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pain frustration

Chronic Pain – Healing with Release

Healing with release is based on the fundamental idea, backed by research, that stress, tension and trauma are both psychological and physical. Twentieth-century science is moving forward to a better understanding of the body’s deterioration. Hans Selye recognized that physiological disease could arise from psychological causes, such as stress (Somatic viewpoint). The pathology of chronic pain is associated with numerous losses such as a decline in physical fitness, disturbance of sleep, strained relationships, loss of energy and fatigue. Social isolation, loneliness and anger are often evident in people suffering from chronic pain. These negative emotions exacerbate pain and increase suffering. An estimated 33 to 35 million U.S. adults are likely to experience depression at some point during their lives.  

In 2011 in USA alone hundred million Americans suffer with chronic pain and the cost of lost wages translated to $ 600 billion due to employees with chronic pain calling in sick because of a pain–related condition such as:

  • Headache—$14 billion, only $1 billion of which consists of health care costs (Hu et al., 1999), partly because most people with migraine stop seeking medical care for the condition (Silberstein, 2010)
  • Arthritis—$189 billion, less than half ($81 billion) of which is for health care costs (Yelin et al., 2007)
  • Spine problems—$2,500 average in incremental medical costs (Martin et al., 2008); and low back problems—$30 billion (Soni, 2010) Opioid pain medication use presents serious risks, including overdose and opioid use disorder
  • Between 1999 and 2015, more than 183,000 people in USA died from overdoses related to opioids.

By having a flexible spine with strong hips and thighs, the human body is ideally designed for movement such as walking, running, squatting, and claiming- throwing objects and swimming.  Unfortunately, during the course of a person’s life, the sensory-motor nervous system continually responds to daily stresses and traumas with specific muscular reflexes. These reflexes, triggered repeatedly, create habitual muscular contractions which cannot be relaxed–at least not voluntarily.

If stressed, traumatized, overused and repetitively used muscles are required to continue to work, the muscle begins to tighten. Once this happens the contraction of the muscle constricts the blood vessels. This reduction of blood flow reduces the oxygen to the tissue. Once a tissue is oxygen deprived, it will shut down and tighten more. This creates a negative pattern of tension, oxygen deprivation, and more tension that ultimately results in rigid muscle tone. This results in one’s postural misalignment and muscular asymmetry with symptoms such as:

  • Chronically hard, tight muscles
  • Chronic tightness or chronic inflammation of a tendon(tendinosis)
  • Chronic joint tension or chronic inflammation
  • Limited range of motion in a joint
  • Impingement of a nerve resulting in numbness or a tingling sensation
  • Compression of a disc resulting in neck or back pain
  • Muscle weakness in one area especially if the muscle feels tight
  • Consistent muscle cramping
  • Joint instability while performing daily tasks
  • Recurring muscle strain or injury to the same muscles

Muscles needed to perform regular, daily tasks (such as sitting and standing) are what we call “functional muscles”.  It is more important in daily life to have functional muscles than it is to have big, hard muscles.  Functional muscles require more endurance than pure strength.  The focus of restoring to maintain a healthy body is to increase the endurance of those muscles which are needed to function throughout the day.

The exercises which safely activate a natural reflex mechanism calming down the nervous system which releases muscular tension are based on restoring blood flow and oxygen to tissue.

Muscular tension release can be done by manual pressure that is applied to the most superficial layer of tissue where dysfunction appears (pain, tension or rigidity). Once the tight tissue is stimulated, blood flow to the area increases and the tight tissue will become suppler. This allows the therapist to access the next layer of tissue without applying excessive pressure.  This pattern is repeated until all layers of dysfunctional tissue are restored and the tight, rigid tissue is replaced with supple and mobile tissue.  Supple and mobile tissue will be free of pain and have a greater range of motion.

The ability to release muscular tension independently one must learn how to align their body and mind while experiencing an alert but relax state of awareness. The SykorovaSynchro Method℠ is a phenomenal educational tool with positive impacts to patients mentally, physically and emotionally and has three stages/ progressive levels:

  1. To balance function of sensory-motor cortex via sensory stimulation mental imagery (sometimes called visualization, guided imagery), progressive muscular relaxation and control breathing. Result is relaxed but alert state of awareness.
  2. To enhance sensory integration/ awareness of somatic movement (movement regulated by feeling, mental imagery, sensation). Result is ability to perform somatic/ intuitive movement.
  3. Ability to perform conscious exercises – via mental imagery, sensation. Positive result is in neuro muscular conditioning/ function – postural improvement, balance, coordination, flexibility and agility.

Research has shown that when we imagine an experience, we often have similar mental and physical responses to those we have when the event actually happens. For example, if one recalls an upsetting or frightening experience, she/he may feel their heart beating faster, may begin to sweat, and hands may become cold and clammy.

In life it is very important to minimize the negative effects and maximize the healthy, healing aspects of the mind–body connection. Each person has a unique capacity for getting better, healthier, achieving peak performance and recovering from injury.

The mind-body connection means that one can learn to use his/her thoughts to positively influence the body’s physical responses, to create abilities to be aware of their own thoughts and actions in the present, without judging them self.

Physical activity has the potential to be not just an activity of the body, but a whole body-mind-spirit system. Exercise can create a unique, beneficial mental state; and the positive mental state can enhance the benefit of exercise as a part of muscular release tension plan, which reinforces the perception that exercise is just an out of body experience.  We have to remember, that our bodies are made to feel good and has abilities to heal.

A unique water exercise program based and structured on those principles will teach you to release tension, increase mobility and build endurance in muscles, tendons and joints. Those physical exercises are performed with an intense focus to utilize four principles such as breathing, proper form, control and concentration.

