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Episode 01 – A Conversation with Cary Berkowitz, CSCS

Episode 01 – A Conversation with Cary Berkowitz, CSCS

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Dr. Robert Pastore: I'm thrilled. My guest today is Cary Berkowitz. Cary is a phenomenal trainer with a rich educational background. He's a certified strength and conditioning specialist, which is a CSCS and holds multiple professional certifications. He is obsessed with human anatomy, kinesiology, breath work, corrective exercise, and biochemistry. He trains a diverse group of clients, from the athlete requiring a competitive edge to the individual that wants to improve strength, the quality of life, and age as pain free as possible. Cary's even educated in training during pregnancy and postpartum. This diverse background makes him such an interesting guest. Cary, welcome and thank you so much for joining me today.

Cary Berkowitz: Hi Robert. Thank you. It's a pleasure.

Dr. Robert Pastore: Thank you. Today, we talked about Cary, we bounced around some ideas of what to talk about. I was always so anxious to capture your wisdom. Today, we decided on one of the topics you're very interested in. Aesthetics versus performance versus longevity in regards to health, fitness, and sport. Can you please enlighten me as to what stimulated you as to these topics and how they are pro and con with each other or can be pro and con with each other? What's the stimulation with this topic?

Cary Berkowitz: I would say personal discussions with clients and with other people in my field. I think they can overlap quite a bit. I think that when people set forth what their fitness goals are and they sort of look at what they want to achieve, the aesthetics and how somebody looks is always very important. I'm talking about the non-professional athlete population, your average person typically wants to look good. That's usually in their top three as far as importance goes. Sometimes the looking good jives really well with their ability to participate in a sport or lift a heavy weight, and sometimes it also helps them live a long, healthy life. But, sometimes, for example, exercising the wrong way or trying to look a certain way that isn't necessarily the healthiest long term, these are some ways where the three may not overlap.

Dr. Robert Pastore: Interesting.

Cary Berkowitz: There's some postural things, some postural dysfunctions that can come from let's say wearing high heels, right? High heels is a perfect example of something that is aesthetically pleasing, but it could lead to catastrophic dysfunction performance wise. There are certain types of exercises if done in a repetitive way or in an asymmetrical way, they could make you look good or they could help you perform in the interim, but they could actually develop into compensatory patterns that will catch up with you eventually. You see that a lot with athletes. I don't think anybody has the absolute solution for fixing injury prone athletes, but usually what happens is athletes develop patterns and they're great compensators, right? Athletes are very, very intelligent. Their bodies are very, very intelligent at getting around any type of limitation, right? If you have somebody who has very tight hamstrings, Chad Johnson was this Wide Receiver who famously would pull his hamstrings a lot. His body just kind of figured out other ways to make him great, right?

But, he had these less than ideal hamstrings. Eventually, his hamstrings just kind of had enough. His body couldn't compensate anymore. Now, when you're an athlete or you're pushing yourself really hard in whatever activity, those things will get exposed a little bit quicker than your average person. Your average person who may not challenge their body the way an athlete challenges their body, those compensatory patterns or movement. I'm trying to think of a nice way to say it, sort of some less than ideal, less than optimal movement patterns, those things may not catch up with people until they're much older, but sometimes it's something that gets revealed through performance. Sometimes there are things that we do for optimal performance that actually hinder our ability, that can benefit us in the short term, but actually hurt our ability to ambulate through the world later on in life, in a nice sort of functional way.

Dr. Robert Pastore: That's very interesting and I'm glad you brought that up, because I sat on a board for a phenomenal think tank type of training facility in New York City knows as Sports Lab, and we would rehab various professional athletes, but what I thought was interesting when the lay public would come in was the desire to change their appearance, the aesthetics was the draw. I hoped they were going to switch over to a performance side, because I would see the person come in, the individual come in with great triceps, great biceps and destroyed elbows. Obviously, I'm not a CSCS and you are, and I think you're amazing at what you do. There's got to be a way to have those really strong triceps, really strong biceps and not destroy your elbows. There had to be that middle ground, so knowing the trainers over there, I used to inquire and ask are they flipping over to have this more of a desire for the performance side?

That leads to a question I'd love to see your opinion on. The feedback I received was, if it was motivated somehow through games, so the aesthetics was the driving force to get them to come into this gym, which was uber and expensive. They want to look better and maybe get that six pack and whatever, for the men. The women, sleek and lean and super strong.

Cary Berkowitz: Women want it, too.

Dr. Robert Pastore: Women want it, too. I didn't know. They want the six pack, too. What I have heard but did not witness firsthand is setting these goals that a trainer would have of performance markers, not being injured. Something as silly as that, let's do this exercise this different way and here's this homework and let's see how many days we can go without an injury that shuts you down. I'm not talking about late onset muscle soreness that everybody may feel, or an unaccustomed exerciser may feel for the first time. But, can a performance reward actually be something that's inspiring to the person who's only in it to look good?

Cary Berkowitz: Yeah, absolutely. As far as the CSCS mentality, we go through that education. We learn about the different motivators and the positive reinforcements, the negative reinforcements. Obviously, most people respond well to some type of positive reinforcement. I don't think there's any problem with coupling a performance, some type of performance marker, with the aesthetics. If your goal is to lose weight but to get there, you have to be able to execute these activities. If you execute these activities to this level of intensity or find the ways to measure that, and also, to motivate people. I think tapping into people's intrinsic motivations is very, very important, because it doesn't last too long, or it's harder to make it last if it's not intrinsic. If it's not coming from a real yearning from that person, this is something that I want to do, this is for me, then it's not as sustainable.

