Menopause and Andropause :“Making the Rest of Our life the Best of Our life”

by Jeffry S. Life, M.D., Ph. D.

The average American women’s life expectancy currently exceeds 81 years of age so most women can expect to live more than one third of their lives well beyond their childbearing years. Today menopause is no longer the hush-hush topic of our grandmothers’ generation. Both the non-medical and medical communities throughout our country now openly address the implications of menopause. Billions of dollars are spent each year by advertising targeted at the 44 million-plus baby boomer women that are near or in the menopausal category.

Likewise, whether it is referred to as a condition or phenomenon, most men begin to experience changes in their bodies somewhere between the ages of 30 and 55. Formerly attributed to “growing old,” a great deal of data now indicates that, like women, hormone imbalance is the root cause of the male menopause – the andropause.

While menopause comes on rather abruptly, the symptoms of andropause tend to come on slowly and gradually, creeping up over a period of as long as 20 years. Hardly noticeable at first, it eventually cuts to the very core of a man when he realizes that he has lost much of his sexual function and finds it harder and harder to keep himself mentally sharp and focused. If left untreated, the andropause can have as severe long-term consequences as those of menopause.

Whether you are a man or a woman in the –pre-, peri-, or post-menopausal or andropause stages of your life, the following information can help you determine what steps you need to take for your own personal wellbeing.

What is Menopause?
Menopause refers to that time in every woman’s life when menstruation ceases completely. The ovaries’ decrease their output of estrogen and progesterone and women begin experiencing the effects of suboptimal levels of these hormones. In addition to signifying the end of a woman’s ability to have children, declines in these female hormones affect the entire endocrine system. This is a process that takes approximately 3 to 5 years to complete. The early phase or transitional phase is referred to as the climacteric, or peri-menopause. Menopause is considered complete when a woman has had no period for a full year. Although timing varies from woman to woman, menopause is generally completed by the time they reach their early 50’s.

What to Expect at Menopause and Beyond
Every woman is an individual, of course, but there are a number of side effects that can generally be anticipated. Though some side effects may be considered temporary nuisances to be “toughed out,” the reality is that the decline of a woman’s hormonal levels results in changes that can seriously affect her physical and mental health as well as her prospects for longevity.

Hot Flashes
The most common side effect associated with menopause are hot flashes, a sudden sensation of intense heat. Some women break out with red blotches on their chest, back and/or arms, some sweat profusely, some also experience cold and shivering until their bodies readjust. While many women never experience hot flashes, others can endure them for up to 30 minutes at a time. Hot flashes are generally considered to be a direct result of decreasing estrogen levels and they can linger for years.

Vaginal/Urinary Tract Changes
As hormone levels decrease, the walls of the vagina become thinner, dryer, less elastic and more susceptible to infection. This condition can also make intercourse uncomfortable. Tissues in the urinary tract also change with the decrease of hormonal levels and can cause incontinence and an increased susceptibility to urinary tract infections.

Loss of Libido
Rarely discussed, the loss of sex drive is another by-product of the menopausal experience. Women generally have 1/10th to 1/20th of the testosterone levels that men have. The waning of pre-menopausal levels of testosterone can be a contributing factor to a woman’s loss of desire for sexual intercourse.

Emotional Changes
For some women, menopause heralds a period of enormous freedom. For others it is a roller coaster ride with emotional peaks and valleys, and for many, depression becomes an all-too-frequent companion. There is no consensus as to just how much lifestyle, alteration of family roles, changing social networks, and emptying of the nest contribute to the emotional changes of post-menopausal women. It is clear, however, that hormonal decline is a major contributor to this emotional instability.

Osteoporosis
Osteoporosis is definitely not just a woman’s disease. More men get it than prostate disease, according to Miriam Nelson, Ph.D., author of Strong Women, Strong Bones. However, it is more common in women and it is now estimated that one out of every two post-menopausal women will suffer some degree of osteoporosis. Those with a history of osteoporosis and those who are thin and fair skinned seem to be more at risk, but osteoporosis is a manifestation of estrogen insufficiency. It is a gradual, yet debilitating, condition in which bones become fragile, thin and more prone to fracture. Building up bone density prior to menopause is the best strategy for osteoporosis prevention, but once menopause has occurred, the most effective therapy is hormone modulation. The National Institute on Aging has said “Remarkably, estrogen saves more bone tissue than even very large daily doses of calcium.”

Cardiovascular Disease
Heart disease is the number one killer of American women. It is responsible for over half the deaths of women over age 50. After menopause the incidence of cardiovascular disease increases. Smoking and a family history of heart disease give women a higher chance of developing cardiovascular disease (as well as other serious diseases), but when these are coupled with low estrogen levels, the risk is much higher than either one alone. As a direct result of estrogen deficiency, LDL cholesterol increases and HDL decreases. As LDL levels rise, fat tends to accumulate on artery walls eventually clogging them, and the falling levels of protective HDL (high-density lipoproteins) make it impossible to remove these fat deposits. Early recognition, lifestyle changes and hormone modulation have been show to be very effective in reducing the incidence and severity of cardiovascular disease in post-menopausal women.

In addition to diminished levels of estrogen and progesterone, testosterone (also produced in the ovaries) and growth hormone (produced in the brain) are also reduced during menopause. As the levels of all of these key hormones diminish, profound changes begin occurring with growth and metabolism that affect the breasts, vagina, bones, blood vessels, gastrointestinal tract, urinary tract, cardiovascular system, skin, brain, and energy levels.

