How to Stay Fit for Life

Analysis by Dr. Joseph Mercola

Story at-a-glance

• It is rarely too late to start resistance training; you can build muscle mass well after age 60. In 2022, I set a new personal record in the leg press for 600 pounds, far better than the 400-pound deadlift I did the year before
• Sarcopenia — age-related muscle loss — threatens a healthy lifespan. Skeletal muscle not only manages physical activity, but also plays a major role in metabolism, circulation and cognition
• Skeletal muscle acts as endocrine organ secreting myokines and transcription factors into the bloodstream, thereby regulating the function of other organs. It also has immune regulatory properties
• The loss of muscle mass is thought to be a primary driver of insulin resistance in older adults. Declining muscle strength and reduced physical activity also contribute to metabolic dysfunction
• In order to gain muscle mass though one needs a critical to eat enough protein. A minimum is about 1.2 grams per kilogram of body weight (0.54 grams/pound) per day. Athletes and the elderly could probably benefit from going up from that level to about 1.6 grams/kilogram (0.71 grams/pound)

This may be one of the most important articles I’ve ever written with respect to helping you understand how important resistance exercise is to not only slowing down the aging process but improving your overall metabolic health. We know this is important because studies have shown that over 75% of those over 65 do not exercise enough to stay healthy.

But, the key is to understand the type of exercise that will give you the greatest benefit for the time invested. If we had to engage in hard physical labor for our work we wouldn’t need to exercise. Formal exercise is only needed because most of us have long ago stopped engaging in manual labor. Modern society has allowed us to obtain food and shelter with relatively little effort. So, we need exercise to compensate for this if we hope to optimize our physical health.

I want to share my experience with you so you don’t make the same mistakes I did 50 year ago. To me the evidence is crystal clear: As you age you need to engage in some type of resistance training to compensate for the degeneration that typically accompanies aging and decreased physical activity. You can do cardio if you have the time, but not at the expense of building lean muscle mass. This is largely because aging accelerates muscle loss.

Understanding the Hazards of Sarcopenia

The medical term for age-related muscle loss is sarcopenia.¹ Sarcopenia is derived from two Greek words: sarx (flesh) and penia (poverty).² So, as you get older you will invariably start losing muscle mass, and if you don’t engage in resistance exercises, you will likely suffer metabolic diseases as well.

An estimated 25% of 60-year-olds have sarcopenia, and nearly two-thirds of those 80 years and older have lost serious amounts of muscle mass, which threatens a healthy lifespan and cuts down on your independence and quality of life.^3,4 Sarcopenia leads to many functional limitations, including difficulties in walking, climbing stairs and carrying objects.⁵ The penalties of this functional decline include falls, disability, institutionalization⁶ and even death.⁷

One of the reasons I’m committed to lifelong exercise is because both of my parents died from frailty, and I’m determined to avoid sarcopenia, which took them prematurely. This was a powerful motivation for me to deeply study frailty so I could avoid their fate.

With society aging worldwide, the prevalence of sarcopenia increases the urgent need to establish prevention and intervention strategies. The U.S. Centers for Disease Control and Prevention now recognizes sarcopenia as an independently reportable medical condition.⁸

Skeletal muscles not only function to generate force and movement, but also play a major role in your metabolism, circulation and cognition, as seen in the following figure. Skeletal muscles also serve an important endocrine function. They secrete special cytokines (i.e., myokines) and transcription factors into the bloodstream, thereby regulating the function of other organs. It’s a metabolically active tissue with an important role in the maintenance of metabolic homeostasis.

Sarcopenia Is a Major Driver of Insulin Resistance and Disease

Skeletal muscle is the most abundant tissue in your body, comprising 40%⁹ to 55%¹⁰ of your body mass, and is the primary sink of insulin-mediated glucose disposal. Muscle is also the major site for insulin-stimulated glucose uptake, as well as the main energy consumer of fat.¹¹ After meals, about 80% of glucose is deposited in your skeletal muscle.^12,13

The loss of muscle mass with advancing age is thought to be a primary driver of insulin resistance in older adults.¹⁴ Again, this is because muscle is the major tissue where insulin causes glucose to be absorbed.