As a trainer or a coach or a movement specialist, sort of finding, tapping into that, and finding that goldilocks zone where you're doing it enough to light the fire under somebody. People may want to look a certain way, to have their bodies be muscular, so people may want these goals when they come in, but it's not easy. At times, trainers and coaches need to get a little creative and they need to find ways to draw out that intrinsic motivation that will be the best recipe for getting somebody to that place. I do that in my own work quite a bit, where I just sort of figure out these little things. I try to find a nice combination of an exercise that suits that bio individual, that will do them no harm, that will move them towards their goal and will obviously be stimulating. If it's fun and exciting and it lights them up, then that's great. It's almost like a missing ingredient for a lot of trainers and people in the exercise world.

To work with an athlete is a little bit different than to work with a client on a regular, weekly basis where you're trying to have this sustained relationship. But, I think that it's easy to burn out mentally and physically. Knowing when to take breaks, knowing when to make little left and right tuns and go off track, just so that you can come back on track even stronger, I think that's really, really important. Yeah.

Dr. Robert Pastore: Is there a top error that you see or top mistake that you think some people that are only in fitness for aesthetics come to you with as a client?

Cary Berkowitz: Yeah. I would say breathing. I think breathing, if you were to put together the Mount Rushmore of healthy movement and fitness, you've got your breathing right at the top. You've got your posture, your static posture, your breathing. Your strength, your essence, everything is sort of built upon your "core" and core is really your intrinsic muscles, the muscles that are the closest to the spine, right? We're talking about your diaphragm, your transverse abdominis, your multifidi, parts of your internal obliques. These are things that run really deep, they're at the center of your pelvic floor. These are really, really important to how everything else around them works. If your core, which I'm just going to call it your intrinsic core, cause there's a lot of different muscles and muscle groups and things that get lopped in when you talk about core, but these sort of foundational intrinsic core things, if they don't function well, everything else has to work harder. That will inevitable manifest itself in some type of dysfunction or injury, especially if you challenge the body a lot. Right?
If you put a lot of load, a lot of stress on the body, it's just a matter of time. When I look at people, that's the first thing I look at is how well do the right things fire at the right time? How well do they breathe? Their ability to do these very foundational things. You have to have a good foundation to build on, otherwise you'll crumble. I don't think, I know it happens subconsciously quite a bit. Our bodies are very intelligent. If our diaphragms are dysfunctional, and I see it all the time. I work with a client whose diaphragm is very tonic, basically hypertonic, which means it's in a very contracted state. Our diaphragms are always working, hopefully if you're alive. They're always working to some capacity, but there are certain dysfunctional patterns that can occur with a diaphragm. He has that and his body has sort of figured out these other compensatory patterns to deal with that. It's very intelligent in a way, but we only have a limited amount of intelligence before it manifests itself into a bulging disc or a muscle pull or something like that.

The number one thing I see when I work with people is a disconnection from their breath, right? Breath is something that when we're born, if you watch babies breathe and move for that matter, they are perfect. They can sit in a deep squat all way, it's the preferred position. They have this beautiful diaphragmatic breathing going on. It's like a balloon filling up in their belly. We lose that over time. The way we lose our abilities to do a lot of movements that babies and toddlers can do. That's just life imposing itself on us. We sit in postures. We get injured, so that's a huge reason why we lose the ability to do these things. Breath is something that just gets taken for granted. We breathe and our heart beats and so we just leave it alone, but the same way that people don't sit the optimal way or they don't stand or they don't walk or they don't throw a ball the optimal way because it's been lost. We also lose the ability to breathe really well, and when you regain that, it just makes everything else easier. It makes everything else much easier.

Dr. Robert Pastore: Wow. I can see that as incredibly challenging to first get a client to understand, because if I may add in, as you are discussing, I immediately switched over to diaphragmatic breathing and did not realize how I was not doing that right.

Cary Berkowitz: Sure.

Dr. Robert Pastore: It's just something as you said, so used to. It is part of our life, right? Especially unfortunately my occupation being a scientist, it's not something you really think about. But, now, you made me very aware of that.

Cary Berkowitz: Sure.

Dr. Robert Pastore: Can you walk me through what breathing is like under the stress of resistance training? How exactly does that work? If you wouldn't mind, please.

Cary Berkowitz: No, I don't mind at all. By the way, the best way to put my theory, I don't know if it's called a theory, but to put this into action, to see this in the world, you just go up to anybody. Anybody who's listening to this could go up to anybody else and just ask them to take a deep breath and watch what happens. Their shoulders will go straight up towards their ears, right? I won't even say there's anything inherently wrong with that, but if you're breathing that way when you're exercising and your center, your energy is going up towards your head as opposed to down towards your core and your pelvis and out towards your center where you'll have much more support and much more pressure in a good way, you're just not doing what you could. You won't have the strength that you could.

To transition that to exercise, could you ask me the question again? How it manifests when it comes to exercise?

Dr. Robert Pastore: Yeah. I was curious to know an example of how you would have someone breathe under. For example, you've been famous for a very interesting leg press.

Cary Berkowitz: World famous.

Dr. Robert Pastore: I've seen video of it. We're not going to say numbers. We're not going to be boastful, but it's an enormous amount of weight. Some say it's about a freight train and you can push that out and pull that back, and I know there's different speeds and exercises that you do, but I would just say in a standard example of you having a client actually doing some type of resistance training movement, be it that leg press, what would the breathing be like? Are they inhaling and exhaling when?

Cary Berkowitz: The general rule is to exhale while you're exerting, the more exerting part of the movement. Typically, when you're going against gravity, right? If you're bending over to pick up a very heavy weight. Let's say you're dead lifting. You're picking that weight up off the floor, the optimal way to go about that from a breathing standpoint is you bend over, you fill up the canister, right? Now, you've got a big balloon. It's called intro abdominal pressure. IEP. Now, you imagine a big balloon that's supporting you right in your core, right, in your center, okay? Then, depending on the technique, so a power lifter or a real professional lifter will probably Valsalva hold their breath for a second, okay?
That's a skill. You have to be very careful, as you know, right? If you hold your breath, a lot of things can happen. Blood pressure could spike. You could get exercise induced headaches, things like that. It's something that certain people should never do, and some people have to do for their sport. When I, as somebody who is far from a power lifter but who can lift a heavy weight every once in a while, I'll bend over, I'll fill up, and then I will hold my breath for about a half of a second. Then, the remainder of the movement will be a forced exhale, right? Where I'm pursing my lips and I'm forcing my exhale out, which now causes a bracing, right? I filled up and I'm still holding that, but while I let out air, I don't lose my balloon entirely. I just brace the balloon. I just sort of reinforce the rigidity of the balloon, whereas when I'm inhaling, it's a bit of a relaxation.

