Run for Your Life: An Ancestral Health Approach to Running [transcript]

Written by Christopher Kelly

Feb. 16, 2019


Tommy:    Hello and welcome to the Nourish Balance Thrive Podcast. My name is Tommy Wood and today I am joined by Dr. Mark Cucuzzella. Hi, Mark.

Mark:    Great to be here, Tommy. I know it's early morning for you there in Seattle. It's a beautiful day here in West Virginia.

Tommy:    Yeah, it's kind of dark and rainy here right now but, I guess, that's what we should expect of the Pacific Northwest. That was a great excuse for having you back on the podcast, is the fact that you've just written a book called Run for Your Life: How to Run, Walk and Move Without Pain or Injury and Achieve A Sense of Well-Being and Joy. It's quite an expansive title and that goes with quite an expansive list of topics that are in the book. Maybe you can just tell us a little bit about what made you want to write it.

Mark:    That's a great question. If you had asked me five years ago when I started this thing, maybe I should have been locked up. I listened to your show and I've even pulled some words like hormesis that you use often. I think that word made it in the book because it gets me curious. But I've learned from so many people in my life just maybe by luck or being in the right circles or just being one of these guys who question everything because I've been hurt all the time running, that and pre-diabetes, eating the heart healthy diet and all that stuff.

    I started to question stuff about 15 years ago in my medical career and then these new books and podcasts started to come out in my community. I started doing some of these changes. I started hosting races, opened a running store with flat shoes only, going against the traditional model there, started to do low carbohydrate diets in hospitals and seeing the effects, seeing how medical students were just so open to change and new ideas.

    They hadn't been embedded in old thoughts. They're the future and just seeing how they respond. We wrote a grant that taught medical students how to cook and that's still going on now year five. And Robert Lustig's work was the lead work to start that grant. He has a book called Fat Chance and Fat Chance Cookbook. He was one of the first disruptive guys teaching about insulin resistance and food addiction, how a calorie isn't a calorie.

    Gary Taubes, he influenced me greatly. And I wanted to give something back. As you accumulate, your laptop probably is more organized than mine by listening to you.

Tommy:    I doubt it.

Mark:    But I've got like three laptops with probably combination of three to 5,000 articles in various folders, 300 books in my basement, because everything you read makes you want to read ten more. Okay, how do you synthesize all that into 19 chapters? It's probably like an introduction to everything. If it encourages the reader that, yes, there is hope that they can run again, they can stay healthy, they can get healthy and find their path. But I wanted to keep it simple for really the every person, not get into too much deep science, but send people to those directions who need it because it is hard to summarize nutrition into ten-page chapters.

    I mean, how many millions of pages have been written to try to pull out the big rocks? I'm pleased with how it turned out and it's done. I started it five years ago and some of this stuff was new thought, low carbohydrate diets, minimal shoes, stuff like that, healthy aging, stress, sleep, some of the big rock topics, youth, nature, outdoors, the power of community.

    These things are softer topics that some people may think but there's actually real science behind that. But as the years went on and there's like draft one and I work on a chapter, the stuff that was in my mind I was writing about was now starting to be validated by more science. That made me feel good that, oh gosh, I've got to throw out chapter 17 or something.

    Nature is bad for us and I can chuck that but books were starting to be published on 400 pages on what I had a chapter. That was all good because what I like, if you want more on this, just read the Nature Cure, something like that. Yeah, knock on wood, in ten years, everything in there would still be legit. I hope it's not like a one off and next year there's new stuff that this is obsolete. Most of it is based on pretty old whether they're ancestral or traditional coaching and medical principles that were taught 50-100 years ago. Most of that stuff just come in back full circle.

Tommy:    Yeah, absolutely. And there's a huge number of topics in the book that hopefully we'll go through, many of them very close to my heart and I believe they're very important. However, I'd love just a little bit more information on the process of writing the book. I often get people saying to me they're amazed at how much I achieved and I feel like you really put me to shame.

    And when I email or text you, I know that I should expect a single line and punctuation is optional because you're usually running a hospital or running your running store or running a race or speaking to government officials or something like that. I know that there's a book that I'd love to write but I have no idea how I'd get it done. Maybe you could tell me how on earth you managed to do it.


Mark:    I guess, it started about five years ago and that's something I want to pass on even to my kids. They don't really care much about barefoot running or nutritional principles or healthy aging much. They're 15 and 13. And they like making fun of me in a good way. They live healthy. They go outside. We don't have junk food in the house. You commit to something and you get it done.

    My kids are actually pretty proud when they saw the book come out and there it is in the hard book. They're at the age now where they know about projects and how difficult that is. I showed my kids that, yes, you can commit. Like this is running a marathon. A few hours is nothing compared to sitting down and writing a book. I had some good help, a co-writer who did a lot of the review work, Broughton Coburn, who lives in Wyoming.

    He spent a lot of time in the Himalayas with climbers. He was very familiar with the outdoor space and a great writer. He really was priceless in keeping me on track and shaping what I was writing. That was a big help. We need to get this chapter done by the end of the week. Luckily, I travel quite a bit as you do too with your job and commitments. So, that was just a priceless time where you were completely off the grid.

    When you're up in the air or sitting in an airport or planes delayed, you make your rule. I'm not going to go on to the airport wifi or something and you just lock yourself while you're in that plane. It's the most productive time. When I was traveling I would always commit. I'd say, "Oh, man, I got this trip coming up. Non-negotiable. I'm not going to do anything else. I'm going to get this chapter done."