  • Exercise is performed with controlled breathing that utilizes full inhalations and full exhalations that follow a specific number of counts or rhythm. The goal is to learn how to breathe at a pace of 6 breaths a minute, about 3 or 4 seconds inhaling and 6 or 7 seconds exhaling. Once we have the slow, deep breathing accomplished, we don’t have to worry about counting and imagine breathing out any tension in the body or thoughts that get in the way of comfort and relaxation. The benefit of the water environment is tremendous. Hydraulic pressure increases human vital capacity in shoulder depth immersion 7x more than air, which promotes deep breathing and natural relaxation.
  • Exercise is performed with proper form or in precision. Quality of movement counts more than quantity in a mind-body exercise. Precision requires mental control. The mind has to be wholly focused on the purpose of the exercises as you perform them. The sensation of water on the skin is enhancing biofeedback’s, which helps with proper form greatly.
  • Neuromuscular exercise always involves the control and balance of your own body-weight. In water exercise we have interplay between gravity and buoyancy, weight and weightlessness. Control of the body can become challenging and at the same time very beneficial for overall success. By implementing movement patterns in a variety of directions, we stimulate and enhance balance, coordination, and flexibility, and inspire the neuromuscular system to become more expansive and creative. Moving in different speeds is an aspect of our physical capabilities that must be practiced in order to maintain a sense of health and well-being.
  • Releasing Movement is performed with intense concentration on yourself, in the present moment. The mind-body exerciser is focusing on his/her body rather than on the instructor, or on other participants. One should never be day dreaming about other things. The point-of-focus in a self- sensing exercise will differ from most other forms of physical exercise. One should be thinking about stabilizing, or anchoring, the area of the body that is NOT in motion. This is contrary to the usual Western method of trying to isolate the muscles that we perceive to be performing the movement.

Working as a health-fitness professional for the past 30 years, I am sensitive to the overall health of students/clients, and I continue to put research developments into practice. The focus in fitness these days for “Active Aging”, “Athletic Recovery”, “Chronic Pain Management”, “Healing with Release” are functional exercises – exercises that simultaneously use multiple muscles and joints to improve muscular endurance, overall strength, coordination, balance, posture and agility – to get a challenging, effective and fun full-body functional workout as well as prepare the body for every day, real world activities.

Join Dr. Sykorova Pritz for her upcoming webinar, Pain-Free Movement Techniques.

Reprinted with permission from Dr. Maria Sykorova Pritz and the Aquatic Exercise Association (AEA). The AEA is the leading educational agency in water fitness and is reaching health-fitness professionals in aquatic field. This article first appeared in the August/September 2018 issue of their AKWA magazine. 

Dr. Maria Sykorova Pritz Ed.D earned her doctorate in education (specialty in Physical Education and Sports) from University Comenius in Bratislava, Slovakia. Maria is an ATRI faculty member, member of AEA Research Council, author of health fitness articles and FLS CE class, presenter for national and international fitness conferences. In her 32 years of professional career Maria is combining academic knowledge with hands on experience in functional fitness, pain management via land based and aquatic fitness. Maria’s unique training method (SykorovaSynchro Method℠) involves integration of multidisplinery techniques to achieve overall health and optimized performance. Maria is an ATRI faculty member, member of the AEA Research Committee, FLS continuing education developer, author and presenter.


  1. BURDENKO I, MILLER J. (2001) Defying Gravity. www.Burdenko.com.
  2. GREGOR T., SYKOROVA PRITZ M.: (2008) Pain management and psychophysical     conditioning through water exercise. Revue Mediciny v praxi, Bratislava, MAURO Slovakia s.r.o. Rocnik 6, cislo 1, 2008, s.29, 30, 38 ISSN 1336-202X
  3. Discovery writers. (2013): Mind – Body Exercise Connection. Discovery Fit &Health; http://health.howstuffworks.com/wellness/diet-fitness/information/mind-body-exercise-connection.htm
  4. INSTITUTE of MEDICINE (2011): Relieving Pain in America. A Blueprint for Transforming Prevention, Care, Education, and Research
  5. JOHNSON, L.S.(2009):”Therapist’s Guide to Posttraumatic Stress Disorder Intervention”, Academic Press is an imprint of Elsevier, San Diego, California, USA.Page146-148, ISBN:978-0-12-374851-5
  6. RAMSEY L. (2018): As America fights opioid addiction, the healthcare system is failing people who live with chronic pain: http://www.businessinsider.com/people-with-chronic-pain-during-opioid-crisis-2018-1
  7. SYKOROVA PRITZ, M. (2007):” The effect of water exercise on selected aspects of overall health on a fibromyalgia population”. Aquatic Fitness Research Journal, October 2007, Volume 4, Issue 2, Nokomis, Florida, USA: Aquatic Exercise Association. page. 6-13
  8. SYKOROVA PRITZ, M. (2018):” Healing with Release” AKWA: Volume 32, No 2;  Brunswick GA. USA; Aquatic Exercise Association, page 31-33,ISSN: 1536-5549
  9. STOLNICK, D.:  (2000-2008) Looking for joint pain relief. Vilage Inc.
  10. VAN HOUDENHOVE, B, – EGLE, U, – LUYTEN, P. (2005): “The role of life stress in fibromyalgia”, Curr Rheumatol Rep. 2005 Oct; 7(5):365-70.
  11. THEARMAN, B.H.: (2007) Simple solutions to Chronic Pain. New Habringer Publication, Inc. ISBN-13: 978-1-57224-482-5.