Just to bring it back to the idea of aesthetics versus performance and longevity, when you see people with six packs. When you see really ripped men or women, most of the time, and I'll just say CrossFit, but I'm not demonizing CrossFit at all, but the CrossFit community is a very muscular, very tonic, hypertonic community of people. When you have such a ripped stomach and your abdominals are so muscular, they are on so often. A lot of people lack the ability to actually relax their stomach and their stomach muscles, that region. That's actually very important. You have to be able to relax, to contract, right? You have to have that back and forth.

For example, your pelvic floor, which is considered your second diaphragm, right? Your diaphragm is here. I know nobody can see me, but for you, your pelvic floor sort of sits underneath and your diaphragm is here, so when you inhale, the diaphragm drops and then the pelvic floor eccentrically lows. It lowers, right? If you're super tonic, if you're very, very tight in your muscularis, in your stomach, in your abdominals, that doesn't happen really well, right? The ability to inhale and expand and relax and then, that reflective tensing. If you look at power lifters, they are brilliant at that. These Olympic lifters, oh my God. Their breathing is spectacular. Their ability to expand, and a lot of times they're not, I can't say this with total certainty, but when I look at power lifters, Olympic lifters, they have some belly.

Dr. Robert Pastore: They do. Yeah.

Cary Berkowitz: They have a little bit of belly there, and it's because they're expansive. They're good at that.

Dr. Robert Pastore: Wow.

Cary Berkowitz: It doesn't really serve them very well to have that ripped completely contracted abdominal region. That's one of those things that could be in direct conflict with longevity, right? Performance, that type of thing could benefit you if you're doing a sit up contest, right?

Dr. Robert Pastore: There's a lot of money in those, by the way, sit up contests. Okay.

Cary Berkowitz: Black market, but it's longevity wise, as far as the health of your core and the health of your movement, not always the best thing.

Dr. Robert Pastore: I always learn something when we have a conversation and I'm regretting not recording our whole history of conversations, because in my mind, as you can imagine, I'm now thinking of all my professional athlete cases where there was a torn, ripped, rolled abdominal.

Cary Berkowitz: Sure.

Dr. Robert Pastore: Major cases, major contracts, right?

Cary Berkowitz: Mm-hmm (affirmative).

Dr. Robert Pastore: In Hollywood, that happened a little while ago with Dwayne Johnson. It makes so much sense, but I never even thought of that that way. Obviously, if something's always firing, can you imagine walking around constantly in an isometric hold with a pretty heavy dumbbell? There's going to be some problems with your bicep over time. Wow, that is fascinating. I did not think of that, Cary.

Cary Berkowitz: I'll give you, it seemed like a tangent, but it's related. I was taking a workshop in something called Neuro Kinetic Therapy. It's called NKT. There's a brilliant, brilliant woman named Cathy Duley who works out of a space near Times Square and there was this big, strong guy. It's muscle testing. It's more than that, but essentially it's a muscle testing technique, how to test if you have pain. What's doing too much? What's not doing enough? How do we restore that balance that would encapsulate it? She was talking about certain physiques and how people with these types of physiques typically don't have their glutes firing well. Now, the glutes are a huge powerful muscle, so the idea of your glutes not firing or not working when they're being tested directly is kind of a weird concept for certain people, right?

She lays this guy on the table, and you can already sense the bull who sees red, right? This ready to path, and she's a fit woman, but strength comparison is she doesn't compare to this guy. She puts him in the position and she essentially just lifts his foot off the table as he's resisting in the glute test, right? He's failed the glute test. She's testing his glutes. He's ready for it. She just lifts his foot right off the table and his glutes are not firing properly. She does a little bit of voodoo, right? She releases a little bit of this as she turns on a little bit of this. She retests him. She can't budge his foot. His glutes are now on and active. The reason I'm bringing that up is we take things for granted. We assume that the whole symphony is working together, but it's not the case. Things get lost. We develop certain things, the paths of least resistance, right? Somebody's hamstrings could be ablaze. They are working big time, but they may be working for your glutes, right? Both of them extend the hip.

You have these two big muscle groups. They both work in this symbiotic way. That's the way they're supposed to work, but one could just be dominating, right? You can still perform really well on 30% glutes and then your hamstrings are doing the rest, but it's not ideal. It's one of the ways that can turn into an injury pretty easily. Yeah.

Dr. Robert Pastore: No. I was going to say, then, you see these people that grab Men's Health, these young men and women grabbing Women's Health and fitness magazines. They see these movie stars or more accurately to this description, these professional athletes, and you instantaneously assume how well their body works together and how every muscle fires at the right time and in concert. We both know that's not true, and you just gave an excellent example of what you have seen in person. Here's this big muscle mass guy, and he can't fire his glutes.

Cary Berkowitz: I'm really glad you framed it that way, because I've, over the last couple years, been really trying to bring this message to the people I work with to make them feel a little bit better about themselves, because as people age, their injuries creep in and I don't know, there's a breakdown. Things don't work the way they used to. Injuries last a little bit longer, and we feel bad about it. It's a perfectly normal thing to feel bad about. It's not fun for your back to hurt and for your knee to hurt and for you not to be able to do what you used to do. But, what I have been really trying to convey to the people I work with is I take a lot of workshops and I interact with a lot of people in the fitness industry.
When you go to a workshop, let's say there's 30 or 40 people there, there isn't a one in there that doesn't have some type of back injury or shoulder injury or overused injury. This woman, in this workshop I was just referencing, it's about testing dysfunction. It is a wealth of dysfunction at these workshops, right? A big part of it is because how hard these people work out. They push their bodies. When you push your body really hard, these compensations that I'm talking about, these little movement flaws, that may be little and small for somebody who doesn't push themselves hard, but when you push yourself really hard, you expose big time, right, you expose that bad flaw. You challenge it, right? Now, you've kind of opened up the wound, so to speak.