    I would do that. That would help me get it done. But like anything, you bite it off one chew at a time. That's why it's 19 chapters, the book. Okay, let's get chapter one done. Review it. That was the only way to do it. It took longer than I thought but that's probably, if you talk to anyone who's written a book that wasn't just a single topic, that's probably 90% of people that does take longer unless you are full time writer.

    A lot of us doing this who have full time jobs are just trying to squeeze it in. It can always be better, I think. At a certain point I just had to say, "Look, I'm done. I could look up ten more articles and try to weave them in but let's just call it good." And that was sometimes hard. I know by listening to you and your work, we worked together on that low carb paper, your precise perfection and when you're covering these super broad topics, I had to let that go a little bit.

Tommy:    It's probably one of those things where you might notice that that's something you could have expanded upon but actually there's no detriment to the reader that's missing and, actually, getting it done and getting it out is probably more important. It sounds like that was the case.

Mark:    Yes, so true.

Tommy:    I think you've given us a broad overview of the book, 19 chapters. Why I think it's a nice structure. Each chapter you have, you explain a problem. There's lots of figures. And then you go over some drills about how to fix that and that could be in your running technique or improving your diet. But, obviously, a lot of the book is based on running and running technique and minimalist running, which is part of your own road to improving your performance in health.

    Maybe you can take us on a little bit of a journey through your approach to running, how we might restructure our running such that it's more in line with our anatomy and physiology. And then also what kind of time and commitment it might take to do that.

Mark:    You're a big proponent and researcher, speaker on ancestral health. I think the first chapter was really going back into our ancestry and evolutionary biology. You cannot argue that the human body was not born to run. I know that sounds a little cliché there but the first article in Nature before the book Born to Run was called Born to Run by Dan Lieberman and had 28 different features of the human physiology and skeleton that supported bipedal running, not just walking, running.

    We're designed to walk and run. That's why I spent a good bit of time on walking. But running is a mass spring mechanism and it's a highly efficient mechanism to travel long distances, not at a sprint but at a sustained speed that if you were to look at other animals, that if you had to cover a sustained speed at a given distance and there was heat, maybe we would be the last one standing and that could be dinner.

    There's articles written about that. Could we have walked the kudu down or run the kudu down? Either way, we had to do it on two feet and we had to have a very efficient energy metabolism as well as cooling efficiency. All of those things are described in Dan Lieberman's book, Story of the Human Body. Yes, it's in our genes. It's in our DNA. But, I think, what I want to explain, Tommy, to people is I think things that are in our genes and our DNA make us happy and if something doesn't make us happy then we're not going to keep doing it.

    I see a lot of runners and they'll seek me out because they've been told not to run. They just want someone to give them hope, to say, "Look, I think you can start running again." It could be really slow. Because when I tell a runner who's been told they can't run, that I think you can run again, their face, their whole body expression lights up.


    If you were to take five things that, non-negotiable, like, "Gosh, you can't do that. That's irreplaceable." If you've been a lifelong runner and you came into my office and I just said dogmatically you can't run anymore, that's unacceptable to someone who runs. They're going to go to the shoe store. They'll go spend all kinds of money to find someone who wants to get them back running because it is their drug. I mean, we know that. That's been one of the chapters on the mind, all the neurochemicals.

    It weaves into the mind and the body. But it is in our DNA to run. And people that do it correctly mostly is by slowing down. I've taught so many military seminars and you can get in the front of the group, might be 100 people. How many of you all like running? Maybe one or two hands. And it's like the kid who is on the cross-country team that they all hate raises their hand. Because they're all scaling at him because he's always good on the PT test but he's not the guy who is going to lift the palette.

    That's the other side of it too, is that we are designed to move and lift things. I have stuff in there on strength training. The human body is designed for a variety of tasks but running is certainly one of them. Running slow is really the key to helping people find the rhythm because it's hard to find that nice happy rhythm if you're in pain and pounding your body or you're in this, a lot of people understand, the zones of training.

    Zone two is that conversational zone where you're burning fat. That's a happy place to be. So, I encourage people who are starting running or trying to get back to running to just spend most of their time there first because that's the foundation. And then after that they can try to load it up with intervals, high intensity, but they have to build this foundation of movement patterns, building that fascia which is the spring.

    If that's been decommissioned by shoes, by years of sedentary behavior, you got to get that spring back. That's what kids all have, that nice rhythm, jumping rope. It's a very process but train for your weakness and, I think, the book kind of tries to help people identify where their weakness is and then focus on that.

Tommy:    In line with that, you mentioned the shoes which are a big part of the way people are running nowadays. What about the process of transitioning to a more minimalist shoe which, again, you are a proponent of? I think of most people who I know who've tried it they often get straight to something like a five finger, they immediately get plantar fasciitis or severe calf DOMS and then they never go back. How do we slowly start to make use of our feet again?

Mark:    Yes. The longer your feet have been decommissioned the longer the process is of retraining them. In my store, Tommy, we go through a process. We don't just throw five fingers minimal shoes on people. We actually look at their feet. We have a plantar pressure maps so we can see the feet deformities, areas where they're pressuring the ground. There's some really simple assessments of foot strength and foot control.

    Can you balance for 15 seconds, 30 seconds on one foot, eyes open, eyes closed? You just see what's happening. Look at the big toe. If the big toe is bent in, the foot stability tripod is off. It's unstable. The foot is the spring. The foot is the master shock. We want to get the foot in the right anatomic position first. Get the toes in the right position, soft tissue work. Walk around first. Reposition the foot. Give an awareness.