Hormone Modulation Can Help
Hormone therapy began in the 1940s and has been refined considerably over the past 60 years. While there are still contraindications for some women (e.g., those with history of breast disease and uterine cancer), many physicians feel that the benefits far outweigh the risks. Much of the medical field agrees that hormone therapy:

* Reduces the risk of osteoporosis
* Relieves hot flashes
* Reduces the risk of cardiovascular disease
* Improves mood and psychological well-being
* Results in a firmer body and a more youthful appearance
* Improves mental alertness, focus and concentration
* Increases energy and vitality
* Improves desire for sex
* Increases physical stamina and muscle strength
* Reduces body fat

Each woman, whether pre-, peri or post-menopausal, can be prescribed a tailor-made program, based upon a thorough and comprehensive diagnostic analysis, including family history, personal medical history, lifestyle analysis, blood tests, physical examination and other diagnostic tests. With a program that synergistically combines hormone modulation, optimal nutrition (including nutritional supplements), and regular exercise women simply need not suffer the debilitating physical, emotional and mental consequences of menopause any longer.

How Safe is Hormone Replacement Therapy?

There has been recent controversy about the use of estrogen and progestin in healthy postmenopausal women. This controversy is a result of an article published in the July 17, 2002 issue of the Journal of the American Medical Association that reported on the results of the Woman’s Health Initiative Trial. The results of this trial linked the use of Premarin and progestin to the development of health risks that, in the opinion of the authors, exceeded benefits.

Many authorities believe this study was poorly designed and has many flaws. One of the major concerns is that Premarin and Provera, the drugs used in the study, are not bio-identical forms of human estrogen and progestin. Premarin, in fact, is obtained from horse urine and contains nearly three-dozen horse estrogen compounds, only three of which are found in humans. Another concern is that during the course of the study, all subjects received the same dose of hormones with no consideration given to adjusting dosing based on blood levels. It is reasonable to conclude that many of the subjects had hormone levels that greatly exceeded normal physiologic ranges—ranges we would consider to be unsafe. Finally, we could also argue that there was a sex bias in the study. A similar study of men and testosterone replacement therapy based on the administration of non-bioidentical hormones (obtained from ground-up horse testicles for example) would be quickly dismissed and viewed with great suspicion by the medical community, but the same circumstance was allowed for thousands of women in the WHI study and recommendations are now being made based on that study.

We believe bio-identical estrogen and progestin replacement therapy that is performed in a controlled clinical setting where therapeutic levels are closely monitored and dosing is adjusted accordingly will dramatically improve a woman’s quality of life. While there are still contraindications for some women (e.g., those with history of breast disease and uterine cancer), many physicians now feel that the benefits far outweigh the risks.

Andropause

Symptoms of Male Menopause

Physical Appearance

* Body fat gain, particularly abdominal weight gain
* Loss of lean muscle tissue
* Bone deterioration
* Loss of hair
* Wrinkling and drying of the skin



Bodily Functions

* Fatigue
* Decreased libido
* Possible erectile dysfunction (ED) – reduced potency and/or penile size, decreased ejaculatory force and volume
* Hot flashes, blushing and sweating
* Aches and pains



Mental Functions

* Poor sleep quality or insomnia
* Nervousness, anxiety and irritability
* Memory lapses
* Depression
* Reduced motivation/apathy

Mental and emotional changes resulting from the andropause can cause increased negativity, loss of focus, loss of drive at play and work, and a questioning of one’s values, accomplishments, goals and directions in life. Physical changes can include loss of strength, muscle atrophy, loss of energy, and stiffness and aching of muscles and joints.

While life’s stresses can often exacerbate these physical and emotional changes, stress is no longer universally accepted as the cause of the loss of male vitality and virility. The signs and symptoms of the male menopause need not be accepted as an inevitable consequence of the aging process. A large body of data collected since the first study appeared in the Journal of the American Medical Association (1944; d126 [8]:472-7) indicates a direct connection between the variety of symptoms described and an imbalance of hormones.

Too little? Too Much?
Simply stated, the imbalance is one of too little testosterone and too much estrogen but this is far from a simple matter and it needs to be noted that testosterone is much more than a sex hormone. With receptor cites in the brain and heart, and in fact throughout the entire body, testosterone is critical in maintaining healthy bone density, lean muscle, red blood cell production, and safeguarding the immune system. It is also vital for proper cardiac output and neurological function. There is a body of literature that supports the thesis that testosterone helps control blood sugar, regulates proper cholesterol levels, and control blood pressure.

As men age, the testosterone they produce diminishes and is increasingly converted to estrogen. The most dangerous effect of too much estrogen and too little testosterone is the increased risk of heart attack or stroke. Estrogen (estradiol) is actually made from testosterone in the cells of every male’s body but when there is too much, no matter what the level of testosterone, they will suffer negative consequences. Furthermore, when a male is experiencing high estradiol levels, he is also producing more sex hormone binding globulin (SHBG), a protein that binds to testosterone and prevents it from doing its work. Since typically about 98 percent of the testosterone in the male’s bloodstream is bound to proteins, only approximately 1 to 2.7 percent is free and available for assimilation into the cells of the body. As SHBG increases the amount of testosterone freely available to act on cells diminishes.

There are a number of factors that can cause the testosterone-estrogen imbalance in men. These include excess “aromatase” enzyme (the enzyme that converts testosterone into estradiol), impaired liver function (often caused by excessive alcohol or certain drug interactions), obesity (which increase aromatase enzyme), and zinc deficiency (zinc is a natural aromatase enzyme inhibitor). To complicate matters even more, there is a wide range of “normality” in the testosterone/estradiol reference range that requires expert interpretation.

In addition to declining levels of testosterone, growth hormone and DHEA levels are also falling during andropause. As these levels decline, profound changes begin to occur with growth and metabolism that affect men both physically and mentally.