I think it's just good for your average person to hear, so they don't feel alone and the main reason they bring that up is because when you look at the Instagram celebrity or the athlete or the fitness model and you see them on this pedestal, I can guarantee you that 90% of them are dealing with some stuff. They have a team or as soon as they turn the camera off, they're foam rolling or they're getting their massage, their acupuncture or something like that.

Dr. Robert Pastore: This makes me think, if you don't mind me jumping in, perhaps these home training systems that are on at two, three o'clock in the morning on cable channels where you buy this box set of 10 DVDs and the guy who's selling them to you is in his 50's and jacked full of muscle, perhaps where they should come with a warning label, I'm just saying. Because there's people who can do sit ups wrong. There's people that do pushups wrong. One of the companies that we sponsored in previous work with this company who does a lot of work with the military. One of the things they love to do to break it up is hey, up everybody. It's time for the pushup contest.

They have these athletes in gaming versus athletes who are professional versus couch potatoes in gaming versus military. One of the gentleman who's incredibly fit said to me "You would not believe how poor the form was across the board". Some people's butts were way up in the air, and I'm thinking this is a great dialogue about injury and making sure we're breathing right, number one, in your building this beautiful picturesque mountain of foundation of fitness. The second one I believe you mentioned was form, correct?

Cary Berkowitz: Yep. Posture, which is a big category, but yeah.

Dr. Robert Pastore: If you don't mind, based on this picture I'm painting, would you agree that if someone were to jump into one of these programs without an expert like yourself, starts just swinging kettle bells around and is maybe not aware of form, doesn't that drastically increase their risk of injury and minus the breathing?

Cary Berkowitz: Sure. Of course. Yeah. I worked with a client years ago who never worked out a day in her life and had no pain. None at all. Perfectly able to move through, literally no pain, felt great. I remember the day I met her. She was just in a great mood, felt good, no pain. She was knocking on wood. No injuries. After about six months of working out with her, she had all this pain. Now, what I didn't know at the time is I was exposing all of these things that was there, right? She was sedentary her whole life, but she stayed in her comfortable ranges of motion. She was limited and she would be eventually that old woman walking. She was 70 years old, who's hunched over who couldn't reach behind her, but staying in her range of motion that was safe for her. What I ended up doing was I exposed all of these underlying things. Now, that's her. There are other people who don't have those, and they could jump into their kettle bell swings and they're good to go.

Our posture and when we talk about somebody's physical makeup, it's a combination of our genetics and the developmental pull on our bodies, right? You may have perfect genes, but if while you were growing up, your Mom always held your right hand, right? Your right hand was always getting pulled overhead like this, right? Day after day for five years of your life. It's going to change you. It's going to change your structure, right? You're going to have a completely different thing going on on this right shoulder than you will on your left. It's a bit of a crapshoot as far as if you took a hundred people and you threw them into a kettle bell class, you don't know. Even if you're accounting for, you're taking form, all these considerations into account, you can't work with a hundred people and account for all these things.

I think unfortunately, a lot of this stuff gets figured out a little too late, right? Once somebody is injured, you need somebody to walk you back and regress you to see where that injury came from, right? Yeah. It's a little bit tricky, cause it just kind of depends. It depends on the person. There are people who are just very equipped to handle loads. Those are the athletes that typically have these long careers. It's a combination of working hard, but really, it's their bodies that are allowing them to work this hard. There's not a lot of attention given to that, because an athlete doesn't want to be told they got lucky, that's for sure, because an athlete works hard. They earned it, and they did. They did.

But, Michael Phelps didn't earn his length and his dimensions. You know what I'm saying? His body gave him a pretty good foundation to build on, right? It's important to appreciate that. You can be working out as hard as you'd like, but if you have these foundational cracks that you're not aware of, it'll expose itself at some point.

Dr. Robert Pastore: I do find that fascinating. One of our advisors and a member of the company, Keith Pyne, he's current Medical Chair for the Washington Nationals. His stories are fantastic. Keith tells me how one of the first things he looks at when a pitcher, and we're talking about the Pros here, right? Their whole livelihoods is their body with their genetics and their innate ability and their training and they're constantly on top of things. The first things he looks at when there's a risk for Tommy John is the hips. It has nothing to do with the elbow, has nothing to do with the shoulder. Of course, those things will be evaluated. But, it's the first thing he's going to look at. Even these very high end athletes, and I'm thinking of these phenomenal pitchers I have known and fortunately, who have went through the surgery, but seeing the ones who want to prevent it. It's looking and drastically examining their form under this incredible, stressful moment. It is so not natural to grab a baseball, have an incredible wingspan, and repeatedly throw it between 80 something and 90 something miles an hour, if you're one of the greats.

Cary Berkowitz: It's remarkable.

Dr. Robert Pastore: And, just never let it up. Look, I'm so sorry. They're amazing. These hero worship we have with these guys, personal friends. I love them. They all agree, including themselves and the doctors that treat them, it is not a natural movement to get you through life. It's why athletes retire. Dare I say it? "Older" physiologically than their chronological age, right?

Cary Berkowitz: Mm-hmm (affirmative).

Dr. Robert Pastore: I would see some of my heroes, being raised a Knick fan, way after their early retirement because 30 something is you're done, retired with bags of ice over their suit on their way to now they switched over to commentary. But, then, there's ones who spent so much time on their physicality and as hard as they worked on their ability to hit a ball, see a ball, catch a ball, win awards, break records, the amount of time they would spend on preventing injury, working and seeking out the best specialists on the planet I found so impressive.