    There's exercises called the short foot posture. Just give people an awareness of what a stable foot is, a foot core, so to speak. And then walk around. The first real step to getting into more minimal shoes, which isn't about the shoes, it's kind of foot rehab, the first step of foot rehab is walking around. If you have a day job and you're walking, get a flat shoe, a thin shoe, one that you could roll up, put in your pocket, because you're not going to hurt yourself just walking around on your day job. You're not loading the body.

    You might be a little sore the next day walking around if you've never walked in the minimal shoe. You don't work for ten hours if by two hours you have discomfort. But that's like going to the gym. If you go to the gym first day and there's a good discomfort and then there's, okay, I went a little over the top discomfort. People need to start to understand that difference between, okay, I'm waking up some muscles and something that's pain.

    Plantar fasciitis, I think everyone can walk themselves out of that if they get the mobility and the intrinsic muscle strength back. We assess people's mobility. If you can't get into a deep squat, for example, then you're tight usually in your Achilles gastroc soleus complex. We go through a little checklist with people and try to identify some weaknesses while they're transitioning to the shoe. It's kind of a holistic approach.

    People with metabolic disease, say you're carrying 100 pounds of belly fat and your whole body is inflamed, your fascia, your tissues are inflamed, I think if you work on the diet that will go a long way to helping you get into a more minimal shoe, if you have any kind of pain or lower extremity discomfort whether it be your knee, your foot, hip.

Tommy:    Talking about the metabolic syndrome reminds me of -- I think, very early on in the book you say something like as a society we need to run because of the obesity epidemic.


    But I also know you're not the kind of guy who thinks running is going to cure obesity. Maybe you can just expand a bit more on the process of how you approach people with obesity and type II diabetes and how you maybe transition them along that spectrum back towards health.

Mark:    Yes. A healthy habits, and I think you and I are pretty aligned on where people need to start, I would describe it kind of like this. There's the insulin resistant phenotype, what is the gene expression, and then there's the healthy athlete phenotype. That's Phinney and Volek's insulin resistance spectrum. Most of the people I see, I have a clinic where we see type II diabetes and obesity with the goal of reversing that.

    Those people are the insulin resistant phenotype. They look Santa Claus, big belly. They may want to run but for them, 90% of the focus initially is fixing the diet, get those insulin levels down, get rid of the refined carbohydrates, all the processed junk food, the junk vegetable oil. That's the trifecta of disaster, sugar, all the refined grains and the refined vegetable oils.

    Then you look at what is a healthy menu that will give them satiety that is going to include natural fats, good quality non-starchy vegetable? Start there and then get them to walk. Get them to do something that they want to do and doesn't put them in pain. If you're carrying -- I couldn't imagine. I've never been 300 pounds. I don't want a 300-pound person to run because that's just going to hurt. That won't be a happy place to be.

    But usually if they start walking -- and then we actually do a drill when I give clinics. It's called slow jogging. This was developed by a gentleman, Dr. Hiro Tanaka. He's over in Japan, head of exercise physiology. We've got a couple videos on the book's website showing this, that slow jogging is the super, super soft easy jogging and it's slower than a walk. You just have to imagine that. Like you see this guy is about 5'2", little Japanese guy, and imagine him just jogging slowly through the airport.

    Maybe he's got a little backpack but just like nice and soft, nice rhythm, super slow. But that is like magic to help people learn that mass spring. That is not two to three times your body weight. It's not really running because it's super slow but you're in a running motion. It's just like tap, tap, tap, tap, jog. Kind of if you were jogging in place really easy and then you just started kind of segueing forward a little bit, segueing back.

    That's different than what most people do when they "go for a jog." They'll put on the big heavy shoes. This is military style. They'll put on the big heavy shoes, go out to the track and pound. If it were a treadmill, the room is shaking. The slow jogging is like quiet, super quiet. I think people can do that. I see people do that on knee replacements, really bad DJD. And this actually can protect the joints because if you develop a good suspension system, your fascia, there's less stress on the joints.

    If we decommissioned our feet, our spring, our fascia, something's going to take the hit even while we're walking. Again, gradual progress. They would do a minute of that slow jog, a minute walk, do it outside, something that they can wake up and want to do the next day. If they don't want to do it the next day because it was painful, they won't. They have to look forward. Gosh, I get to out. Today is a beautiful day here. It's like 60 degree fall day and looking out my window I see about 50 colors of leaves and they're all falling off the trees. If you don't want to go outside in that today, there's something. You need more help than I can give you.

Tommy:    You mentioned the fascia quite a few times and you mentioned it quite extensively in the book. Maybe you can talk a little bit about the fascia. You've kind of mentioned slightly how it relates to running but what is it? How does it work and how do we know what's going on with the fascia? Because you also talked about the fact that it is very hard to image, it's very hard to figure out exactly what the fascia is doing. How do we tie that all together?

Mark:    You did your basic anatomy lab, Tommy. Did you do that in London or where did you do it?

Tommy:    Yeah. I did that in Oxford in second year of med school was when I spent most of my time doing anatomy. That was 2008, so about ten years ago.