NOTE: To learn more about SykorovaSynchro Method, it is recommended that you take the course “Application of Water Exercise for Health Fitness Professionals Specializing in Pain Management.” to increase your knowledge and skills.  For more information, log on to www.FitnessLearningSystems.com.


towel, dumbbells, apples and water bottle isolated on white

Call To Action: May is Global Employee Health and Fitness Month

What is Global Employee Health & Fitness Month?

Global Employee Health and Fitness Month (GEHFM) is an international and national observance of health and fitness in the workplace, created by 501c3 non-profit organization, the National Association for Health and Fitness. The goal of GEHFM is to promote the benefits of a healthy lifestyle to employers and their employees through worksite health promotion activities and environments.

Formerly titled National Employee Health and Fitness Day, GEHFM has been extended to a month-long initiative in an effort to generate sustainability for a healthy lifestyle and initiate healthy activities on an ongoing global basis with a reach into South America, Europe and Asia.

Employers everywhere are invited to participate. The website and toolkit are available to participants, healthandfitnessmonth.org

Employers will challenge their employees to create Healthy Moments, form Healthy Groups and develop a Culminating Project. Participants will be able to log these activities on the website through the month, allowing employer and employees to track, share and promote their individual and group activities. GEHFM is structured very simply for ease of use and primarily targeted on companies with 500 employees or less.

Healthy Moments are occasions of healthy eating, physical activity or personal/environmental health. (e.g., cooking a healthy meal or scheduling a dental/doctor visit.)

Healthy Groups are formed to create a sustainable activity continuing even beyond the month. (e.g., healthy lunch groups; company sports team; walking club.)

Culminating Project is an event that promotes health throughout the whole company or community. (e.g., planting a community garden; company/family fitness event.)

When is GEHFM and how it works?

GEHFM is held during the month of May every year (traditionally physical activity month). Health Moments occur daily, even multiple times a day and are created by individuals and groups. Healthy Groups implement activities to be performed several times throughout the month. Finally, the Culminating Project is developed during GEHFM and is executed at the end of May.

Why should employers/employees participate?  

GEHFM is a great way to kickoff wellness and fitness programs and bring excitement and can complement existing programs. Workforce wellness programs have been shown to benefit the employer through enhanced employee productivity; reduced health care costs; reduced employee absenteeism and decreased rates of illness and injury. These programs benefit employees by lowering stress levels, increasing well-being, self-image and self-esteem, improving physical fitness, increasing stamina, increasing job satisfaction and controlling BMI and blood pressure.

Benefits of GEHFM

  • Free, innovative and proven tool kit provided to help guide activities and events
  • Promotional items advertising GEHFM available for purchase by participants
  • Ability to log and track moments, groups and projects
  • Option to implement friendly competitions and challenges to build teamwork
  • Simple and adaptable to any wellness and fitness program
  • Creates sustainable healthy programs, environments and policies

About the National Association for Health and Fitness (NAHF)

NAHF was founded in 1979 by the President’s Council on Physical Fitness and Sports and has as its vision that America shares in the social economic, health and environmental benefits that come from living an active lifestyle.  Our mission is to improve the quality of life for all individuals in the United States by promoting physical fitness, sports and healthy lifestyles. We also champion environmental and policy support for active living and encourage and share innovation in the States. NAHF values active living (integrating physical activity into daily lives) community involvement and leadership development for all societal sectors; promoting quality physical education in our schools; developing workforce health promotion programs and active-aging programs. With our focus on the States, NAHF “bridges the gap” between federal and local action and unites researcher and community practitioner.

Global Employee Health and Fitness Month website: healthandfitnessmonth.org

Diane Hart, Owner of Hart to Heart Fitness, is a Nationally Certified Fitness Professional, Personal Trainer, Health Educator and is current President of the National Association for Health and Fitness founded in 1979 by the U.S. President’s Council on Sports and Fitness. She is also Chair and one of the original architects of Global Employee Health and Fitness Month, which strives to make healthy the norm in the workplace.


Weight Management: Carbs, Calories, or Keto?

For most of the past 40 years, dieters have been told to limit dietary fat, believing it leads to obesity and heart disease. Today, dieters hear messages to indulge in a very high-fat (ketogenic) diet and limit the carbohydrate-based foods that fueled their low-fat diet. Confusing, eh? The bottom line is: calories count. You can lose weight by limiting carbs and/or fat. Let’s look at the weight management picture, as we understand it to date. (Nutrition is an evolving science!)

Are carbs fattening?

Foods such as white bread, pasta, rice and potato (“carbs”) have been demonized as being fattening because they have a high glycemic index. That is, they digest quickly and can spike blood glucose when eaten solo in 50-gram carbohydrate (200-calorie) doses. That happens when the average (unfit) American devours a basket of warm dinner rolls. Blood glucose rises quickly; the pancreas secretes insulin to carry glucose out of the blood and into the muscles. Insulin can stimulate hunger, the desire to eat, and the potential to gain weight.

 But how often would you eat rolls without butter? A plate of pasta without sauce and Parmesan cheese? A large potato all by itself — with no butter or protein? Most likely, rarely. Eating “carbs” as part of a meal elicits a lower glycemic response than eating them solo. Protein and fat slow their conversion into blood glucose, thus blunting the glycemic response.

The advice given to the general public to limit high-glycemic foods often results in eating fewer calories (and losing weight). The advice can appropriately help stabilize blood glucose in women with polycystic ovary syndrome (PCOS), and unfit people with obesity, pre-diabetes, and Type II diabetes. But the advice may not pertain to YOU, an athlete. The bodies of athletes eagerly take up blood glucose to fuel exercise and replenish depleted muscle glycogen stores. Too little carb (grain, fruit, vegetable) results in needless muscular fatigue if you train hard day after day.