Cary Berkowitz: Yeah.

Dr. Robert Pastore: I don't want us to frighten anyone away from exercise. I think it's one of the most important things you can do in your life.

Cary Berkowitz: Yes.

Dr. Robert Pastore: I think it can be another, dare I say it, I'm redundant a panacea. There's such a wealth of data on the good things exercise can do. This isn't a scare tactic podcast, but we do want to bring up do you know how depressing it would be if you're that woman, that you trained, and she had no pain because she was living in a world of injuries about to happen at some point in my life? Or, worse, she's got Dowager's Hump. She's all folded over. She's got all these other complaints that can go along with it. She has the reflux disorders that may require medications just by physics, she now has reflux and we can go down this terrible trail of drugs and misfortune. I can imagine the challenge of just trying to motivate her to understand this is something you need to stick through. Please tell me there's a good ending to this story. Did she feel better? Did she heal?

Cary Berkowitz: No. There's a very good ending to this story.

Dr. Robert Pastore: Please, tell us the ending.

Cary Berkowitz: Yeah. I'm really glad you brought that up, because the Keith Pynes of the world are brilliantly preserving athlete's lives by looking at these things and the biomechanics and you see it. You see it with athletes nowadays, having longer careers, and you see some of the experts. There's a guy named Charlie Winedrop. There's people in that world of performance who are really, really smart and they know all this foundational stuff. I don't want to scare people off, because that type of tension and that type of impact on the body is typically reserved for the athletic sphere. Pro athletes, what's the word I'm looking for, it's the job hazard.

Dr. Robert Pastore: Job hazards, yes.

Cary Berkowitz: That's the deal, typically, unless you're a curler. Your average person doesn't necessarily have to have the same type of attention to detail that an athlete does, whose body is their livelihood. In regards to that woman, we essentially scaled back and we paid much more attention to these fundamental movement patterns like crawling and rolling over and these things that sound silly on the surface, but if you do them the right way, they can be very, very hard and honestly, we focused a lot on her diet and her lifestyle and her nutrition. It's really important, I think, for anybody listening who wants to get healthy or move well or start exercising, you need to be met where you're at. You need to really have a good understanding of managing your own expectations, but also just knowing where you are in your life and what your body has.

If you are someone like her and you want to live a long, fruitful life, there's a couple of things to look at before you start to press heavy weights. If you want to press heavy weights, it's hard, right? It was hard for her to do without getting hurt. We could've worked around it if that's what she really wanted to do. She and I both agreed all right, I'm not feeling good with this, so what do we need to do? We need to take a couple of steps back. We need to focus on just moving well, doing very fundamental things well, reading well, and maybe if I improve my lifestyle, some of the inflammation in my joints, some of the load on my knees and my uncles will decrease, right? It'll make a lot of this easier. For her, exercise was more of a compliment to these other things that needed to occur.

Everybody's different. There's this teacher that I had, his name was Robert Lardner, another brilliant Robert. He talks about plantar fascitis and how the reason why plantar fascitis is very hard to research is because it could manifest from a lot of different places, right? It's a specific illness, but like cancer, I don't want to be morbid and equate it to cancer, cause it's obviously not so drastic. But, cancer, there's a lot of ways that cancer can manifest to just make a general statement. There's a mechanism behind it, and you can obviously speak to this a lot better than I can, but as far as what causes it, there's a lot of debate. It seems like it could come from a lot of different angles. Because plantar fascitis can be caused by a lot of different things, you can give some general good advice, yeah?

Foam rolling the bottom of your foot, being mindful of the way you step, addressing their footwear, right, addressing the way their heel strikes when they run. If you follow some of these good principles, eight out of 10 people will probably help to reduce their plantar fascitis, right? There's good, general advice you can give to the general public to follow and they'll mostly have success with it. Those two out of 10, it could be something, they have a problem with their sesamoid bone at the bottom of their foot or they have an old hip injury that they or the trainer didn't know about or didn't address and that's somehow leading to their plantar fascitis. Yeah, that takes a more highly trained eye and for those people, they may need more attention. But, there are these general principles that your average person can follow and have success with exercise and not have to be so worried that they're going to hurt themselves in the long run.

Dr. Robert Pastore: Yeah. Studies have shown that we can put on muscle mass well into our 90's. There was even a study done on sedentarium, so it shouldn't be. You don't have to sit there and be a power lifter to apply pressure and tension on a muscle and on a bone to actually stimulate bone building activity, to stimulate muscle activity, and if anyone's listening wants to listen to the podcast I did on muscle protein synthesis that breaks it down into a little bit more of a minute and technical aspect. There's things that can be done even at rest, like you said, making sure your diet is adequate, making sure you're controlling your protein and nitrogen ratio, staying in positive nitrogen balance, the importance of eating foods rich in branch chain amino acids. I definitely agree with you there, and I'm glad you mentioned that, because as we age, look, inotrope increases, right? Things are breaking down. It's a part of life. It's fascinating to me that what I'm seeing in the research and I'd love your opinion on this, Cary. How little muscle you can actually try to stimulate that can keep you out of trouble.

Cary Berkowitz: Yeah.

Dr. Robert Pastore: Right? I have witnessed under your care and other trainers that you worked with and an 80 year old woman gets stronger but she's not sitting here lifting record breaking amounts of weight. She's comfortable. She's able to walk herself to the gym, exercise, leave the gym not on a stretcher, and rinse and repeat, right?

Cary Berkowitz: Yeah.

Dr. Robert Pastore: Don't you agree that for any age one, it's never too late to start? Two, it's amazing how a little can go a long way. Please feel free to challenge me if you think I'm wrong.

Cary Berkowitz: No, I couldn't have said it better myself. I think it depends on the individual, especially if you're a 75 year old person and you don't have a history with exercise or strength training. In a way, you're a welcome sight, because you're somebody who probably has this untapped potential and you probably have the ability to put on muscle but at the very least, maintain muscle.

