory stimulus to the affected area such as vibration, kinesiology taping, skin stimulation, pressure, or temperature.
Weight Bearing Exercise Therapy – Loading, appropriately and progressively, compound movements.
Motor Skills Training – Exercises to target accurate movement such as multi-directional movements based on visual stimulus.

The important take away is that building a “library” of prior movement patterns is especially important for the post-medical joint replacement client. We want to get their new joint moving in multiple directions, at multiple speeds, under multiple loads.

The concept of proprioception and how to harness it is not only for joint replacement, but also for general fitness, performance, and pain clients! Begin learning a neuro-centric approach to medical fitness and how to work with joint replacement clients with our Joint Replacement Fitness Specialist online course, available through the MedFit Classroom!

Pat Marques is a Z-Health Master Trainer and NSCA-CPT specializing in training the nervous system to improve performance and get out of pain. After retiring from the Active Duty Army, Pat pursued his education and certifications in exercise science, initially working with wounded, ill, and injured soldiers. During this time that Pat discovered the power of using a neurological approach to training to get out of pain and improve fitness and performance. He currently provides exercise therapy, movement reeducation, and strength and conditioning for all levels of clients at NeuroAthlete, from chronic pain sufferers to Olympic-level and professional athletes.

References:

Lephart, SM and Fu, FH. (2000). Proprioception and Neuromuscular Control in Joint Stability. Champaign, IL: Human Kinetics.
Roijezon, U., Clark, N., and Treleaven, J. (2015). Proprioception in musculoskeletal rehabilitation. Part 1: Basic science and principles of assessment and clinical interventions. Massage Therapy (20).
Cole, J. and Waterman, I. (1995). Pride and the Daily Marathon. MIT Press.
Roijezon, U., Clark, N., and Treleaven, J. (2015). Proprioception in musculoskeletal rehabilitation. Part 1: Basic science and principles of assessment and clinical interventions. Massage Therapy (20).