Mark:    Maybe tell me if anything was different. I did my med school, started in 1988, and I don't think that word was even used in anatomy lab other than something we would cut through and dissect to get to the muscles, to get to the nerves. We called it like the tendon. There was the Achilles tendon, the patellar tendon. All of these other connective tissue that encase the organs, encase really every muscle belly, attached, nerve sheaths are encased by it, we didn't really pay much attention to it.

    Probably a lot of that stuff just kind of dissolved away. I didn't get it. Did you guys spend any time in 2008 or maybe in the UK did you have at least one lecture on the connective tissue, the loose connective tissue other than the big tendonist type that you can see grossly with your eyes?

Tommy:    Yeah, probably not that much, actually. Unfortunately, I didn't get to do actual dissections myself.


    We always worked with sections of body that somebody had already dissected and usually that means they've already dissected away the fascia, right, because you're doing exactly what you said, you're looking at the muscle, all the nerves, all the vasculature. I guess, even in those 20 years, we probably weren't doing that much more on the fascia than you were when you were in med school.

Mark:    Someone says you're as smart as your five closest friends or something. I put you in that camp. The people you talk to and I've come across some just amazingly smart people in my life. One is that gentleman named Lawrence van Lingen. He lives in LA now but from South Africa and he's worked with just dozens and dozens of Olympians his whole life.

    He is a chiropractor by trade and started to listen to him a little bit after going to a lecture and he turned me on to a book called Anatomy Trains by Thomas Myers. That may have been six years ago when I've first heard Lawrence and we've become good friends and actually showed up at conferences together to compliment each other's work.

    I kind of knew a little bit about it just by the way people ran but couldn't define it. He turned me to the whole science of fascia. There were world congresses of fascia going on and the interworlds of people doing disruptive things to the modern medical establishment. But this was well-established science going back and Thomas Myers was one of the lead.

    Carla Stecco is an Italian. He's got a wonderful book too. And I read all those books and then looked at how athletes move. You look at sprinters and javelin throwers, golfers. We have this fascia lines. Runners, when you extend your hip, you have this spring, like this bungee cord that's extending from your opposite shoulder because you get a little shoulder rotation. Say, your left shoulder is rotated back a little bit and your right thigh is extended, kind of in that take off position, that's like a powerful spring.

    You see that in athletes. And then when you're hunched over, the bungee cord isn't loaded. It made sense to what I knew from running drills and skips and barefoot running where the foot spring is set up. So, I would just -- If you're interested in the topic, start with Thomas Myers' book Anatomy Trains. There's a little video. It's called like the Fuzz Film. Maybe we could link to that. And there's another one that's called something Strolling Under the Skin, is another one. We could find the links to those.

    They just show you real time what the fascia is. These are live video showing fascia anatomy. Yeah, it's super important. And then as far as what do you do with it, okay, I got this info. So, Lawrence made up this term, and I think it makes sense. He phrases it like this. Know your fascia. Mind your fascia. Keep it keen and treat it mean.

    For example, the things that keep our fascia healthy are the same things we talk about with diets. So, anything causing inflammation, inflamm-aging crappy diets, sitting all the time, stress, lack of sleep, all these things causing this global inflammation, we all know we wake up the next morning and we're a little bit sticky and stuck. That's why a cat stretches. And when we're kids we probably didn't have that so much but as we get older, no one wakes up out of eight hours of sleep ready to do burpees. You would tear something. It takes a little bit of time for that connective tissue to melt and soften.

    But the healthier we are in general, the less of that that we experience, less of that fuzz gets laid down. But then we know that if we have just some osis or it is, you'd call it, some areas that's like really super stuck, you got a big knot in that. Think if you have a rope, for example, Tommy, and you wanted to get that knot out. You wouldn't just pull it tighter, kind of like traditional stretching. You'd have to somehow work on that knot.

    That's where like foam rolling. Each of us probably have some areas where we just by life or our anatomy we get stuck. I have a little foam rolling routine I do every morning and that treated a little bit mean. I do have time I have to sit to commute with patients. So, every morning, I'll foam roll my quads a little bit, foam roll my hip flexors, just get those knots out. A lot of people the Gastroc soleus complex are just so knotted up there. They need to get in there with Mr. foam roller, the little spiky toys, all this stuff you see at the running store now.

    But if you're uber well, you don't really need any of that stuff, I don't think, but most of us are not in that space. So the older you get, I think you need to do some maintenance work on the fascia. And if you have an area that's really -- The hip flexors, I think, in most people, super gummed up, upper back, like upper traps, because we all text and type, and those areas, you need to get a spiky ball and go up against the wall and just go in there. Your body tells you like, "Oh, that's a good pain. You're getting this crap out of there." But apply individuality to that. Everyone needs their own little routine for their spots.


Tommy:    You mentioned the calf couple of times, the Gastroc soleus complex. For those who haven't had training in anatomy, they basically mean that the back of the calf or the muscles of the calf. You also mentioned those in relation to squats. If people have poor range of motion in the squat, is that where you recommend they spend some of the time fixing?

Mark:    Definitely. So, if you just assess him to do a basic squat and you get kind of stuck about half way, could be the hips, but most people it's somewhere in the ankle. Then you have to assess whether it's bone, if they have ankle arthritis, or if it's soft tissue. You can do a couple of manual things there. But if they can't get down into a deep squat, in most people, it's Gastroc soleus, calf mechanism, Achilles tendon.