Dr. Robert Pastore: Yeah.

Cary Berkowitz: You talk about sarcopenia, at a certain point, your ability to maintain, if you're a 40 year old, you can maintain your 40 year old muscle mass til you're 80, my lord. What an incredible success that it.

Dr. Robert Pastore: I was just going to say I saw a 65 year old man break a record on America Ninja Warrior.

Cary Berkowitz: Oh, I saw that.

Dr. Robert Pastore: Completing two events.

Cary Berkowitz: Yeah, that was incredible.

Dr. Robert Pastore: Grandpa's jacked.

Cary Berkowitz: Sure. Yeah. The reason I brought up the 75 year old man, if you're 75 years old, whatever your physique is, but you haven't attempted to build a lot of muscle in your life, and you haven't strength trained, your muscle mass is probably much lower than it could be, right? If you haven't been doing that resistance training, now you're 75. You haven't been doing that resistance training, so you probably experience a pretty good amount of sarcopenia and muscle loss over the course of your life. Probably, let's just say, on average. Now, you're 75 and your diet is right and all the things that you mentioned. If you start strength training at 75 and your diet is what it is, I see no reason why you can't start putting on some muscle, especially if you haven't maxed out your muscle.
Everyone knows some older people, some older gentleman or woman, who just has that gene where they hold muscle and they build muscle really well. We all know the jacked grandpa, but it's pretty rare. If you're somebody who hasn't worked out or strength trained and you haven't maxed out your genetic capacity to build muscle, if there is such a thing, barring other circumstances that I can't think of, you absolutely can build muscle and reverse sarcopenia or, at least maintain muscle well into your 90's.

Dr. Robert Pastore: Absolutely. Even with the discovery of various gene errors known as polymorphisms, and transcribing specific genes that are primarily expressed in skeletal muscle, you can still work with that problem. You can still offset that problem. It's not an end of the situation scenario, and with our aging population increasing, which is wonderful, I feel that this is something we really need to focus more attention on, which is moving right, breathing right, and trying to be strong for the performance of life, right, not just for performing on the field. We know that's great.

You said something great where you talked about they have their team. You know you've got the guys coming out with the massage therapists and the foam rollers and the acupuncturists and they do have their squad. They are very well paid to do an incredibly admirable task. For the regular person out there that works their nine to five job, there should be no fear from exercise. If you just start and it's a form of exercise you haven't done before, the aforementioned woman that you worked with who experienced this delayed onset muscle soreness, it sounded to me though I am not a trainer, but as a scientist who works up on these things and studied protein research extensively in the musculature, it was unaccustomed. It's an unaccustomed vow to training, and there's going to be that very normal onset of this soreness post-exercise, and there's ways to ameliorate that to the best of that individual's ability.

One quick note I want to mention on this genetic polymorphism cause it really is interesting to me. There's many different genes that are involved, right? We know that there's Vitamin D receptors that play a role in muscle protein synthesis, hypertrophy and the health of the muscle. We know that there's something called angiotensin and one converting enzyme. Then, there's the one I think is most popular right now is Alpha-actinin-3 and that's ACTN-3 gene if memory serves me correct. That's really being looked at, because if that has a polymorphism error, if someone's expressing that, there's a specific allele in that where there's a stop code on of R577X of that gene, they're prone to having more risk of sarcopenia and bone loss. For me, I would see that as a motivational factor, as precision medicine becomes more on the population landscape of usage. I would take that as the glass is half full. I need to really get in the gym and really train better and really focus more on my breathing and my proper posture to perform these exercises, so I can do everything in my power to offset this genetic polymorphism.

I pose the question to you that I brought up with a lot of general practitioners. I really believe that muscle loss should be advocated as a true biomarker of aging, and that more part of a standard history and physical when you're having your biannual checkup, I believe should on some level have a standardized set of muscle measurement unique to the individual patient.

Cary Berkowitz: 100%. Yeah. I completely agree. There's no reason to not have that information. I think as we were discussing a little bit earlier, the lack of mobility. Our bodies are at the breakdown, the physical breakdown in our lack of ability to move and ambulate through the world is sort of the leading cause of mortality. Outside of disease, when somebody stops moving and they can't move themselves and they're bedridden, that's a big deal. That leads to a pretty rapid decline. If somebody fractures their hip or injures themselves or their muscles are so weak that they're just so much more susceptible to fractures, that's a really important thing to monitor. It's a huge deal for quality of life. To have that snapshot over the course of somebody's history, so whether it's taken annually or every few years the way certain, I'm not sure how often colonoscopies or things like that are, but kind of along those lines. Something where you reach a certain age and then, you get a muscle biopsy or how would you go about that?

Dr. Robert Pastore: That's what's so great. We could standardize this and make this really simple. In the geriatric community, you could do something as simple as a baseline bicep circumference, arm circumference and under flex it. Say hey, the muscle's contracted. Let's see how this changes. I'm asking for a dental x-ray to get a baseline. Are there cavities in an area that I think there are cavities in the medical science of practicing, right? One of the things I feel blessed, because I come from a both of both worlds, right? The academic environment with heavy duty bench science and research, and then, the practicing side. When I would attend conferences and lectures and to this day, with my profound addiction to education, part of me thinks towards the studies I'll be doing the next decades, and the other half says I wonder if this will play impuria on Monday morning, right?

Since I'm retired in practice now, but what can I see today that could help me, that I could actually immediately apply into practice environment? When I'm seeing these new publications in the last several years for example of the Korean population will be over 65. About 24.3% of the population will be over the age of 65. That, we know, is a ripe age for sarcopenia. In the literature, the aforementioned polymorphism that drastically effects muscular on a negative level is present in this population. While the scientist in me says let's identify more populations, let's identify more polymorphisms. Let's give the practitioners the knowledge, right? Data is data. Turning data into facts ends up with knowledge, and then we can apply that knowledge, translational bioinformatics is what that's known as, and we can apply these principles to actually measuring and making a diagnosis.