Available Help
The good news is that male hormone imbalance is correctable, and a youthful hormone balance can be safely restored. An evaluation to determine free and total testosterone levels, estradiol (estrogen), DHEA, dihydrotestosterone (DHT), growth hormone levels, along with a PSA blood test are required to establish deficiencies and imbalances. If therapies are indicated, a personalized Andropause Program can be developed.

Conclusion
Hormonal health plays a large part in determining one’s overall well-being. Today both menopause and andropause, along with the symptoms that accompany them, can be treated successfully. Men and women and their loved ones need not suffer the consequences of a mid-life crisis. There is definitely hope. It is within our power to make the rest of our life the best of our life!

Jeffry S. Life, M.D., Ph.D. - Institute Physician
Dr. Life is a Diplomate of both the American Board of Family Practice and the American Board of Anti-Aging Medicine. He is also a Fellow of the American Academy of Family Physicians and is certified in Age Management Medicine. After receiving his medical degree from the University of Iowa, Dr. Life completed his Residency in Family Medicine and Internal Medicine at West Virginia University. In 1998, after reaching a lifetime high body weight, percentage of body fat, and level of deconditioning, he decided to enter EAS’ National Body-for-LIFE Challenge at the age of 60. He won the contest after losing 35 pounds of body fat and gaining 15 pounds of muscle as a direct result of improving his nutrition and starting an exercise program. Today he continues to live a lifestyle that promotes health and fitness and writes a column on Performance Nutrition for Muscle Media Magazine. He has also written a chapter on “Exercise, Fitness, and Lifestyle” for a popular medical textbook that was published in 2002. Prior to joining Cenegenics, Dr. Life was a full-time Family Physician and a part-time Assistant Professor at Marywood University in Scranton, Pennsylvania where he taught graduate courses in the nutritional sciences and exercise physiology. He is currently completing a Masters of Science program in Sports Nutrition and Exercise Science and working on his book. Dr. Life joins the Cenegenics team with an intense desire and enthusiasm to share with our patients the lifestyle changes and knowledge that have had such a positive impact on his life.

About Cenegenics

Cenegenics Medical Institute is the largest and most experienced Age Management Medicine Practice in the world with patients from every state in the United States and several countries, 25% of whom are physicians and their families. Cenegenics consistently receives regional, national, and international media exposure and has been the featured expert in the media, including USA Today, Wall Street Journal, ABC’s 20/20, and CBS’s 48 Hours.

Alan P. Mintz, M.D., is the Chief Medical Officer, Chief Executive Officer, and Co-Founder, of Cenegenics Medical Institute. He is a Diplomate for the American Board of Radiology, including Nuclear Medicine and Radiation Therapy and is certified in Age Management Medicine. For further information contact Dr. Mintz or Dr. Life at 1-866-953-1530 or email at doctor@cenegenics.com.

http://www.drlife.com/rcsasp/showquestion.asp?cmd=1&questionid=184

Testosterone

-
A Critical Hormone for Men and Women
by Jeffry S. Life, M.D. Ph.D.

Men and Testosterone

Testosterone is a hormone that has been intimately tied throughout time to a man’s virility and sexuality. It is the major steroid hormone of the testicles. However, testosterone is much more than just a sex hormone. With testosterone receptor sites in the brain and heart, and in fact throughout the entire body, testosterone plays a critical role in maintaining a healthy immune system, insuring proper cardiac output, and regulating mood and cognition, controlling blood sugars, regulating healthy cholesterol levels, controlling blood pressure, preventing heart attacks, and even reducing the risk for prostate cancer (Steiner & Raghow. World J Urol. 2003 May; 21(1): 235-41).

Testosterone production in the male begins when the pituitary gland, located deep inside the brain, secretes lutenizing hormone (LH), which in turn, stimulates the Leydig cells in the testicles to produce testosterone. It is estimated that men are born with 700 million Leydig cells and they begin losing 6 million each year after their twentieth birthday. In spite of these losses, studies have found that testosterone levels peak in men at about age 30. After this, testosterone levels begin declining an average of 2% a year.

Declines in testosterone production are due to several factors besides decreases in Leydig cell numbers. Diminished testicular response to pituitary signals that initiate testosterone production and a poor coordination of the release of these pituitary signals play the most important role in testosterone decline. Another reason for testosterone declines is because most of the testosterone that is secreted into the bloodstream attaches to a protein called sex hormone binding globulin (SHBG). Testosterone that is not bound to SHBG is called free testosterone and it is only in this form that testosterone can exert its powerful effects on all of the body’s cells. An increase of SHBG occurs in many men as they age, especially if they are obese. As SHBG levels increase, the amount of testosterone that is available to act on cells diminishes even further.

These age-related declines in total and free testosterone levels in men are associated with easily identifiable, classic signs and symptoms called andropause. Andropause can cause significant problems that include negative attitudes about life in general, a loss of focus and drive, a questioning of one’s values and accomplishments, loss of goals and directions in life, decreased libido, depression, and even cognitive impairments. Declines in sex drive, frequency of sexual thoughts, and erectile dysfunction are additional problems that are directly related to falling levels of free testosterone and these can have a profoundly negative impact on the male psyche and relationships.

Physical changes also occur and are characterized by thinning hair, a decline in lean muscle tissue, and an increase in body fat (particularly abdominal and pectoral fat). As muscle mass declines, strength declines and risk for falls and fractures increases. A decrease in bone mass is another major problem associated with declining levels of testosterone. Osteoporosis is not just a woman’s disease—up to 30% of men aged 60 and over become osteoporotic. One out of every six men will fracture a hip at some point in their life as a result of decreased bone density. Declines in stamina and exertional performance are also a direct result of inadequate levels of testosterone as are declines in cognitive skills, concentration, and memory.