But it doesn’t end there. Remember, muscle makes up nearly half of your body’s tissues, so once your body runs out of sugar in the form of glycogen, it uses fat, especially if you are metabolically flexible. So, muscle is also the main energy user of fat in your body.¹⁵ The declining muscle strength and progressive mobility impairment with age also tends to reduce daily physical activity, which also contributes to metabolic dysfunction.^16,17

The loss of resilience as a result of sarcopenia is underappreciated as a major factor in the ability to recover from life’s inevitable challenges. It is clear that elderly with low muscle mass experience delayed recovery,^18,19 and have higher rates of complications and infections following surgery,²⁰ greater drug toxicity²¹ and higher disease-specific and all-cause mortality.²²

Sarcopenia also predicts both the risk for community-acquired pneumonia in the elderly,²³ as well as 90-day mortality in patients suffering from aspiration pneumonia.²⁴

Muscle Play a Role in Your Immune Function Too

Muscle is increasingly recognized as an organ with immune regulatory properties. As such, skeletal muscle cells modulate immune function by signaling through different soluble factors, cell surface molecules or cell-to-cell interactions.²⁵ It is also speculated that sarcopenia contributes to immunosenescence — the gradual deterioration of your immune system — which is a leading cause of death in the elderly.²⁶

Additionally, recent reviews found strong evidence that frailty due to sarcopenia²⁷ is a risk factor for adverse outcomes, such as longer hospital stay, functional decline at discharge and both in-hospital and medium, lower quality of life,²⁸ and long-term mortality.²⁹

My Strategy and Recommendation to Combat Sarcopenia

So, what can we do about this progressive decline in muscle loss that sets you up for frailty and metabolic catastrophe? Why, exercise, of course. But here’s a little-known fact: Despite the well-known benefits of resistance training, less than 10% of those under the age of 75 in the United States participate in muscle-strengthening activities.

I believe one of the main reasons for this low rate of participation is that over half of those who do exercise engage in conventional resistance training end up getting injured. Another reason is that conventional strength training is considerably less effective in healthy older adults than in young adults.

This blunted anabolic response to exercise training in older individuals³⁰ is likely a result of the age‐related decline in muscle fiber perfusion.³¹

This has been known for a long time. Seventeenth century physician Dr. Thomas Sydenham, who is known as the “English Hippocrates,” recognized nearly 400 years ago that vascular health and aging are interdependent and inversely related.³² His famous quote is: “A man is as old as his arteries.”

Microcirculation is the term used to describe blood flow through the capillaries. The main function of the microcirculation is the delivery of oxygen and nutrients to tissues while removing CO2, metabolic debris and toxins. Researchers believe this is related to a decrease in muscle fiber microcirculation of Type II muscle fibers and their associated stem cells.

Studies have shown that Type II muscle fiber-associated stem cells are located at a greater distance to their nearest capillary in older compared with younger men.³³ There are a large number of circulating growth factors that are regulators of stem cell function³⁴ and the delivery of these signals to activate your muscle stem cells and promote muscle growth relies on how close they are to the capillaries.

Once your microcirculation becomes compromised with age, Type II muscle fibers and their associated stem cells will be unable to receive enough nutrients and oxygen. Thankfully, there is a solution to this dilemma, and it is called blood flow restriction (BFR) or KAATSU in Japan, which is where it originated.

How I Radically Changed My Exercise and Lean Muscle

Now, I am no stranger to exercise. I have been exercising since 1968, which is 54 years. The problem is that the first 43 years were exclusively cardio, and in my case long distance running. I like to compete, so I got relatively decent and was eventually able to run a 2:50 marathon, which was good enough back then to get me on the post-graduate University of Chicago Track Club.

Unfortunately, I didn’t realize that while cardiovascular exercise can lower your risk of heart disease, it is a highly catabolic activity and will actually lower your ability to build muscle. Below is a picture of me taken during my peak running condition. As you can see by the arrow, I had a “gigantic,” 10.5-inch arm circumference.

Contrast that to the picture below, taken December 8, 2020, where my arm circumference is 15 inches. I had just finished doing a PR video for the deadlift at 370 pounds. The video (below) was posted to Instagram on the same date.