That said, some very athletic people live in large bodies. They tend to be frustrated they don’t shed fat despite religiously abiding a low calorie diet plus rigorous exercise.  As one triathlete complained “I should be pencil thin by now, for the exercise I do…” What’s going on? The answer might relate to that athlete’s personal insulin response to carbohydrate. Research suggests genetics causes some people to be high insulin secretors. Just as not all couch potatoes secrete excess insulin, not all lean athletes escape Type II diabetes.

What does this mean for you, a weight-conscious athlete? If you struggle to lose weight, you might be a high insulin secretor. Take a look at your family genetics: Do your relatives gain weight easily? Do they have diabetes? If yes, you want to talk with your doctor. You might be better off choosing a low glycemic diet, trading processed carbs for whole grains and combining them with lean protein and healthy fats such as nuts, nut butter, and avocado. And plan to keep exercising, religiously.

Keto or veto?

You have undoubtedly heard people rave about the keto diet. This very rigid high fat, low carb food plan with more than 70% of the calories from fat and less than 5% of the calories from grains, fruits and veggies is touted to reduce weight and risk for heart disease, diabetes, cancer, and Alzheimer’s. Here’s some food for thought on the current keto rage. You can figure out if you want to jump in or think twice.

  • Nutritional ketosis (NK) (as opposed to diabetic ketoacidosis, a life-threatening condition) curbs hunger due to the appetite suppressing effect of ketones. To induce NK, a person needs to restrict carbohydrate to about 20 to 50 grams a day. That means eating only a few berries, some leafy greens, mushrooms, no milk, yogurt or grains. You’d eat lots of avocado, olive oil, nuts, nut butter, and some cheese, bacon, and fatty meats.
  • When carbohydrate is not available for fuel, the body adapts (painfully over several weeks of feeling lousy, hence the term “keto flu”) to burning fat and makes a byproduct called ketones. Infants burn ketones; the adult body needs to relearn how to use them.
  • Due to lack of carbohydrate, keto dieters secrete very little insulin, which contributes to reduced appetite which, when combined with limited food options and consumption of fewer calories, leads to fat loss—and the health benefits associated with weight loss, including reduced risk of diabetes, heart disease, etc.

The questions arise:

  • Would following a ketogenic diet suit your lifestyle? No bananas, beer, or birthday cake. What would you eat on Meatless Monday? Plant proteins like beans come with too many carbs. No hummus, burritos, chili.
  • Would a high intake of saturated fat (bacon, sausage, spare ribs) create cardiovascular issues?
  • Does the low fiber intake have a negative impact on your gut (constipation)?
  • If you happen to love crunchy apples, fruit smoothies, and roasted veggies (to say nothing of a social life) how long could you sustain the keto lifestyle?
  • What would happen when you get out of “Keto Jail”? Would you end up binge-eating carbs? Would that leave you with rebound weight gain, feeling depressed and being worse-off than your pre-keto status?
  • Would changing the nutrient-poor food choices in your current lifestyle be the wiser weight management solution? Meeting with a registered dietitian (RD) could help you make those changes more easily than you may think.

You have to figure out your answer to the keto or veto question. For serious athletes who do intense exercise, take note: It is a lot of work with no proven performance benefits to date.

Nancy Clark, MS, RD CSSD (@nclarkrd) counsels both casual and competitive athletes at her office in Newton, MA (617-795-1875). Her best selling Sports Nutrition Guidebook offers additional fueling information, as does her blog at NancyClarkRD.com and online workshop NutritionSportsExerciseCEUs.com.

mixed nuts

The Protein Problem: How the source affects cardiovascular risk

Thanks to popular wisdom, we tend to consider animal protein our dietary MVP – it’s associated with building muscle, and high-animal protein weight loss diets are still popular. In contrast, plant protein from vegetables, legumes, nuts and seeds is considered a “second string” source. But as usual, popular wisdom only gets part of the story right. When it comes to protecting your cardiovascular health, it is the source of your protein that matters most.

Many studies have demonstrated that plant protein is beneficial – and animal protein is harmful – regarding outcomes such as cardiovascular disease, cancer, and death from all causes. But new data, gathered by the Adventist Health Study 2, takes a more nuanced look at exactly which types of plant and animal proteins have the greatest impact on your risk of heart disease. Researchers decided to ask which protein-containing foods in particular contribute to increasing or decreasing cardiovascular risk. It will come as no surprise to Nutritarians that nuts and seeds emerged as the most beneficial source of this vital nutrient.

All protein is not equal

In this new study, researchers focused on the specific sources of the subjects’ protein intake. A total of 81,337 participants were asked about their usual intake of these foods during the previous year, and then they were followed for 6-12 years. Data was analyzed to determine the percentage of total protein that came from these animal and plant sources.

Of all the plant and animal protein sources analyzed, risk of cardiovascular deaths steadily climbed with higher consumption of meat protein, and steadily fell with greater consumption of protein from nuts and seeds.

In the groups with the highest meat intake, risk was about 60 percent higher than in the group with the lowest intake. In the group with the highest intake of nuts and seeds, the cardiovascular risk was about 40 percent lower compared to the group with the lowest intake of nuts and seeds.1

These results are consistent with previous research that has compared nuts to meat as a major calorie source.2 Plus, there have now been numerous studies linking higher nut intake to longevity.3

Why is meat so harmful to the cardiovascular system?