Testosterone can be converted, by enzymes, into other hormones. One of these enzymes is called 5-alpha reductase. It is found in especially high concentrations in the prostate gland where it converts testosterone into dihydrotestosterone (DHT). Another enzyme, called aromatase, is found in skin, brain, fat, and bone. Aromatase converts testosterone into estradiol, the human form of estrogen. As men age, more of the testosterone they produce is converted into estradiol. When there is too much estradiol it competes with testosterone and negative consequences can develop. These include prostate cancer, heart disease, and stroke. Abnormal increases of estradiol are caused by excess amounts of aromatase enzyme, impaired liver function (often caused by excessive alcohol or certain drug interactions), obesity (which increases aromatase enzyme), and zinc deficiency (zinc is a natural aromatase enzyme inhibitor). In addition to declining levels of testosterone and increasing levels of estradiol, growth hormone and DHEA levels fall during andropause. As these levels decline, profound changes occur with growth and metabolism that affect men both physically and mentally and add to their testosterone deficiency problems.

Today the signs and symptoms of andropause should not be accepted as an inevitable consequence of the aging process. By utilizing bio-identical hormones and accurate monitoring techniques, replacement therapy is now possible (Katznelson L. Neuroendocrine Center Bulletin. Winter 2000; vol 6, Issue 2). Hormone optimization programs offered by Age Management Medicine physicians have rapidly moved into the forefront of preventive medical care and have greatly contributed to the enhancement of quality of life as men and women age.


Women and Testosterone

Testosterone may be well known as a hormone that has been tied to a man’s virility and sexuality, but few realize that it is also a very important hormone for women. As women age, estradiol and progestin levels begin falling as they enter menopause. Testosterone (produced in the ovaries and adrenal glands) and growth hormone levels also decline during this time. As the levels of these key hormones diminish, profound degenerative changes begin occurring with growth and metabolism that affect the breasts, vagina, bones, blood vessels, gastrointestinal tract, urinary tract, cardiovascular system, skin, brain, and energy levels (Davis et al. Maturitas. 1995; 21: 227-236).

We now know testosterone is critically important for a woman’s libido, sexual responsiveness, mood, and generalized feelings of well-being. Women, like men, also need adequate testosterone levels for peak mental acuity and the maintenance of healthy bone density and muscle tissue. Maintaining bone density is absolutely critical for women. Unsupplemented women have a 50% chance of experiencing a pathological fracture of their hip or vertebra at some point in their life. This is a frightening statistic because a hip fracture carries with it a 25% six-month mortality rate, and a 50% two-year mortality. Testosterone also plays a key role in the prevention of the accumulation of unwanted body fat, heart disease, and loss of cognitive function in women. Testosterone replacement therapy is now recommended for women with suboptimal blood levels. Like men, women must have all of their hormones at optimal levels and be followed with laboratory studies on a regular basis.

Testosterone Measurement

Clinical signs and symptoms are important indicators that an individual needs testosterone replacement therapy. However, objective laboratory measures must be obtained to properly institute and manage therapy. These lab measurements are also necessary to rule out or address any accompanying medical problems. To adequately measure testosterone levels, both total and free testosterone studies should be obtained. For males, a level of 260-1,000 ng/dL is given as the normal laboratory range for men aged 20-70. For females, this range is 15-70 ng/dL. Free testosterone levels average approximately 2% of the total.

Obviously, the fifty-year span from age 20 through 70 with the same normal range is not a useful guide to determine optimal testosterone levels for older individuals. A decline of 70% from the more youthful levels to the levels typically seen after age 40 will produce most, if not all, of the problems associated with low testosterone levels described above. Yet a level that falls in this broad range is declared "within the normal range" by today’s laboratory standards. A more accurate approach would be to use the 60th percentile values of a 44-year-old man or woman as an optimal range. This is 700-900 ng/dL of total testosterone for men and 50-70 ng/dL for women. It should be stressed that these levels represent the upper 25th percentile for a 70-year-old man or woman, so we are talking about optimizing normal hormone levels, not pushing levels into supraphysiological ranges (Dotson A. “Methods of Testosterone Supplementation for Men and Women”. Cenegenics Testosterone Medical Information Gateway. 2004; www.testosterone-articles.com).

The decision to institute testosterone replacement therapy should always be made in the context of other hormonal and laboratory studies. Prostate Specific Antigen (PSA) measurement and a digital rectal exam of all men must accompany testosterone blood levels at the time of the initial evaluation to screen for any pre-existing prostate disease and need to be followed at regular intervals. Other studies, such as thyroid hormones, growth hormone (hGH), leutinizing hormone (LH), dehydroepiandrosterone (DHEA), estradiol, progesterone, blood count, lipid profiles, and other laboratory and metabolic markers (such as body composition and bone density) all play important roles in maximizing a testosterone replacement program in both men and women. Once therapy is initiated, follow up hormone levels and other markers must be monitored over time at regularly scheduled intervals in order to maximize success and assure safety.



Testosterone Therapy

Before any testosterone supplementation program is started, all key hormone levels must be evaluated and therapy should be based on the augmentation of all hormones with suboptimal levels. After the decision has been made to optimize hormone levels, the next step is to decide on the best means of delivery. The best method of testosterone delivery varies from individual to individual, and is dependent upon several factors. Optimally, a testosterone delivery method should be clinically effective in correcting the signs and symptoms of testosterone decline and produce predictable and reproducible optimal levels of testosterone without increasing levels of other potentially harmful hormones. The fact that testosterone can be converted to estradiol by an aromatase enzyme is a serious concern for men because, in some, any intervention that raises testosterone levels will raise estradiol levels. With proper laboratory follow up, this is easily identified and corrected. The raising of serum levels of dihydrotestosterone (DHT) can also be clinically important in men. DHT, as discussed earlier, is the agent associated with male-pattern baldness and prostate enlargement. These do not become a problem if DHT levels are closely monitored and controlled.