The blue plates are 45 pounds each; the black ones are the same width as the blue ones, but are plastic and are 25 pounds; and the bar is 50 pounds. My team wanted me to do a story on how I did this to, hopefully, inspire you to similar, if not better, levels of strength.

I’m very proud to say that I’ve come even further since then and, now, even approaching 70, I’ve been able to regularly set personal records with some of the lifts that I’m doing, and have deadlifted four plates, which is 405 pounds.

Watch Me Leg Press 600 Pounds

Without doubt, building muscle is one of the most important strategies to improve and safeguard your health, especially as you age. You need protein reserves to survive serious disease, and most of your protein is stored in muscle. If you have very little muscle, you’re going to pass away prematurely because you have no amino acid reserves.

As mentioned, your muscle is also a primary regulator of your metabolism. It’s a primary site for glucose disposal because of the GLUT4 insulin receptors embedded in the muscle cell membranes. These receptors lower your glucose levels after a meal and decrease your risk for diabetes. It also interfaces with your immune system and helps optimize it.

If you take away one tip from this article, let it be this — it is rarely too late to start resistance training. You can build muscle mass after 60, which is about when I started and, earlier in 2022, as you can see in the video above, I set a new personal record in the leg press for 600 pounds, a significant improvement over the 400-pound deadlift I did in 2021.

How did I do it? That’s the focus of this article, and the great news is that virtually anyone can use this strategy, even if you’re older, like me, or already a bit frail, or have previously experienced exercise injuries.

The BEST Strategy I Know of to Increase Muscle Size

There are loads of ways to increase your muscle mass but they mostly involve moving, pushing or pulling heavy weights or resistance bands. The problem with this strategy is that if you are not in good shape, and especially if you are elderly, there is a very high likelihood that you will get injured. In most cases, it is not if you will get injured but when.

The answer to this problem is an exercise strategy known as BFR or KAATSU. As the name implies, BFR involves modifying the arterial inflow and venous outflow while you’re working the muscle by placing an inflatable band around the extremity.³⁵ It is not like a tourniquet that stops all your blood flow, which is dangerous.

BFR was developed by Dr. Yoshiaki Sato of Japan about 50 years ago. In Japan, where it’s widely popular, it’s known as KAATSU, meaning “training with added pressure.”³⁶ However since Sato does not speak or write English, the first article published about it in the U.S. was about 25 years ago.³⁷

Conventional resistance training typically uses resistance at 70% to 85% of your one-rep max, i.e., the maximum amount of weight you can lift only one time. Since this weight is relatively heavy and close to your limit, injuries are almost guaranteed.

BFR is different, as it is a low-intensity resistance training, using weights that are just 20% to 35% of your one-rep max. With weights this light, your risk of injury is largely eliminated. In many elderly and frail individuals, weights of just 1 or 2 pounds, or no weight other than your body, are all that is needed to achieve the benefits.

How BFR Works

BFR’s ability to achieve such remarkable physiological benefits is directly related to slowing venous blood flow from the muscle group being engaged and creating a relatively hypoxic environment or low oxygen pressures in the exercising muscle.

Venous flow moderation is optimally achieved by wrapping the extremity being exercised with an inflatable cuff or band.

The band needs to be tight enough to slow venous return to the heart, allowing venous blood to “pool” in the region of the limb that is being exercised, while loose enough to allow arterial blood to flow through.

With very light exercise, and in about 15 to 20 minutes, you get an exhaustive workout that sends a signal to your brain that says, “Hey, I’ve done something really hard here — you better help me recover and adapt to it.”

Your brain then sends out hormonal responses that cause your muscles and blood vessels to grow. Most would think that such light weights would be insufficient to provide any muscle strength improvements, but studies show a 36% to 40% increase in muscle strength after only 12 weeks, depending on your load and health.³⁸

BFR Mimics Heavy Weight Training Without Any of the Risks

BFR training is frequently misunderstood as simply a conventional resistance training program with the addition of resistance bands. Nothing could be further from the truth.

Because the exercise is done with such low weights, there’s far less muscle fiber trauma and damage, especially relative to conventional strength training. This means you are able to recover much quicker, so you don’t have to dig yourself out of a hole the next few days. In most cases, you can exercise different body parts nearly every day and rapidly attain the metabolic and physical benefits.