  • Meat is high in Advanced Glycation End Products (AGEs), which contribute to vascular damage, especially in people with diabetes.4,5
  • Meat is high in heme iron, which has pro-oxidant effects that promote cardiovascular disease.6
  • Meat contains pro-inflammatory components such as arachidonic acid,7 saturated fat,8 and carnitine.9
  • Meat consumption (and animal protein consumption in general) is associated with weight gain.10,11
  • Meat promotes the growth of unfavorable bacteria that lead to the production of TMAO, which inflames the endothelium and promotes atherosclerosis.9

In addition to cardiovascular disease, diets high in animal protein also promote cancer. Animal protein, which has a higher biological value (compared to plant protein) because of its greater essential amino acid content, is absorbed and utilized quickly by the body. This raises IGF-1 to dangerous levels, which promotes the growth of tumors and enhances fat storage.12-15

Why are nut and seeds so protective?

  • Nuts and seeds are the optimal protein choice for a cardio-protective diet.
  • They are rich in a variety of heart-healthy nutrients: potassium, magnesium, fiber, plant sterols, tocopherols (vitamin E), flavonoids and other polyphenols.16
  • They have been shown to reduce total and LDL cholesterol.17
  • The fat-binding fibers are not absorbed, carrying fat into the stool and toilet.
  • They are highly satiating, promoting a healthy weight.18-20
  • Nuts are rich in arginine and glutamic acid, which aid in the production of nitric oxide and are important for maintaining a favorable blood pressure. 21,22
  • They promote favorable blood glucose levels in studies on patients with type 2 diabetes.16
  • Nut consumption is associated with better vascular (blood vessel) function and reduced oxidative stress.23-25

In addition to their cardiovascular benefits, nuts also facilitate the absorption of vegetable-derived phytochemicals, which increases the anti-oxidant potential and the protective function of immune system cells.24 Calories from nuts and seeds are absorbed very slowly, which means that the body is more likely to use them for energy rather than storage. IGF-1 levels that are too high or too low are detrimental to health, and the major determinant of IGF-1 levels is essential amino acid intake.14,27  A diet rich in plant protein sources (such as seeds, nuts, and beans) provide adequate but not excessive amounts of all of the essential amino acids, enabling the body to modulate (lower) IGF-1 to the most protective levels, without getting too low.28

As protein and fat sources, nuts and seeds are the clear winner over animal products. Nuts and seeds are crucial for cardiovascular health and longevity. Now that’s the kind of wisdom that deserves to be popular.

Quick and delicious ways to put some muscle in your protein

Now that you know why your protein should come from the dirt rather than off the hoof, here are a few easy ways to improve the quality of your diet. And if you have any great tips that work for you, please share them in the comments section!

  • Limit animal protein to no more than 2 ounces in a day.
  • If you have animal protein, skip a day (at least) between servings.
  • Use mushrooms, beans and even crumbled tofu to add a meaty texture to a dish.
  • Eat nuts and seeds with leafy greens to aid in the absorption of fat-soluble nutrients from the greens.
  • Eat some omega-3-rich chia seeds, ground flaxseeds, and/or walnuts every day.
  • Add hemp seeds to a smoothie for a protein (and omega-3) boost.

Joel Fuhrman, M.D. is a board-certified family physician, six-time New York Times bestselling author and internationally recognized expert on nutrition and natural healing, who specializes in preventing and reversing disease through nutritional methods. Dr. Fuhrman coined the term “Nutritarian” to describe his longevity-promoting, nutrient dense, plant-rich eating style.