Testosterone is available directly in oral, injectable, topical, and implantable formulations, and may also be supplemented indirectly by the administration of human chorionic gonadotropin (hCG). Oral testosterone and androgens such as fluoxymesterone, methyltestosterone, oxandrolone, or danazol are available for clinical use, but are not appropriate for long-term testosterone replacement therapy. Their use is specific for certain clinical disorders and must be used with great caution as they can cause liver damage, and even malignant liver tumors. They also dramatically raise serum LDL cholesterol, decrease HDL cholesterol, and have been associated with increased risk of heart attacks and stroke. Testosterone undecanoate is an oral testosterone compound that is taken up by the lymph ducts in the intestines and able to bypass the liver, thus minimizing side effects. However, it has a very short half-life (or length of effect), has low and frequently variable bioavailability from dose to dose, and is not approved by the FDA. At present, there are no recommended oral testosterone formulations in the United States for men.

One oral preparation that is useful for helping normalize testosterone levels in women is DHEA. Men do not convert DHEA into meaningful levels of testosterone, but many women do. A good first step in improving testosterone levels in women is to optimize DHEA levels and re-check testosterone levels after 5-7 weeks. If testosterone levels have not increased, testosterone therapy can be started at that time. Testosterone pellets have also been developed that can provide augmented serum testosterone levels up to six months. Pellets, however, require a surgical procedure for implantation and removal, and once they are placed they do not allow for altering dosages based on an individual's testosterone blood levels.

Testosterone cypionate for use in men comes in a low cost, easily self-injectable form. It is not associated with the undesirable effects of oral androgen administration and is available in a formulation that provides a long biological effect time. A dosage interval of once a week works very well. Delivering testosterone in this way has a 100% success rate in providing every cell with usable hormone. It is also easy to precisely control the dosage of testosterone and manage the results by following levels over time at regular intervals. This is the supplementation of choice for men whose testicles are no longer able to produce testosterone in adequate amounts.

Testosterone formulations are also available for topical placement, which allows testosterone to be absorbed through the skin. Testosterone cream is the therapy of choice for raising testosterone levels in women. There is only limited application for this delivery system for men because this method can produce elevated serum levels of DHT. Testosterone that is absorbed through the skin is exposed to high levels of 5-alpha-reductase, which converts much of the testosterone to DHT, thereby, increasing exposure of the prostate and hair follicles to excessive amounts of this hormone. The very small amounts of testosterone cream required to raise testosterone levels in women have not been associated with any problems. Testosterone patches (available by prescription for men) have been associated with problems including, inability to achieve adequate serum testosterone levels and local reactions from the adhesive. Mild to moderate reactions occur in as many as 50% of men using some formulations of the skin patch, which have also been shown in studies to produce a 30-50% failure rate in clinical applications.

An interesting new way of increasing testosterone levels in men with deficiencies has been achieved through the use of human chorionic gonadotropin (hCG). hCG is a hormone that is able to bind to lutenizing hormone (LH) receptors with the same binding affinity as LH. Administration of hCG can, therefore, mimic the same effect as LH and increase testosterone production by stimulating Leydig cells in the testicles. In men who still have a functional LH/testosterone control loop, testosterone production with hCG is the most physiologic method, and is not associated with the testicular atrophy that can occasionally happen with direct testosterone administration. The preferred method of administering hCG is to give subcutaneous doses with a tiny insulin syringe twice weekly. While direct injection of testosterone has a 100% success rate, there is an approximately 10-15% failure rate seen in individuals using hCG. With normal aging, the testicles will at some point stop responding to the LH and hCG signals. If testosterone levels do not rise in a patient receiving hCG after 6 weeks, we know the "disconnect" between the testicles and the pituitary gland has occurred and direct testosterone supplementation is the preferred route.

Once a hormonal augmentation program is initiated, laboratory markers, which include hormone blood levels, should be followed at regularly scheduled intervals and therapy must be adjusted accordingly if an endocrine supplementation program is to be safe and effective. Physicians specifically trained and certified in Age Management Medicine are best suited to oversee such programs.

Conclusion

Hormonal health plays a large role in determining the overall health and wellbeing of both men and women (Tenover JL. Mayo Clin Proc. 2000 Jan; 75 Suppl: S77-81, Raisz et al. J Clin Endocrinol Metab. 1996; 81: 37-43). Today age-related hormone deficiencies and imbalances are correctable and optimal hormone balances, that place individuals in the upper percentiles of their normal hormone range, can be safely achieved. Men, women, and their loved ones need not suffer the consequences of a mid-life crisis. There is definitely hope. It is now within our power to make the rest of our lives the best of our lives!



Jeffry S. Life, M.D., Ph.D. - Institute Physician
Dr. Life is a Diplomate of both the American Board of Family Practice and the American Board of Anti-Aging Medicine. He is also a Fellow of the American Academy of Family Physicians and is certified in Age Management Medicine. After receiving his medical degree from the University of Iowa, Dr. Life completed his Residency in Family Medicine and Internal Medicine at West Virginia University. In 1998, after reaching a lifetime high body weight, percentage of body fat, and level of deconditioning, he decided to enter EAS’ National Body-for-LIFE Challenge at the age of 60. He won the contest after losing 35 pounds of body fat and gaining 15 pounds of muscle as a direct result of improving his nutrition and starting an exercise program. Today he continues to live a lifestyle that promotes health and fitness and writes a column on Performance Nutrition for Muscle Media Magazine. He has also written a chapter on “Exercise, Fitness, and Lifestyle” for a popular medical textbook that was published in 2002. Prior to joining Cenegenics, Dr. Life was a full-time Family Physician and a part-time Assistant Professor at Marywood University in Scranton, Pennsylvania where he taught graduate courses in the nutritional sciences and exercise physiology. He is currently completing a Masters of Science program in Sports Nutrition and Exercise Science and working on his book. Dr. Life joins the Cenegenics team with an intense desire and enthusiasm to share with our patients the lifestyle changes and knowledge that have had such a positive impact on his life.