To understand the mechanism of BFR you need to know that you have two basic types of muscle fibers. First you have slow-twitch oxidative (Type I) fibers designed for low-intensity long-lasting contractions. Secondly, you have fast-twitch glycolytic (Type II) fibers designed for high-intensity short-duration contractions. When you lose muscle, it typically occurs as a reduction in Type II muscle fibers.

If you are going to increase muscle mass and strength in anyone, but especially the elderly, it is important to activate Type II muscle fibers during training, since these fibers have been shown to be far more responsive to growing muscle than Type I fibers³⁹ and are generally much larger.

Weight training done at low weights will not activate Type II fibers — unless it’s done with BFR. Type I fibers are relatively more sensitive than type II fibers to hypoxia (low blood oxygen), as they have a greater oxygen consumption at rest compared to Type II fibers.⁴⁰ BFR training takes advantage of this difference. Producing a relatively hypoxic environment in your muscles⁴¹ causes premature fatigue of the Type l fibers, thus forcing your body to rely on Type II fibers to continue the exercise.

At the same time, you’re also activating their associated muscle stem cells. This is likely one of the main mechanisms by which BFR can trigger muscle growth and prevent or prevent or treat sarcopenia. Simply moving light weights with high repetition without BFR will not engage Type II fibers because there is plenty of oxygen for the Type I fibers to work. Hence, the fast-twitch Type II fibers just aren’t called into action.

How BFR Affects Your Muscles and Overall Health

When you exercise and activate your Type 2 fibers with BFR, your muscles will generate a waste product called lactic acid or lactate, which is responsible for much of the metabolic magic. Activating Type 2 fibers also lowers the pH of the muscles. This is not because of lactic acid, but more related to the release of extra protons released in generating energy.⁴²

Both lactate and proton accumulation are potent stimulators of growth hormone and insulin-like growth factor (IGF-1), which in turn leads to muscle growth.⁴³ IGF-1 is a hormone that helps manage growth hormone (GH) in the body. It’s typically made by your liver, which is the largest contributor to IGF-1 circulating in your blood. However, when your liver secretes IGF-1, it will not act on those tissues that have capabilities of producing the hormone themselves, such as skeletal muscle.⁴⁴

Interestingly, it is not the circulating levels of IGF-1 in your blood that cause your muscles to grow but, rather, the IGF-1 produced by your muscles when engaged in exercises like BFR, as that’s the key determinant for switching on the anabolic muscle building pathways.

While high levels of IGF-1 in your blood will inhibit autophagy and decrease your longevity,⁴⁵ this does not appear to be the case when you increase IGF-1 in your muscle using anaerobic exercises like BFR. This IGF-1 does not leak out into your blood to suppress autophagy.⁴⁶

BFR will not only will add solid muscle mass, but also significantly increase your strength and endurance while reducing your body fat. For most people who are not competitive athletes, it’s really the only form of resistance training they need.

Competitive athletes also seem to benefit from BFR, but they would need to combine it with conventional strength training.⁴⁷ In short, BFR works on a very simple principle: It tricks your body into believing that it’s moving far heavier weights than you’re actually using, and as a result generates compensatory metabolic responses, further detailed below.

Local and Systemic Effects of BFR

If you are elderly, what is really amazing is that your muscle growth with BFR is beyond what strength training with heavy weights can do. This is because you need good blood flow to your Type II muscle fiber stem cells, and as mentioned earlier, virtually everyone’s microcirculation decreases with age.

So, even if you send the signal to grow by doing conventional strength training, it won’t work as well if there isn’t enough capillary supply to your Type II fiber stem cells. BFR increases your microcirculation, your capillaries and venules and arterioles that are associated with them (see image below), largely because your muscles are working in a hypoxic (low oxygen) environment.

 

Microcirculation

How BFR Increases Your Microcirculation

This low oxygen tension causes the release of hypoxia-inducible factor-1 alpha (HIF-1 alpha),⁴⁸ which in turn increases the hormone vascular endothelial growth factor (VEGF), which is one of the most powerful angiogenic signals in your body. It’s an extremely potent pro-blood vessel building cytokine or myokine. VEGF will help repair damage that has occurred to your blood vessels, improve elasticity and make them far more resilient to damage and accidents.