    If you've been in heels, any heel, not even high heels, say you're a male out there and you have a dress shoe on for the last 20 years which has about an inch heel, your foot's been on about a ten to 12% grade walking, standing. All of that stuff shortens. It's going to take quite a bit of time. I recommend people hang out at least three to five minutes, a couple of times a day in a deep squat. If you can't get all the way down that's where you reduce like a block or a book, elevate the heel a little bit, but gradually lower that down.

    You can do some foam rolling to loosen that stuff a little bit too. You can do some ankle and a drop, some heel drops, kind of like in the Achilles tendon type of program. You would just do an eccentric drop and come back up. That works on your foot strength. But things that will get in there, a lot of people just have the soleus dysfunction where things have just been so locked up so long that they may even need some manual therapy.

    With anyone who's got chronic swelling, they call it the second heart, the soleus muscle is the second heart. So if you have a chronic swelling in your ankle at the end of the day when you're either sitting or standing, that means you probably got some soleus dysfunction because that second heart, if you walk, meaning flex and extend your ankle, that should be working as a pump as the second heart, allowing all that venous return, that lymphatic return.

    Most of you all listening to this have probably been on at least a six-hour flight where your legs are down and you come out of the flight and your ankle is swollen whereas if that were six hours in your bed where your feet are horizontal, you don't have that swelling. It's because you're not activating that soleus muscle for those six hours. We see that a lot in the elderly that just sits all day. They plop them out of bed and they sit all day. And, unfortunately, we just give them lasix. We call that lasix deficiency.


    When they need to pump -- you see it in the geriatric wards of the hospital. We need to put stockings on those people and have someone pump their feet multiple times a day but that takes effort. We tend to just give them meds which have their own toxicity.

Tommy:    So, there are a couple of scenarios that, I guess, you mentioned. If you try to get people back to running, so people come to you and they've been told that they should stop running and you have various ways to get them back on the field as it were, the first one, I think, is fairly common, which is plantar fasciitis, fasciosis, as you mentioned. You have some tips and tricks in the book and many of them are things that I would recommend to people. Maybe you can talk about how you'd approach that, how you start to loosen things up, you get rid of some of the inflammation in there and then prevent that plantar fasciitis recurring.

Mark:    Yes, I think you have to get, to prevent the plantar fascia, I put a link to an ebook we did on plantar fasciitis with myself and Ray McClanahan who is podiatrist, and Emily Splichal, also a podiatrist, who's been a big advocate of barefoot movement and barefoot therapy. The first thing is identify the culprit. Look at someone's foot. The plantar fascia, there's no muscle. It's not contractile tissue. If the intrinsic muscles, meaning, these four layers of muscles in our arch, in our foot, are just completely weakened, atrophied, that plantar fascia is going to have to take the load.

    You kind of want to lumberjack him so to speak. So, these big thick muscles. But that's going to take time. If they have intrinsic muscle weakness get them to just start walking in their own home barefoot while they're making dinner or going to the living room, doing the laundry. Just get them to start walking around barefoot. Don't be afraid to do that.

    Because I think what people are told sometimes, not often -- It's nice, I'm seeing the movement in podiatry now which is going back to -- I just got back from a conference in San Francisco. Almost every speaker in there was talking about foot strength and fancy ways to measure this with MRIs and muscle girth and minimal shoe showing that, yeah, if you walk around in a minimal shoe your foot strength will improve.

    That shouldn't be like a bizarre weird concept. That should be pretty obvious. You're exercising those muscles. Identify the weaknesses. Quite often, people have, it's called hallux valgus but it's pretty easy for your audience to visualize. Does your foot look like a foot or does your foot look like a shoe? If your foot looks like a shoe, meaning, it's pointed, that's not how you came out of mama. You see that picture when you came out of mama, the toes are really wide?


    The toes should be wider than the ball of the foot. That's how the foot is designed. And if we take that big toe and you bend it in, squeeze it into a shoe that's designed to look stylish, you've kind of altered that support of the foot. Because if you think of the foot as an arch, arches are supported on the ends, not in the middle. Think of any bridge out there that's an arch bridge. Think that nice bridge that cuts where they do the crew. Is that an old stone arch bridge? I'm trying to remember that bridge.

Tommy:    I think so. Are you talking about the one in Seattle? I think it's a metal bridge over there.

Mark:    It's metal but all these old stone bridges. You'd go over to Europe. There's nothing supporting underneath. They're supported on the ends. But if one of those ends is gone, your big toe bent in, the foot will collapse in. You can imagine that if you have like a three-legged stool and you cut one of the legs super short, it would just tip. And when that foot collapses in, the plantar fascia is just constantly just getting jacked. It's just getting stressed.

    So, getting the big toe back out aligned, there's a product called Correct Toes, which I still wear to run because I had operation for this condition. That got me to understand how important the big toe was. It spaces. It's almost like a pedicure thing where you'd have space put up between your toes and spaces are not really wide but they fit in your shoe. It puts that big toe back in the right position.

    People feel that immediately. If you put those on people's feet, just have them balance for 15 seconds with and without that, right away they see how important that big toe being in the right position is. I think that's the start. Look at the muscles. Look at the foot. Get the toes wide. And it's okay. This is the one injury, I think, because it's not really an injury per se and it's not a running injury. This is a lifestyle issue.

    Plantar fasciosis is most prevalent, Tommy, in the obese and the inactive. It's just the runners go to the running store because they want to run. But like you go to a podiatrist office and they aren't all distance runners. It's like normal people that their feet are just horribly weak. You start there. Get them walking. It's like everything. Go back to the root cause of why they have the problem. And it's okay to have a little discomfort with this because what you're doing is you're doing that foam rolling of the fascia all day.