About Cenegenics

Cenegenics Medical Institute is the largest and most experienced Age Management Medicine Practice in the world with patients from every state in the United States and several countries, 25% of whom are physicians and their families. Cenegenics consistently receives regional, national, and international media exposure and has been the featured expert in the media, including USA Today, Wall Street Journal, ABC’s 20/20, and CBS’s 48 Hours.

Alan P. Mintz, M.D., is the Chief Medical Officer, Chief Executive Officer, and Co-Founder, of Cenegenics Medical Institute. He is a Diplomate for the American Board of Radiology, including Nuclear Medicine and Radiation Therapy and is certified in Age Management Medicine. For further information contact Dr. Mintz or Dr. Life at 1-866-953-1530 or email at doctor@cenegenics.com.

http://www.drlife.com/rcsasp/showquestion.asp?cmd=1&questionid=189

The Importance Of Exercise and How To Incorporate It Into Your Lifestyle

by Jeffry S. Life, M.D. Ph.D.

The United Nations, the World Health Organization, and 37 countries including the United States have proclaimed 2000-2010 as the Bone and Joint Decade to promote the importance of a healthy musculoskeletal structure for a lifetime. The number of people older than 50 will double between 1990 and 2020. Advances in medicine continue to make it possible for more people to live longer, but today most want to live stronger and maintain their quality of life. Each year, musculoskeletal conditions and injuries account for about 102.3 million visits to physician offices, 10.2 million hospital outpatient visits, 25 million emergency department visits, 3 million hospitalizations, and 7.5 million procedures, and they cost an estimated $300 billion.1

As the baby boom generation ages, people in their 50s begin to notice more aches and pains after performing the same activities that were painless in their 40s, and those in their 60s can't do as much as they did in their 50s. Roy Shephard, MD, PhD, professor emeritus of applied physiology at the University of Toronto, points out that, "Both aerobic power and muscle strength decline by as much as 10% for every decade of adult life, but a progressive exercise prescription can enhance function by 10% to 20%; thus, in terms of functional capacity, conditioning can reduce biological age by 10 to 20 years."2

In 1998, the American College of Sports Medicine issued its first position statement on aging and exercise,3 in which it recommended strength training for frail older people. Petrella says, "We now know that older patients can perform to very high levels, so exercise prescription does not differ for older and younger persons, and training effects for the elderly can exceed those of younger people at the upper end of VO2max."
Exercise is the key to maintaining quality of life, as well as extending the number of years of life expectancy. It's never too late to start, and an early start is better. Even 90- and 100-year-olds can do strength training.

Exercise is really a form of medicine that can prevent or treat many disabling or fatal diseases. Seventy percent of deaths (1.5 million) each year in the United States are a result of eight killers: heart disease, cancer, stroke, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, and osteoporosis4. Other diseases treatable with exercise--obesity, arthritis, depression, and dyslipidemia--contribute considerably to disability and premature death

The health rewards of exercise extend far beyond its benefits for specific diseases. Exercise reduces blood clotting, enhances self-image, elevates mood, reduces stress, improves appearance, increases energy, gives the feeling of well-being (probably by stimulating endorphins). It reinforces other positive life-style changes, such as healthier eating habits and smoking cessation5. It also stimulates creative thinking 6.

Furthermore, the ability of exercise to restore function to organs, muscles, joints, and bones is not shared by drugs or surgery. Paradoxically, conventional medical practice favors physical rest and inactivity during recovery from illness.

Aerobic Exercise vs. Resistance Training

For many years doctors have advised middle-aged and older people to get plenty of aerobic exercise—that is, exercise that requires the rhythmic movement of their arms and legs. This form of exercise, which includes walking, jogging, swimming, bicycle riding and so on, has always been thought to be the best exercise to help prevent and/or treat heart disease. Doctors have traditionally discouraged people with heart disease or older people from engaging in strength training with weights or exercise machines because they believed that this would put dangerous stress on their hearts.

Recently, an expert panel of scientists, organized by the American Heart Association, has finally put to rest that age-old myth that weight training and other forms of resistance exercise are bad for the heart. In fact, this committee has advised doctors to actually start recommending this form of exercise for their healthy older patients, as well as those with heart disease, including some people with recent heart attacks as long as they are closely monitored and supervised by experienced health professionals.
Aerobic exercise and resistance training clearly work hand-in-hand to prevent, reduce, or even eliminate heart disease by preventing or controlling diabetes, high cholesterol and high blood pressure. Aerobic exercise does a great job lowering systolic blood pressure, and both aerobic and resistance exercise help reduce diastolic blood pressure. This makes it much easier for the heart to do its job of pumping blood throughout the body. Both forms of exercise also strengthen the heart muscle making it work much more efficiently.

Obviously, this is great news. Now doctors can encourage their patients with healthy hearts (no matter what their age or gender) and those with unhealthy hearts (under medical supervision) to start using resistance training along with their aerobic training as an integral part of their heart-disease prevention and/or treatment program.