BFR has been shown to raise VEGF levels by 410% in young adults.⁴⁹ Essentially it acts as “fertilizer” for growing new blood vessels and capillaries to your muscle stem cells. BFR training has been shown to increase muscle stem cells by 300% after eight days of training.⁵⁰

Here is the KEY point: The VEGF released by BFR is systemic and carried in your blood to your entire body. It just doesn’t work on the limbs you are exercising. It increases blood vessel growth throughout your entire body, which seems to be the perfect antidote for Dr. Syndenham’s theory that a man is old as his arteries.

In short, BFR will help aging men have the arteries of boys. VEGF also increases microcirculation in your brain and heart. In Japan, BFR is frequently used for stroke and cardiac rehab precisely for this purpose.

BFR also increases the production of the important regulatory free radical, nitric oxide (NO), which further contributes to an increase in VEGF.⁵¹ NO is an important signaling molecule produced at high levels in muscle by neuronal nitric oxide synthase (nNOS). BFR, by way of increasing NO, has been found to stimulate muscle satellite stem cells and proliferation.⁵²

There is a load of interest in NAD+, as it’s a primary fuel for longevity proteins, and it becomes depleted as you age. A combination of BFR along with 50 milligrams of niacinamide per day will radically increase NAMPT, which is the rate limiting enzyme for NAD+. Honoring your circadian rhythm is also an important part of the equation.

The Benefits of Osmotic Pressure

Metabolic stress, or the accumulation of metabolites during exercise, has been documented to be important for muscle growth.^53,54,55 One of the most important metabolic stressors produced in BFR training is lactate, which I touched on earlier. The lactate released by the muscles is largely a result of Type II muscle fiber burning glucose into pyruvate and then converting pyruvate to lactate.

When you occlude the veins in BFR, you limit the venous blood flow return back to your heart, which allows the lactate to accumulate to high concentrations in your muscle,⁵⁶ where it creates an osmotic pressure differential that requires the influx of water to normalize.

As you can see by the figure below, osmotic pressure is the pressure that must be applied to a solution to halt the flow of solvent molecules through a semipermeable membrane (osmosis). It is determined by how many molecules are in the solution. The more molecules, the higher the osmotic pressure.

This flow of water into the muscle⁵⁷ contributes to intracellular swelling,⁵⁸ which creates an acute and measurable increase in the size of the muscle that is typically quite visually obvious.

The mechanical pressures created by this cell swelling also trigger the activation of Type II muscle fiber stem cells, which causes muscle growth and further increases muscle protein synthesis and decreases protein breakdown in your muscles.⁵⁹ So, the higher the lactate levels and swelling created with BFR training, the better the muscle-building results will be.

Interestingly, some of the lactate produced locally in your muscles actually diffuses into the bloodstream and crosses the blood brain barrier through monocarboxylate transporters (MCTs), and is utilized as fuel for the brain.^60,61

Similar to ketones, lactate can be an important brain fuel, as at high lactate concentrations, up to 60% of the brain’s energy can come from lactate. Once the lactate reaches your brain — which occurs when you release the bands from your extremities — it increases brain derived neurotropic factor (BDNF),⁶² a member of brain growth factors that contributes to neuroplasticity and enhanced cognitive performance.^63,64

I first learned about BFR in 2017 at a Beverly Hills biohacking event. I’ve been using it nearly every day for at least an hour a day since then and have compiled a number of insights in that time. The main difference between KAATSU and BFR is the tool you’re using. BFR can be done with restriction bands, but KAATSU uses a device that also provides intermittent and not just constant pressure. 

From the start, I was really intrigued with the concept of BFR, so I purchased a KAATSU unit developed by Sato. In cycle mode, the KAATSU device produces 30 seconds of pressure followed by five seconds of no pressure, and does this for eight progressively increasing pressure steps per cycle. What this does is provide intermittent hypoxia, which catalyzes the steps I described above.

Since the intermittent hypoxia does not last more than 30 seconds, it does not damage your body, which can happen when you use the cheaper KAATSU bands or BRF bands that provide constant pressure. When I first started using BFR, I felt it was important enough to encourage people to get inexpensive bands that don’t provide intermittent compression. The BFR bands were only $15 and allowed far more people to access this powerful fitness strategy.