I think if it was something as simple as measuring muscle with a tape measure and the same one every time with that individual and seeing the attenuation, I don't know about you, Cary. You're a very fit individual, so I think you'd be motivated very quickly. But, for me, an aging male, it would be so motivating. It's like seeing if my Vitamin D was low, I would want to run right out and fix it. If there's anything wrong in my lipids or my blood pressure, what lifestyle changes, knock on wood everything's great, but what lifestyles could I make expeditiously and safely that would give me this improvement? If a doctor looked me in the eyes and said "Robert, I'm so sorry. From last year, you lost 1.8% of your muscle". Oh my goodness.

You would be the first person I would be calling, and I think I would be walking out of that office with ankle weights on and wrist weights on. I'm being flippant, but I think you get my point. I would see it as a wonderful motivational factor. If I'm wrong, please call me out, but I think we have a smart population, and I think if the public knew more about how they can help themselves, they would want to do more.

Cary Berkowitz: Yeah. If you want to manage something, it always helps to measure it. If you want to increase your muscle mass, it's always good to know where you're at and to know where you're starting at. I don't know enough about the practicalities and what it would take to institutionalize that. Off the top of my head, there are a couple of issues I could think of with just taking a tape measurement, because let's say you're swapping muscle mass for fat mass, for fat tissue, you may get the same measurement.

Dr. Robert Pastore: Absolutely.

Cary Berkowitz: I'm sure there's a creative way, because you could obviously measure somebody's body fat as well. You can do some type of process where you're figuring out the lead tissue to the fat tissue ratio and get it done that way. That aside though, honestly, it's a fantastic idea that I wouldn't even have thought of until you proposed it. It's an excellent, excellent idea. I also think, kind of to what you were alluding to, it's a great motivator factor. You know, Robert, doctors are authority figures. That's the bottom line. We listen to our doctors. I think the internet has brought a wealth of knowledge to people, but it's hard to parse through that. People still do go to doctors and we see them as authority figures and they sort of sift through this stuff. If it's look at as something that's important enough for doctors to measure, it would be a very big deal.
It would be a huge motivating factor, and it's this thing you can see changing over time. If it's measured every year or couple years, you can watch it. You can look at your chart, right? It can light a fire, and if it doesn't do it for everybody, okay. Nothing does, but you could probably enthuse a pretty large number of the population, a large percentage of people.

Dr. Robert Pastore: I hope it gets to a point where it becomes like cholesterol, right? Because I remember when that was something you would have to ask for, to show you how old I am. It's incredibly commonplace. My father-in-law called me yesterday just to shout out "This is my cholesterol". It's normal nomenclature and I think that this needs to be part of a regular checkup, just an annual checkup. I would also like to add that to go back to echo that woman, I don't know if there was potential fear on her side, not putting any thoughts in her head. But, the fact that she went from having no pain to having some pain, it worked out great. You found out what was right for her.

Cary Berkowitz: I still work with her.

Dr. Robert Pastore: That's the best thing I could hear.

Cary Berkowitz: Yeah.

Dr. Robert Pastore: That's beautiful, and it also echos how great you are. But, what interests me is you can start slow. Looking at the chemistry of how we can preserve muscle mass, I can use an adjacency to the injured athlete, right? I was called in on a case where I was working on a linebacker and knee replacement is required. Just monitoring the protein and nitrogen ratio, making sure high quality branch chain amino acids were coming into the diet. You can trigger specific genetic pathways of rest that up regulate the million target of rapamycin, which is part of the role of this ribosomal biogenesis of muscle tissue, muscle cell growth.

There's small changes you can make. A lot of older people I have seen, look, they don't have much of an appetite when I would first see them in clinical practice. They would lean more towards the starch. I would in great duress and stress and any stress word you can think of as a synonym for that, watch my mother eat one tiny two ounce piece of chicken in favor of a mound of some type of highly processed carbohydrate.

Cary Berkowitz: Smart woman.

Dr. Robert Pastore: Just not get that. Obviously, she's at a protein deficit. As we age, we require more protein and we need to preserve muscle mass. Something that simple could be the first start, and then, getting on the right track to breathing right and moving right and watching your posture and actually putting some resistance training, no matter what that is, I think could be a great help.

Cary Berkowitz: Do you mind if I ask you a question as a student and as a Dr. Robert Pastore fan?

Dr. Robert Pastore: Please.

Cary Berkowitz: It may be loaded and you may have answered this in your protein synthesis podcast, but I'm curious for your average Joe and Jane.

Dr. Robert Pastore: Yes. Yes. I think so.

Cary Berkowitz: What are the top things or the top three things that people are doing or not doing that disrupts their ability to synthesize protein? I was talking about going past consuming protein. Let's just imagine this population we're talking about are eating, consuming, putting in their mouths enough protein. What are some of the lifestyle things or some of the maybe it's medication, maybe it's other foods that are disrupting things, but what are maybe the top one or three things that people are doing or eating or breathing in or having in their environment that are actually disrupting their ability to synthesize protein?

Dr. Robert Pastore: That is a fantastic question, and it's not something that I really talk about much now that I'm outside of practice. But, I could start at one of the biggest ones is over the counter and prescription medication to address what seems to be an epidemic of various gastrointestinal maladies starting with heartburn, acid reflux, that burning sensation.

Cary Berkowitz: [inaudible 00:59:54]

Dr. Robert Pastore: Yeah. Something as simple as TUMS can drastically reduce how well you digest and unfold the larger proteins into amino acids. We deaminate. Not only is that a great term for a punk rock band, but The Deamination. First song, Archening. When we masticate and the bullous gets into the first part of our digestive track, our stomach there, past the mouth, the first part, which is amylase driven, we unfold proteins through hydrochloric acid. Then, they go through a sodium bicarbonate wash, and they pass through the pyloric sphincter and through the first part of the small intestines knows as the duodenum, where their further unfold in an alkalinized environment by various protease enzymes. These protein digesting enzymes that are proteolytic, they continue the unfolding, breaking them down into smaller peptide chains and single amino acids where so many different factors enhance how well they are absorbed. If we go back to the stomach, if you're neutralizing that acid medium and you're this person who got this really bad result from their doctor. I'm losing my muscle mass. Oh, by the way, please renew your prescription on the way out for this proton pump inhibitor.