  1. Tharrey M, Mariotti F, Mashchak A, et al. Patterns of plant and animal protein intake are strongly associated with cardiovascular mortality: the Adventist Health Study-2 cohort. Int J Epidemiol 2018.
  2. Bernstein AM, Sun Q, Hu FB, et al. Major dietary protein sources and risk of coronary heart disease in women. Circulation 2010, 122:876-883.
  3. Grosso G, Yang J, Marventano S, et al. Nut consumption on all-cause, cardiovascular, and cancer mortality risk: a systematic review and meta-analysis of epidemiologic studies. Am J Clin Nutr 2015, 101:783-793.
  4. Goldberg T, Cai W, Peppa M, et al. Advanced glycoxidation end products in commonly consumed foods. J Am Diet Assoc 2004, 104:1287-1291.
  5. Goldin A, Beckman JA, Schmidt AM, Creager MA. Advanced glycation end products: sparking the development of diabetic vascular injury. Circulation 2006, 114:597-605.
  6. Brewer GJ. Iron and copper toxicity in diseases of aging, particularly atherosclerosis and Alzheimer’s disease. Exp Biol Med 2007, 232:323-335.
  7. de Lorgeril M, Salen P. New insights into the health effects of dietary saturated and omega-6 and omega-3 polyunsaturated fatty acids. BMC Med 2012, 10:50.
  8. Kennedy A, Martinez K, Chuang CC, et al. Saturated fatty acid-mediated inflammation and insulin resistance in adipose tissue: mechanisms of action and implications. J Nutr 2009, 139:1-4.
  9. Koeth RA, Wang Z, Levison BS, et al. Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med 2013.
  10. Bujnowski D, Xun P, Daviglus ML, et al. Longitudinal Association between Animal and Vegetable Protein Intake and Obesity among Men in the United States: The Chicago Western Electric Study. J Am Diet Assoc 2011, 111:1150-1155 e1151.
  11. Rosell M, Appleby P, Spencer E, Key T. Weight gain over 5 years in 21,966 meat-eating, fish-eating, vegetarian, and vegan men and women in EPIC-Oxford. Int J Obes (Lond) 2006, 30:1389-1396.
  12. Key TJ, Appleby PN, Reeves GK, Roddam AW. Insulin-like growth factor 1 (IGF1), IGF binding protein 3 (IGFBP3), and breast cancer risk: pooled individual data analysis of 17 prospective studies. The lancet oncology 2010, 11:530-542.
  13. Rowlands MA, Gunnell D, Harris R, et al. Circulating insulin-like growth factor peptides and prostate cancer risk: a systematic review and meta-analysis. Int J Cancer 2009, 124:2416-2429.
  14. Thissen JP, Ketelslegers JM, Underwood LE. Nutritional regulation of the insulin-like growth factors. Endocr Rev 1994, 15:80-101.
  15. Levine ME, Suarez JA, Brandhorst S, et al. Low Protein Intake Is Associated with a Major Reduction in IGF-1, Cancer, and Overall Mortality in the 65 and Younger but Not Older Population. Cell Metab 2014, 19:407-417.
  16. Kim Y, Keogh JB, Clifton PM. Benefits of Nut Consumption on Insulin Resistance and Cardiovascular Risk Factors: Multiple Potential Mechanisms of Actions.Nutrients 2017, 9.
  17. Del Gobbo LC, Falk MC, Feldman R, et al. Effects of tree nuts on blood lipids, apolipoproteins, and blood pressure: systematic review, meta-analysis, and dose-response of 61 controlled intervention trials. Am J Clin Nutr 2015, 102:1347-1356.
  18. O’Neil CE, Fulgoni VL, 3rd, Nicklas TA. Tree Nut consumption is associated with better adiposity measures and cardiovascular and metabolic syndrome health risk factors in U.S. Adults: NHANES 2005-2010. Nutr J 2015, 14:64.
  19. Jackson CL, Hu FB. Long-term associations of nut consumption with body weight and obesity. Am J Clin Nutr 2014, 100 Suppl 1:408S-411S.
  20. Mattes RD, Dreher ML. Nuts and healthy body weight maintenance mechanisms. Asia Pac J Clin Nutr 2010, 19:137-141.
  21. Vasdev S, Gill V. The antihypertensive effect of arginine. Int J Angiol 2008, 17:7-22.
  22. Stamler J, Brown IJ, Daviglus ML, et al. Glutamic acid, the main dietary amino acid, and blood pressure: the INTERMAP Study (International Collaborative Study of Macronutrients, Micronutrients and Blood Pressure). Circulation 2009, 120:221-228.
  23. Katz DL, Davidhi A, Ma Y, et al. Effects of walnuts on endothelial function in overweight adults with visceral obesity: a randomized, controlled, crossover trial. J Am Coll Nutr 2012, 31:415-423.
  24. Kris-Etherton PM. Walnuts decrease risk of cardiovascular disease: a summary of efficacy and biologic mechanisms. J Nutr 2014, 144:547S-554S.
  25. Bullo M, Juanola-Falgarona M, Hernandez-Alonso P, Salas-Salvado J. Nutrition attributes and health effects of pistachio nuts. Br J Nutr 2015, 113 Suppl 2:S79-93.
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Exercise Combats Frailty

Exercise is key to maintaining muscle mass that enables performance of the activities of daily living.

US Census projections suggest that the majority of baby boomers will turn 65 between 2010 and 2030, reflecting the impending need for increasing medical care within this demographic.(1-3)

“Baby boomers are now senior boomers, and just as this group has influenced everything in the past, they will impact tomorrow’s health care services as well,” says Patrick Kearns, MD, a geriatrician at El Camino Hospital in Mountain View, California.

The health and function within this group will range from those who are extremely fit and healthy to those who are physically dependent. How an individual ages is, to some extent, determined by the cards (genes) they were dealt and, to a larger extent, how they’ve played those cards. Research confirms the relationship between living a healthful, active lifestyle and both quantity and quality of life. Proactive steps taken throughout a person’s lifetime may prevent or delay the advent of frailty.(3-5)

The medical profession continues to make significant strides in treating conditions that would have caused death years ago. And while the average life expectancy has increased dramatically since the 1900s, this increase in longevity comes with the possibility of living more years with physical limitations and reduced functional ability.(3,5)

Some studies have discovered that a sizable number of adults over the age of 65 cannot lift a 10-lb bag of groceries, walk a mile, or easily get up from a chair. One study suggests a significantly increased risk of falling for individuals who cannot lift themselves out of a chair at least eight times in 30 seconds.1 But how can frailty be prevented or even reversed?

Identifying the Problem

Anyone, young or old, can experience frailty, which is the loss of some physical function and can result from various causes. Among the most common are a chronic medical condition; loss of a sensory system; changes in medical, mental/emotional, or functional fitness status; age-related muscle loss (sarcopenia); falls; or a sedentary lifestyle.(1,3,5)

Many times a combination of these factors results in a person’s inability to function independently, leading to the classification of frailty. The term “frail elder” often refers to the role age plays in the above conditions. Most of us can visually identify a physically frail person, but currently no definitive criteria exist for defining frailty. However, some professionals are attempting to develop a universal objective definition of elder frailty traits.(3,6)

Often family members, in concert with health care professionals, are the first to recognize an elder’s decline in strength and level of independence. Assessment of diminished balance and muscle strength suggest the need to initiate a comprehensive general conditioning program.(1)

Never Too Late

A recent study published in the Journal of Aging and Health showed that a group of octogenarians involved in a 16-week program of walking or resistance training could improve significantly in strength, flexibility, agility, and balance.(1,7) Of course, prevention is cheaper than treatment, so the intervention of a well-rounded fitness program should begin long before frailty concerns emerge. Some older adults admit that if they had known they’d live so long, they would have taken better care of themselves when they were younger.