But after using the unit for five years, I have learned that when you use the cheap bands, or even KAATSU in the constant mode, you can get spastic large muscles. Using constant pressure increases the hypoxia time, and hence the lactic acid can build up to excessive levels. The only way to get the benefits without the downside is to avoid the constant mode and cheap bands.

This is why I only use the cycling KAATSU mode, not the constant mode or cheap bands, and why I now only recommend using the KAATSU intermittent hypoxia system, which is far safer and provides greater health benefits. Sato himself admits that the constant mode requires a lot of experience and know-how before it can be used safely. The cycling mode, however, is safe to use for anyone. “Even someone in their 80s can do the KAATSU cycle mode without risks,” he says.

If I had only done strength training without KAATSU, I would likely not have gained anywhere near as much muscle mass. Again, this is largely due to older people having decreased microcirculation to feed the Type 2 muscle stem cells. You need the VEGF to increase blood supply to these cells, and conventional strength training does not do that very well.

Why I Only Recommend KAATSU Cycle Mode

The KAATSU set is ideal as it is far easier to dial in to the correct pressures. You also get the benefit of intermittent pressure automatically, without having to adjust the bands yourself. With the KAATSU system you can control the tightness in two ways.

The initial tightness is after you manually tighten the bands. This is the base pressure and typically around 10 to 25 mm/Hg for the arms and 15 to 35 mm/Hg for the legs, depending on your age, vascular elasticity and physical condition.

The inflation pressure is what you set the compressor to pump the cuff up to. This ranges from 80 to 400 mm/Hg for both the arms and legs. KAATSU is the only unit that will cycle the inflation of the bands on and off, which, again, is far healthier for your muscles. Sato notes (see video above):

“I gradually increase the pressure on each set, personally, doing up to eight sets. The first set has no effect, but my muscles pump up significantly from the sixth to eighth sets. If you do that for two or three circuits, the KAATSU cycle mode will have the same effect as the KAATSU constant mode. Therefore, I recommend the KAATSU cycle mode to the general public.”

How to Determine Your Ideal Level of Resistance

Instead of using heavy weights that can increase your risk of injury during conventional strength training, BFR requires just 20% to 33% of the resistance used in conventional resistance training, which makes it much safer for everyone. This light weight is then combined with a high volume of repetitions while externally applied compression mildly restricts blood flow to the active skeletal muscles in the legs or arms.⁶⁵

As for weight, your goal is to find the “sweet” spot. If you are elderly or have not been exercising regularly, this may mean no weights at all.

Ideally, you would have access to a variety of progressively increasing resistance movements to choose from, including body weight exercises. You typically won’t need to go higher than 25 pounds, though.

Once you have access to the weights, you can find the heaviest weight you can do for just one repetition of your planned exercise. This is your one-rep max (1RM).

Then you divide that weight by five (20%), four (25%) or three (33%). For example, if your max weight for a bicep curl is 25 pounds, you would select a 5-pound dumbbell to start.

If you don’t know your one-rep maximum, then it is always better to start too low, especially if this is your first time, as your tissues will need time to adapt to these pressures and movements. Eventually you will want to increase your weight so you notice the following signs during your KAATSU session.

Unless you are just starting (see warning box below), it is best to start by limiting your weight to only 20% of your 1RM and build up from there. By starting at a lighter weight, it will give your body a chance to adjust to BFR and avoid potential injuries.

An additional benefit is that if you stick with lighter weights you can train more frequently because you won’t cause as much muscle damage. For those interested in greater strength or muscle gains, you can increase to one-quarter and then to one-third the weight of your 1RM. If you are doing the exercises correctly, it will likely take you about three months to progress up to 33% of your 1RM. There is no need to go any higher than this.

If you don’t know your 1RM, then all you have to do is pick a weight you believe you can easily do 30 reps with and start there. If you can easily do all three sets at that weight, then it’s clearly too low a weight and you would benefit from increasing the resistance, especially if you don’t notice an increase of at least one-half inch in the circumference of your biceps after the exercise.

Conversely, if you are unable to complete 20 repetitions on your first set, the resistance is likely too high and needs to be decreased.