You go out and you get this really healthy grilled chicken salad with olive oil and a light no-sugar vinaigrette and you're enjoying your multicolor salad and protein, you're actually really not getting the full absorption that you should have been getting because you're really suppressing the full unfolding of these proteins. This is my opinion. Any listener should discuss this with their doctor, but it's something I saw in clinical practice. The patient will complain of gastrointestinal reactions to not fully breaking down their protein, which may cause discomfort as gas and bloating and guess what they end up doing on their own? Reducing their intake of protein. They end up running in this vicious cycle that results in having this problem, so I've always been a fan of what is the problem that you're having? If it isn't something that is completely biologically forced, physiologically structural, like you were born with your stomach upside down, that you should be on a path to figuring out what's wrong with you.

I have celiac disease, and it absolutely changed my life. I never said woe is me and sat in a corner and said well, I guess I can't eat anything now. I went after it and wanted to know everything there was about it. That led into the genetics of it. Not only did that led into long term education and a profession, but it motivated the heck out of me to find out what was making me sick and how could I optimize my digestion and thus absorption of what I was eating. We really are byproducts of what we absorb, process, and utilize metabolically. We are not products of what we eat. I've always debated that argument, though I do love Ben Franklin's "We dig our grave with our knives and our forks".

Cary Berkowitz: Oh, that's good. I don't think I've ever heard that.

Dr. Robert Pastore: I've got to dig Franklin on that one.

Cary Berkowitz: Smart man.

Dr. Robert Pastore: What's so interesting is that would be number one is having some type of medication. The second would be an undiagnosed gastrointestinal problem. If I may mention my disease for a moment, what absolutely drives me nuts and it motivates me for the rest of my life and it's the reason I'm building a clinical decision making system actually making a brain that acts as a expert physician is 83% of people with my disease are never diagnosed. I can tell you if I had a headache and my mother gave me Tylenol or an aspirin as a child, I apologize for being graphic, it left my body the same exact way it went in. If that isn't the most amazing piece of evidence of malabsorption, I have no clue what is. I had very late stage celiac disease. Identifying those abnormalities, I think, are massive. In addition to that, I don't care that it's controversial because it is fact.
There are many people that have food allergies and there's growing awareness of it. We're seeing soundbites of it all the time that way pass the classic peanut allergy that we see in children. This is, please, separate from celiac disease. Celiac disease is not an allergy. I have an immunological autoimmune disease reaction to the proteins that are found in gluten containing grains and anything that contain those. An allergic reaction is an abnormal immunological response to a normal innocuous substance that you ingest or are exposed to. This was drastic in my personal private work in clinical practice, where I was examining and looking at professional athletes.

But, the first time I really heard it discussed publicly was by the aforementioned Doctor Keith Pyne. Doctor Keith Pyne, actually, there's a video on website where Keith talks about testing his athletes and what he saw. He would have athletes say "This didn't have any negative effect on me. I didn't feel it", like the woman who never exercised, but said "Hey Cary, I feel fantastic". Meanwhile, she was probably going to be one of the worst 75 year olds, God forbid. But, Keith would say but, look what it's doing to your chemistry. Look how it's effecting you absorbing this. Look how it's up regulating inflammation. Then, that's why your shoulder's shot. Then, we would manipulate and work on your physicality, work on your corrective exercises, do all that right, but also remove your source of inflammation, because you are biochemically unique. You are a biochemically unique individual, as we all are. That would be another one.

Cary Berkowitz: Yeah, a big one.

Dr. Robert Pastore: Then, I think the third one would be compound protein consumption. Someone would say oh my goodness. My doctor told me I'm losing muscle mass and I saw my trainer and the two are in complete agreement and in concert that I must consume enough protein, so I'm going to eat all the protein I need for the day at this one meal. That'll be awesome, because I work out with Cary and I'm crazy fit, so I'm going to eat my pasta and all my other stuff. I'm going to have me vegan meal the rest of the meal. You know what? I would actually do that with a slash of also the assumption that I'm consuming enough protein. One of my favorite falsehoods that was taught in undergrad that was as long as your athlete is ingesting enough calories from healthy foods, you could be sure they're getting enough protein. That's another throwback. That's how old I am.

But, Cary, if you and I right now went to one of our favorite restaurants, Rosa Mexicano. That's an unsolicited plug, by the way. I just love them. We consumed a double guacamole for a table of six just ourselves. We're getting plenty of calories. We are getting very low protein. We'll probably walk away from that with maybe four to six grams of incomplete protein and an enormous amount of healthy fats and all the wonderful things that are in avocados. Really being meticulous and measuring what your athletes are consuming and what regular people are consuming. Those are my top three. I hope that answers your question.

Cary Berkowitz: No, it certainly does. I'm glad I asked. I'm really glad I asked. That's great. Thank you.

Dr. Robert Pastore: Awesome. All I can say is it is always such an unbelievable pleasure to speak with you. You are a wealth of knowledge for such a young man. You are an old soul at this. I feel like you lived a couple of lifetimes studying the pertinence and the importance of training clients properly and I don't throw compliments around. You just are, in my humble opinion, the Zenith of what you do. I can't thank you enough for being with me, Cary. Thank you my friend.

Cary Berkowitz: Oh, thank you. Honestly, I feel the very same about you and times 10. Thank you very much. I really appreciate it. It's amazing talking to you.

Dr. Robert Pastore: Thank you so much. Everyone, thanks so much for listening. Talk to y'all soon.