    If they have a big knot in that plantar fascia, sure, they can roll that. But just by walking it gently pulls that fascia out to length again. At nighttime, so this is where they all really just hate life, is that first step in the morning, you just tell them before you get out of bed, say you're going to take a pee in the middle of the night, hang your legs over the side of the bed and do 20 foot pumps. Just do 20 foot pumps before you take that first step.

    And then when they take that first step, it's not like, "They're good." Tell them to trust it. Give it a month. And we also have an insole which is called Barefoot Science which teases the ball of the foot and the arch a little bit to wake up these muscles. It doesn't support the arch. It teases the muscles. It's a little pod that goes in there and activates. You're just reminded to turn those muscles on.

    I think there's a little bit of magic in this stuff. If you just do these simple things they get the foot behaving. This is like metabolism. Ultimately, get rid of junk food, start eating real food. Get your sleep. And then one day you start to feel good and you're like, "Wow, I feel good." The further down the road you are the longer that process is going to take.

Tommy:    So then related to that is something which is very common again in people, I guess, people who are obese and people who are long term endurance runners, is problems with knee osteoarthritis and pain. I'm thinking of a colleague I met with this week who has a previous ACL tear so has had quite a serious injury to the knee, the knee is quite painful and they're unable to run currently. However, I believe that you might sort of think about ways that they could start running again. So, do you have any thoughts on how they would build that back up?

Mark:    Yeah. There's plenty of people running with severe levels of arthritis because the x-ray and the MRI findings and pain don't correlate. Sometimes, I mean, gosh, what is the pain? And is the pain just the brain inhibiting the movement, afraid to move because they're experiencing this pain and it's wired in? One of the fascinating things is back in the early days of this minimal was the work of Casey Kerrigan who used to be the chair at UVA of rehab and PM&R, they call it physical med and rehab, but she developed the first gait lab there about 20 years ago when she was studying the effects.

    And her and Jay Dicharry, who is another colleague, he's out in Bend, Oregon now, works with runners from all over the globe. He's probably the premier running physical therapist gait analysis. Because I have all the fancy tools. These are $2 million gait labs. But what they found was when you elevated up the heel of a shoe, they call it joint torque forces which are these rotational forces which at a certain level, enough of these adverse forces over years are likely, you can't study people for 60 years however long, even these days people are getting OA in their 40s and 50s, how many of these movements in a non-optimal position is going to ultimately start to cause degeneration?


    But they notice from the heel especially and putting arches in people that these joint torque forces increased compared to just being barefoot. This is just not in people who are trained or untrained barefoot runners. These are just taken general population and looking at what happens to the joints. To me, that's important because people say maybe 15 and they say, "Well, I like this big heeled shoe because I feel good in that," and that all maybe well and good but if that person actually wants to run up into their 50s, 60s, 70s and 80s and they're loading that knee and hip incorrectly, they could be walking into my office in 40 years and say, "Doc, my knee hurts. My hip hurts." That's DJD.

    At that point, advanced DJD is tougher to treat than preventing it early on. Dan Lieberman published an article a few months ago showing OA, modern OA compared to I think it was maybe two or three generations ago and trying to control everything else like the weight, the activity levels. Is there something in the modern environment that's contributing to this more?

    Yeah, he had a few hypotheses. One was the footwear because everything else looks pretty equal. Why are people getting more knee and hip arthritis? Maybe it's some of the dietary things too. I wrote a chapter on pediatric footwear two years ago just trying to state the case that keep kids barefoot as much as possible and the minimal shoes. I didn't think they were going to publish it. It was for a major podiatric sports med text.

    It's going against the whole footwear thing but they accepted it which is nice. It's like, wow, this is cool. They listened and it was interesting enough that they put it in there as their pediatric textbook. I have that linked on our book webpage that you can just download that textbook chapter. People can run also, Tommy. So people have been told that they can't run with knee replacements and that's not true either.

    Dick Beardsley, some of you all who are runners probably have heard that name. He challenged Salazar in '82 Boston. That was the Duel in the Sun. Lost by, I think, three seconds or something like that, just took him down to the wire, had a couple of farm accidents and ended up with two knee replacements. He ran like a 240 mid with two knee replacements.

    Roger Robinson, I saw him at the Marine Corps marathon last weekend, has two knee replacements. He's running. If you're running correctly, actually, that loading, that little bit of a trap run, that impact actually helps. All impact isn't bad. I think sometimes runners have been told that all impact is bad. But impact helps our bone remodeling. So, jumping is a powerful stimulus to bone remodeling in the right direction.

    We shouldn't be telling our people who have knee replacements and hip replacements absolutely not to run or jump again. if they are 350 pounds, that might not be a good idea but, like your friend, if they had ACL, they had a traumatic injury and they somehow got bad DJD, need knee replacement, have good movement mechanics, good metabolism, heck, yeah, those people can run especially if they want to run. It's going to make them happy.

Tommy:    Yeah. And this is going to be a case of slowly building back up through all the drills and retraining yourself, the form and function of running as you go through in the book?

Mark:    Yeah. And they might need to reset their goals. If it's someone who has a 230 marathon or they were highly competitive and they had busted their knees skiing and ended up needing an operation, maybe they did need a replacement ten years later. Most people actually, they just want to run. They could care -- people that are lifelong runners -- If I never showed up at another race, I'd be totally fine. I just like going out for my dog. The races are just fun to go to every now and then. But if I have three months and there's no races on schedule, that's actually like a beautiful time, like every day. There's no real goal. Just go out there and smell the air.