Sarcopenia plays a major role in what many believe advances functional loss and contributes to becoming frail. Studies have shown that without the intervention of progressive resistance training, lean muscle tissue loss can begin as early as the age of 30.(1,3,5) These small changes go unnoticed or are even accepted as part of normal aging until a person finds difficulty in completing simple tasks. While the outward circumference of a limb may remain the same, the interior integrity of the muscle mass is decreasing. We can visualize the muscle loss as analogous to a lean steak’s transformation to one with marbled fat. So it is with humans: A muscle biopsy shows intermuscular fat within the muscle.

Why is less muscle detrimental? One reason is that muscle tissue is the furnace that revs the metabolism, thus assisting an individual to better control body weight, which in many cases decreases the risk of type 2 diabetes, hypertension, and other metabolic diseases. An increase of only 7.7% in resting metabolic rate derived from strength training would result in an increase of 50,000 extra calories expended in one year, which could result in a loss of 14 lbs of fat (in a 180-lb person).(1,5,7)

Strong leg muscles lead to improved balance.1 Strong functional muscles enable a more active and independent lifestyle. Being involved in a sensible strength conditioning program can foster improved bone density. Wolf’s Law says the strength of the bones is in direct proportion to the forces applied to them. If a person sits during most of the day, then he or she will have bones made for that kind of lifestyle. “Use it or lose it” applies to muscle strength as well as bone strength.

The hallmark study done by Maria Fiatarone, MD, a researcher at Harvard Medical School, placed 100 frail nursing home residents aged 72 to 98 into several experimental groups.(1,3,5-7) Her research found that those participating in progressive resistance exercises improved their strength significantly vs. those who were given nutritional supplements. The strength-training group increased their overall strength by 113%; gait velocity improved significantly as well stair-climbing ability over the nonexercising groups.

The take-home message was that resistance training is superior to nutritional supplementation and is far more cost-effective.

Exercise Benefits

A review of the literature appears to prove that proper physical activity has broad and positive influences over many of the characteristics associated with normal aging. It could be said that everything that physically declines with age can be positively influenced with proper exercise.(4,8,9)

We’re all familiar with normal aging, but healthful aging often is determined by the activity or lack of activity that precedes old age. An inexpensive strategy to improve the prospects of living long and well includes a regular dose of sensible physical activity. Some commonly acknowledged benefits of a well-rounded exercise program include improved self-efficacy, metabolism, sleep patterns, cardiovascular capacity, balance, muscular strength, endurance, and movement along with reduced fatigue, depression, anxiety, and arthritic and low back pain.(1,8,9)

Designing a Fitness Program

While it’s never too late to feel great, it’s best to start early. While this article attempts to show ways to intervene with a patient experiencing some level of frailty, the best solution is to encourage patients to engage in activities that help prevent it. It’s better to do a little bit of anything than a lot of nothing. Remind patients to start slow and progress cautiously. All of the exercises suggested below can be done simply with a chair. It’s even possible to perform some of the exercises in bed.(4,8,9)

Providing motivation to embark on an exercise regimen and stick with it presents a challenge, though. Suggesting participation in activities patients don’t want to do requires patience and skill. Focus on ways to make the activities appealing while preventing injury. Matching the exercise routine to a person’s personality and physical abilities often is more of an art than a science. A good coach/teacher can motivate a patient to do something he or she doesn’t want to do—and thank the coach for it later.(4,8,9)

It’s wise for health care professionals to provide patients with guidelines of indications and contraindications related to exercise. If possible, try to match patients with suitable options within the community that match their physical abilities, personalities, and social and economic issues. Some long term care facilities offer in-house and/or programs available to local older adults.(4,6,7)

An exercise program for patients at risk of becoming frail should aim to improve functional activities of daily living. An assessment by an occupational therapist, physical therapist, or nurse should provide some direction on the major areas to be addressed. While the aim of the intervention is to improve function, make sure the person leading the session keeps some fun in functional. This may require some socializing and interacting with patients. If patients are unmotivated to perform activities or exercise, even the best program will have low compliance rates and not produce the desired outcomes. All programs should follow some type of evidence-based guidelines.(8,9)

Improving muscular strength and endurance helps enhance patients’ functional muscular endurance and strength to perform daily activities without becoming fatigued. The basic concept of progressive resistance training, commonly called strength training, weight training, or weight lifting, is to begin with a resistance that can be comfortably performed six to eight times and then continue increasing the number of times (reps) until he or she can perform the movement easily between 10 and 15 times.(6)

Once that level is attained, patients can add small amounts of resistance to again challenge the muscles. As an individual advances, another set (a grouping of reps) can be added. The number of reps and sets varies depending on the objective. Matching activities to the functional tasks a person needs to perform can involve lifting a milk jug, opening jars, getting up from the toilet, or walking outside to get the mail, for example. The goal should be to build up a reserve of strength so patients can engage in any necessary activities.(4)

Strength training can include the use of resistance bands that come in varying levels of resistance. Light water bottles, hand weights, or attachable wrist/ankle weights work well. For patients who are particularly weak, simply using the weight of their limbs is a fine starting point.(4)

Cardiovascular Fitness

Aerobic simply means with oxygen. Most exercise physiologists use the example of anything you could do while holding your breath as anaerobic while the opposite characterizes aerobic exercise. Running a 100-yard dash could be called anaerobic and walking a mile aerobic. The goal of aerobic exercise is to improve the ability to move freely without becoming winded or to execute activities that facilitate locomotion, whether it’s propelling a wheelchair farther or safely walking unassisted to the dining room. This addresses breathing function as well as aerobic exercise to assist in reducing cardiovascular diseases and burning calories. Seated aerobics, peddling a stationary bike, and even walking exercise can be suitable options.