The following table, by Pollock and Vincent, from The President’s Council on Physical Fitness and Sports Research Digest, is found in my article entitled “Why Everyone Should Lift Weights” in this website. This table helps us better understand the differences in aerobic (cardio) training and resistance training.

Comparison of the Effects of Aerobic Endurance Training to Strength (Resistance) Training on Health and Fitness Variables

Variable


Aerobic Exercise


Resistance Exercise
Increases Bone Density
Decreases Body Fat
Increases Muscle Mass very little effect
Increases Strength
Decreases Insulin Response to Glucose
Decreases Basal Insulin Levels
Increases Insulin Sensitivity
Increases HDL very little effect
Decreases Resting Heart Rate very little effect
Increases Stroke Volume of the Heart very little effect
Decreases Systolic Blood Pressure very little effect
Decreases Diastolic Blood Pressure
Improves Cardio/Vascular Fitness
Increases Endurance time
Improves Physical Function
Increases Basal Metabolism


Dr. Kenneth Cooper, who coined the term aerobics in 1968 and a staunch advocate of aerobic exercise, now believes a mix of aerobic conditioning and strength training is the best exercise program for aging adults. He proposes an “aerobic-strength axis” with the balance changing depending on how old you are. At age 40 and younger, he suggests 80% aerobics and 20% strength; age 41 to 50, 70/30; 51 to 60. 60/40; and at 61 and older, 55/45. So he still favors aerobics, but the bias practically disappears after age 60. “A good rule of thumb, “ says Cooper, “is that you should always include at least 50 percent aerobic/endurance work in your personal fitness routine, regardless of your age and sports interest.”

As individuals age they need more strength training. In Regaining the Power of Youth At Any Age, Cooper writes: “Up to age 50, people lose about four percent of their strength and muscle mass per decade. After that, the loss increases to about 10 percent per decade.” “By age 60”, he goes on to say, “the average man will have lost about one third of his muscle mass—unless he makes an effort to reverse the process through weight training.” Women have a similar decline as they age.

Cooper still leans toward aerobics because he believes the supporting evidence at this time is stronger. He cites a number of impressive studies showing that endurance training slows the steady erosion of oxygen uptake capacity with age that appears to occur for both trained and untrained individuals. He cites one study, which indicates that it may even be possible to stop the decline with hard consistent training. That study, reported in the Journal of Applied Physiology, followed a group of track athletes, age 50 to 82, who remained highly competitive for 10 years – and found that their aerobic capacity remained unchanged during the entire time.

Individuals who aren’t satisfied with a moderate level of fitness can take heart from a study published March 14, 2002, in the New England Journal of Medicine. The researchers concluded that exercise capacity is perhaps the most powerful predictor of mortality. They found a direct relationship between greater fitness and longer survival.

Most previous studies have emphasized that the least fit have the most to gain from exercise, that the most striking reduction in mortality results when one becomes active and moves out of the poor fitness category. An earlier study reported in 1989 by the Institute for Aerobic Fitness in Dallas highlighted that those in the high-fitness group were only slightly less likely to die than those in the medium-fitness groups, but this study shows that people benefit in proportion to their level of fitness.

As in other studies, the researchers found a "striking difference" in mortality rates between the least fit 25 percent and the next quintile of fitness. "This observation concurs with the consensus," the researchers wrote, "that the greatest health benefits are achieved by increasing physical activity among the least fit." They also demonstrated that there is a nearly linear reduction in risk with increasing quintiles of fitness. With each 1-MET increase in exercise capacity there was a 12 % improvement in survival. Participants whose exercise capacity was less than 5 MET were roughly twice as likely to die as those with exercise capacity of more than 8 Met.

Absolute exercise capacity measured in METs predicted risk of death better than percentage of age predictions. In both healthy participants and those with cardiovascular disease, peak exercise capacity was found to be a stronger predictor of death than risk factors such as hypertension, diabetes, obesity, heart arrhythmia, high cholesterol, and even smoking. Poor fitness proved to be the deadliest risk factor of all. Lead author Jonathan Myers, a professor of medicine at Stanford University, told the Washington Post "No matter how we twisted it, exercise came out on top."
Exercise pays big dividends. It’s even more important than smoking in its impact on life span. Greater fitness means longer life. What could be a bigger dividend than that? Doctors who don’t encourage their patients to exercise are missing the boat.

Gary J. Balady, M.D., summarized the message in an editorial which accompanied the report: "The data from the study compel the clinician to go beyond the identification of risk to the initiation of interventions, such as the prescription of increased physical activity and exercise, in order to modify risk, particularly in patients with low levels of fitness."


Benefits of Exercise Therapy for the Common Serious Diseases

Coronary artery disease7-11. Coronary artery disease (CAD) is our number one killer, responsible for 2,000 deaths in the United States each day. About twice as many heart attacks occur every day. CAD claims many people who are at the peak of their career.

Exercise combined with diet therapy can reverse established heart disease. Furthermore, exercise improves heart function, reduces several coronary risk factors (hypertension, high cholesterol, low high-density lipoprotein (HDL) cholesterol, and obesity), enhances psychosocial wellbeing after a heart attack, and improves survival.

In summary, exercise is an effective strategy for preventing heart disease, and it is a beneficial, low-cost, pleasure-giving treatment without the side effects of drugs or the risks, pain, and expense of surgery.

Cerebrovascular disease12-14. Vigorous exercise in early adulthood confers considerable protection from strokes in later life. This effect is independent of other risk factors. Furthermore, exercise is essential for restoring function following a stroke--again, a benefit not shared by drugs or surgery.