Tommy:    Yes. That actually brings me onto an important point that you mentioned at the back of the book. You give a marathon training program but you also say that you recommend running no more than one or two marathons a year and a total of one is perfectly fine for a lifetime. Again, somebody I was speaking to earlier this week runs a marathon a month and it often becomes the race is the goal. But actually you talk about the importance of why that's not the case and the process and all that is much more important. Can you expand on that?

Mark:    Yes. I think for people that race, people like -- I mean, gosh. They like. We're humans. It was Meb. I heard Meb Keflezighi, silver medalist, New York City marathon, Boston marathon winner, American, and he was given a talk at one of the races I was at. He said, "Everyone should do one marathon. The rest is optional." I'd give that to Meb and I put him in the book. Meaning, if people, whether it's a marathon, a half-marathon, even a 5k, if you set a goal and you achieve that goal and it was something that you didn't think you could do or people questioned you or maybe you questioned it yourself and you did that, it empowers you in so many other ways in your life.


    That's why I think now you're seeing this big flux of ultra marathons which I think is awesome. It's like a great community. Okay, I've done 50 marathons. These people have done marathons in every state. There's a whole club of people like that. And at certain points, you're like, "Okay, I need something new to keep it interesting. Maybe I'm going to go do an ultra 50 mile or a trail race, a 50k." Not that they're going to do that every weekend but just to set a goal and do it.


    I've done some of these crazy ultra marathons but they take something out of you that's way different than a marathon. It'd be foolish. I did the comrades this June which is in South Africa. It's a 56-mile race. I don't know how many thousands of feet of elevation gain and descent. But after that, my next race was four months later because it just takes something out of you. I went back to nice light training a week after that but to go put myself out in another race wouldn't have been smart.

    People do over race. I think if you look at the cardiovascular benefits versus complications, we all know that running, any physical activity, is massively good for the cardiovascular system. But everything is a U-curve or J-curve as I described them in the literature. Do nothing, die. There's a sweet spot and do too much, die. Going out and pounding yourself every day in high heart rate zones for an hour every day, racing hard every weekend, I don't think the human body was designed to do that. I don't know if you would agree or disagree.

     We got here ancestrally. Maybe you'd have some tribal games every now and then but there wasn't ten-mile race every weekend out in the aboriginal Australia with the indigenous societies living traditionally. They had to move from place to place. They probably did that as easily and efficiently as possible for the weather conditions, not as hard as possible.

Tommy:    Yeah, absolutely.

Mark:    Do you have any thoughts about -- From your side, you've worked with so many athletes. Where does that sweet spot end in objective measurements? People want all the objective measurements like a lab. I think your brain is the objective measurement.

Tommy:    That's a great question. Although I think many of the people that we end up speaking to, the brain is the objective measurement, at least at that moment in time is no longer valid because you've put yourself in a position where you think you need to do more than you actually need to do or the way that you feel. You think that's normal but actually you could feel so much better but you've sort of like normalized either some degree of injury or illness or over training and it takes some time to bring that back.

    Chris and I did a podcast with Simon Marshall about this. There's sort of the balance between performance longevity. What's the dose that best gives you a health benefits as well as performance benefits? It's right in line with what you're saying is probably more of a polarized approach, low intensity volume, lots of walking, and then 45 minutes a day of moderate to vigorous physical activity which can be more brisk walking or jogging or, obviously, some weight training and all that kind of stuff, is something that we really focus on as well. Balance of that.

    But, yeah, going out and crushing yourself for an hour in that gray zone, we call it, around lactate threshold, that's the way a lot of people traditionally train for endurance sports but that's where you get the least performance benefit and it's also the largest stress on the body.

Mark:    Yeah. I think not just short term stress, long term stress. I can't imagine. I'm 52 now and the thought of doing that to myself every week, I'd shut that off almost 20 years ago and it changed my life when I finally started to understand. You probably got -- How much exercise physiology did you get in London in med school?

Tommy:    Again, very little.

Mark:    Yeah. I had zero. We're probably pretty equal there. You have to go -- And I think everyone out there listening too, you have to go make mistakes yourself and feel it, feel what it's like to be in the hole, to be hurt. And then you have this awareness. Because if you haven't gone there yet, I think you read all this stuff but you don't even know what that feels like because you haven't really been there.

    If you're there and you're aware of it and you're smart enough to know that, okay, put the type A on the shelf, I'll listen to you, I'm sure you give a lot of that, a lot of your advice is hard for people to take. It's like, look, you got to shut it down. Bernard Lagat's going to run the New York marathon on Sunday. I think he's 43 now, Tommy, Bernard Lagat. He could win the damn thing. He shuts it down. He takes one month completely off, no running.

    He's been running at a world class level since he was 18. Here he is, 43, and he is one of the best marathoners, distance runners in the country right now. I'm cheering for Bernard. He's such a humble guy too. He's like the most gracious person. I think that has a lot to do with it too. You just listen to him speak. Eliud Kipchoge just ran a 2:01. He's like Yoda. When he says something, it just epiphanal and they follow him because he understands how to treat his body.


Tommy:    Yeah, absolutely. Recently or, I guess, this is a few months ago now, I watched the Sub 2, the Nike Sub 2 product and some of--

Mark:    Yeah. That was Kipchoge.