Balance and posture exercises should aim to improve the muscles that influence posture, such as the core muscles and muscles that retract the scapula as well as muscles that promote proper neck alignment. There is evidence that improved posture translates into standing erect and improved balance.

Balance activities should include both static and dynamic movements. Physical therapists can offer recommendations on exercises to enhance balance. Experts suggest patients can begin balance work in a chair, similar to activities for spinal cord-injured and post-stroke patients, as a safe exercise method.

Comprehensive Program Design

Attempting to include all of the aspects listed above would be ideal; no one element supersedes another. However, it’s often advisable to establish a baseline of patient stamina. A comprehensive exercise class can easily include each element. An example of such a class could include five to 10 minutes of warm-up moves, five to 10 minutes of upper and lower body strength training, and five to 15 minutes of light aerobic exercise followed by some light flexibility moves. All of these can be done safely if the activities match a patient’s ability. Individualization is the key even for a group exercise class.(4)

Ideally, providers can perform individual patient assessment. Utilizing a group assessment method such as the Senior Fitness Test also can provide information on fitness levels and achievable goals.

The bottom line is that exercises and activities should be adapted to a patient’s abilities and should never exacerbate an existing condition, as patient safety is more important than any exercise. If an instructor cannot appropriately adapt the movements, then he or she is not qualified to be teaching this segment of the population.

Basic Activities

A sample exercise program to prevent and improve the status of frailty should include the following:

• Range of motion/flexibility: Motion is lotion to stiff joints. A warm-up that addresses the major joints and helps prepare the body for physical activity should last between five and 15 minutes. Include gentle range-of-motion/flexibility activities that foster functional movements, such as putting on socks and shoes or getting dressed. In the early stages, this may be the limit of a patient’s capability, so stopping here is fine.

• Muscular strength and endurance: The focus is to improve functional muscular endurance and strength to enable a patient to perform daily activities without becoming fatigued. The activities should be matched to the tasks an individual needs to perform, such as lifting, dressing, and walking.

Plan of Action

There are not enough physical and occupational therapists nor insurance dollars available to provide all the functional fitness needs of this burgeoning group of older adults. We need to have a stable of well-trained fitness professionals prepared to serve the fitness requirements of today’s elders. The medical community needs to have confidence that when they refer someone to a fitness class, the instructor will do no harm. The fitness trainers of the future should understand the diversity within this group and understand how to assess and train older adults with varying degrees of ability and fitness. It’s essential to adapt fitness methods to a patient’s abilities and conditions and focus goals on improving functional wellness.

Ideally, this article will serve as a wake-up call, not only to the fitness industry but also to health care professionals to work toward establishing national standards for trainers who work with older adults. A great opportunity will be lost if there are not enough trained fitness professionals available to serve this burgeoning demographic.

The field of gerontology promotes aging in place as a viable option. If early and comprehensive frailty prevention programs can be conducted in senior centers, hospital settings, or assisted-living communities, it could possibly delay the onset of frailty along with the associated costs.

In Conclusion

The evidence is convincing that elders’ chronic illness is a powerful driver of medical costs. Research shows that a proactive lifestyle can lessen the challenges often seen in old age. Think of prevention as wholesale and treatment as retail in helping patients understand physical maintenance of their bodies. The goal is to inspire patients to be internally motivated to take positive steps toward becoming the best they can be, no matter what their age or disability.

Originally published in Today’s Geriatric Medicine. Reprinted with permission from Karl Knopf.

Karl Knopf, Ed.D, was the Director of The Fitness Therapy Program at Foothill College for almost 40 years. He has worked in almost every aspect of the industry from personal trainer and therapist to consultant to major Universities such as Stanford, Univ. of North Carolina, and the Univ. of California well as the State of California and numerous professional organizations. Dr. Knopf was the President and Founder of Fitness Educators Of Older Adults for 15 years. Currently, he is the director of ISSA’s Fitness Therapy and Senior Fitness Programs and writer. Dr. Knopf has authored numerous articles, and written more than 17 books including topics on Water Exercise, Weights for 50 Plus to Fitness Therapy.



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2. Durstine JL, Moore G, Painter P, Roberts S. ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities. 3rd ed. Champaign, IL: Human Kinetics; 2009.

3. National Institute on Aging. Exercise & Physical Activity. Bethesda, MD: National Institutes of Health; 2009. NIH Publication No. 09-4258.

4. Knopf K. Total Sports Conditioning for Athletes 50+: Workouts for Staying at the Top of Your Game. Berkeley, CA: Ulysses Press; 2008.

5. National Institute on Aging. In Search of the Secrets of Aging. 2nd ed. Bethesda, MD: National Institutes of Health; 1996. NIH Publication No. 93-2756.

6. Brody LT, Hall CM. Therapeutic Exercise: Moving Toward Function. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:1-49.

7. Ehrman JK, Gordon PM, Visich PS, Keteyian SJ. Clinical Exercise Physiology. 2nd ed. Champaign, IL: Human Kinetics; 2009:135-146.

8. Knopf K. Creating wellness. Paper presented at: Wellness Conference at the Palo Alto Medical Foundation Annual Meeting; October 2012; Palo Alto, CA.

9. Knopf K. Grow well, not old. Paper presented at: El Camino Hospital Aging In-Service; May 2013; Mountain View, CA.