Tommy:    Yeah, and seeing him, Kipchoge, in action, this guy is a millionaire but he still is just living and training out of very humble surrounding with friends. There's a lot of community and being outdoors and all that kind of stuff. That's still the way he approaches training. Maybe he will eventually get under that two-hour mark even in a competitive setting. He got pretty close.

    This is, I guess, part of your success as well. You mentioned that you've pulled back some of that longer high intensity training that maybe you would have traditionally or previously done but you're still performing at an incredibly high level. I believe you're still on track to create a record of successive yearly sub three-hour marathons. Can you talk a bit about that?

Mark:    Yeah. I have 30 years under three and then this year, without beating myself up, show up to the same races of Boston was horrible conditions. If any of you all follow marathoning, it was pouring rain, 30 degrees, head winds and everyone was way off their time. I ran a 3:04 there and I just ran Marine Corps marathon this weekend and I ran a 3:02.

    I put myself on pace for about 22 miles but it's been a super busy year. So, following the advice of my book, because I honestly don't think -- I think to have set myself up to run that time this fall, I directed a race three weeks ago, it would have been unhealthy to really put that training into my body. I was lined up and I would just let it go. I ran a 3:02.

    It was a decent day. You don't have no excuses. I did the right plan. I was spot on 650 mile, like clockwork until 22 miles. And then anyone who has joined a marathon, that's when the spring is just kind of like dense, some wind kicked in, and I gave it my all. So, I'm going to let it go at 30 years unless I get some--

Tommy:    That's still a pretty good run.

Mark:    Some epiphany. Like the week before New Year's that I want to go find a marathon but right now I'm content. As soon as trying to keep some streak, it's not fitting with -- It wasn't an intent to do that every year. I would show up kind of like the book described. Just show up at a race and you run. It wasn't like there was some time goal. I had enough margin to be able to sneak in under that time.

    As you get older, I'd probably run 50 miles a week at the most, just with busyness of things. That's pretty hard to run those times consistently on that kind of training but I'm uber healthy which is fine. I wouldn't be a healthier person doing a 2:59 than a 3:02. It's all the same when it comes down to that. I wasn't even disappointed. It's actually kind of nice that I'm off the hook for that. Maybe I'll go run Boston next year completely barefoot. I want to start just running these things barefoot.

    Because you do go slower barefoot. But if you're shooting for a time you can go a little more reckless and the shoes or even sandals. Maybe if the weather is nice, because people don't think you can do that, but that's actually really fun to go run these races barefoot.

Tommy:    That's actually, even though maybe your streak has ended, I think your approach to that kind of summarizes everything that I think is important about this topic in terms of that it's more important to be healthy, it's more important to do things that are in line with how you are at that time rather than always trying to push the envelope. I think that's a really nice way to summarize, again, a lot of the messages that come across in the book. Maybe we can wrap up there. Tell people a little bit about where they can find more information on you, on the book, or all the great work that you're doing.

Mark:    The book, I just encourage people to go out and buy the book. It's on Amazon or you can get it at my store. If you purchase shoes through my store, we'll throw the book in for free. The place where you would do that, you can go with my book's website,, and we have a lot of resources there, links to videos that we talk about in the book. It's like a resource page for the book, some articles, some media running about the book, and then links to where you can buy the book. If you just go to that page, that will set you off on where to go.

    It's not about running per se. if you're a walker, if you're an obstacle racer, you're just someone who wants to dig into a little bit of the simple science of healthy aging and like to get out and run every now and then or interested in some of that geeky running mechanic stuff, that stuff's probably like 10% of the book, is that part. I think there's something in it for everybody. I feel good about how it turned out and I thank you and others for sharing it and talking about it.

    I've learned so much from you, Tommy, listening to all the amazing guests on your show. I think the world of podcast really -- When I started writing this book there weren't podcasts and it was a lot more difficult just to almost confirm that -- It was always awesome to listen to one of your guests just completely confirm what I was thinking and they were way smarter than I am. And then it's like, okay, I'm done. I don't need to find out more whether that's true or not. Some preeminent PhD neuroscientist just laid it out.


    So, I'm good there. I can describe it in a few bullet points and not go into all the metabolic pathways. Yes, that world. Your world has really helped me out.

Tommy:    That's one of the great things about getting you back on the podcast is that you then confirm all things that I believe and recommend to people so we can keep that cycle going.

Mark:    Yeah, I can be your 50-plus-year-old guinea pig. I've had all the cardiac scans and I've been involved in a couple clinical trials on aging and running for all these hypotheses that too much running is going to kill you. Yeah, you try to match people and, knock on wood, because I don't run hard, all my markers are good. I hope to keep that going.

Tommy:    Yeah. And we will hope that that continues. Thanks as ever for your time, Mark. Hopefully, you and I will hang out in--

Mark:    I hope to see you.

Tommy:    In person soon.

Mark:    At the Physicians for Ancestral Health in Scottsdale. Link to that from the show. If you're a physician, some like-minded people will be in Scottsdale this winter.

Tommy:    Yes, the last weekend of January. If you're a physician or you know any physicians or if you want to come and hang out with some ancestral physicians, you don't have to be a physician to come to the winter retreat. We're here, myself and Mark and a load of other ancestrally tune doctors talking about topics close to our hearts. Hopefully we'll see you all there. Mark, thanks again for your time.

Mark:    Thank you, Tommy. Have a great day.

Tommy:    You too.

[0:52:00]    End of Audio

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