Hypertension15-19. Substantial evidence shows that exercise is an effective treatment for mild and moderate high blood pressure and is a useful adjunct for the treatment of severe hypertension. Many patients who adhere to a regular, specifically prescribed aerobic exercise program can reduce their blood pressure without taking drugs. Thus, they avoid the potentially toxic effects and considerable expense of long-term drug therapy. Drug and exercise compliance are reported to be similar. Postexercise blood pressure reduction in normal and hypertensive patients disappears 2 weeks after exercise stops.

The degree of blood pressure reduction depends on the type, duration, and intensity of the exercise, as well an individual's genetics. Therefore, the prescription must be carefully individualized. Among non-pharmacologic means for lowering blood pressure, physical activity provides better patient compliance and quicker results than weight reduction or alcohol and salt restriction.

Diabetes20-22. Exercise can prevent or delay the serious complications of diabetes, namely, the vascular disease of the brain, heart, kidney, eyes, and legs that commonly occurs in diabetics who are under age 40. The same benefits of exercise are seen in those who develop the disease in later life.

Exercise improves the abnormal blood lipid pattern and reduces the high blood pressure common in people who have diabetes. In addition, exercise increases insulin effectiveness and the metabolism of sugar, thereby reducing the insulin requirement, which in turn reduces the risk of vascular disease. Elevated blood insulin has been implicated in the pathogenesis of arteriosclerosis.

The complexity of diabetes treatment requires a combination of methods to achieve healthy blood sugar levels and to prevent or reduce the serious complications of the disease. An exercise regimen, properly taught and followed, helps accomplish this goal and allows diabetic patients to lead healthy, active lives.

Arthritis23-26. In patients who have rheumatoid or degenerative arthritis, exercise improves endurance, strengthens muscles, and increases joint flexibility and range of motion. These, of course, are benefits that drugs or surgery cannot achieve.

Osteoporosis27-29. Osteoporosis affects 20 to 24 million postmenopausal American women and an unknown number of men over the age of 80. It results in musculoskeletal weakness, loss of height, bone fractures (primarily spine and hip), and painful disability. Two hundred fifty thousand hip fractures occur each year in the United States, resulting in 12,000 deaths and $11 billion in medical expenditures. Research indicates that regular exercise can prevent and control the disease.

Dyslipidemia30-32. Abnormalities of blood fats (high total cholesterol and triglycerides and low HDL cholesterol) are major risk factors for vascular disease of the heart, brain, kidney, eyes, and legs. Regular exercise reduces total cholesterol and triglyceride levels and raises HDL cholesterol.

Obesity33-36. The amount of body fat is a useful indicator of health and fitness, as well as an early warning signal of many serious diseases. Excess body fat is a risk factor for heart disease, hypertension, diabetes, many cancers (breast, prostate, colon, uterus, and gall bladder), and premature death from other causes. It appears that being overweight aggravates a very wide spectrum of diseases and is also a handicap to getting a job, obtaining admission to a university, and forming social relationships.

The magnitude of the problem in the United States is greater than in any other country. Estimates of the number of overweight Americans range from 50 million to 200 million. The average American is said to have 20 to 30 lb of excess body fat. Daily, lifelong exercise is an essential strategy for achieving and maintaining optimal weight. Diet, though essential, cannot be relied on exclusively for successful weight loss and maintenance.

Depression37-39. Depression, the most common mental disorder in America, affects approximately 5% (about 12 million) at any given time. Psychologists have observed that walking or running has both physiologic and psychological benefits for people who are depressed. These forms of exercise reduce depression and anxiety, increase feelings of wellbeing, improve tolerance to everyday stress, and improve the self-image of depressed patients. It is difficult to sustain depressed feelings while one is physically exercising. Furthermore, exercise stimulates the release of the "feel good" hormones (endorphins).

One report38 concluded that walking or running while talking with depressed patients was more effective than talking and listening to them in an office because (1) the walking approach is non-confrontational--the patient and therapist are side by side, looking ahead rather than looking directly at one another; (2) the talking is being done in a less threatening setting; and (3) the patient is actively experiencing life rather than passively observing it in a chair.

Cancer. There is evidence that physical activity reduces the risk for cancer of the left side of the colon40 and the breast41.

COPD. Recent data42 suggest that adding an exercise component to the rehabilitation program for patients who have COPD results in physiologic as well as psychological benefits, even for those with severe air flow obstruction.

A Plan for Therapy

To be maximally effective for therapy or health enhancement, an exercise program must fulfill certain basic requirements: It must be a daily activity (7 days a week), it must be fun, not painful or excessively fatiguing, and it must fit an individual's preferences5-6. The selected activities must be readily available, not distant or difficult to reach, and preferably be close to the home or workplace. The clothes, equipment, and/or club membership associated with the activity must be inexpensive. Ideally, the activity should not depend on other people (team, class, or partners), but should permit group participation if desired. And finally, the activity must be suitable for lifelong participation.

The major form of aerobic exercise should be (walking, running, cycling, swimming, or cross-country skiing). Variety is an important part of the prescription: At least two or preferably three different activities are recommended, for example walking-running-tennis or walking-cycling-swimming.

The choice of exercise should be guided by individual preference and previous experience. Walking and running are most often recommended because they do not require special training or skills. They are inexpensive, readily available, safe, and suitable for doing alone or with others. The acronym DF ALIVE is helpful to guide one’s exercise program: Daily, Fun, Available, Lifelong, Independent, Variety, & Endurance.

Encourage Lifelong Habits

The daily goal is to exercise for at least 30 to 60 minutes (2% to 4% of the day) and to make a conscious effort to do body movement throughout 16 hours of the day (i.e., doing household chores, working, shopping, gardening, running errands, visiting, or socializing in an active manner5-6).

Everybody should have an individualized lifelong exercise program designed to fit his or her lifelong situation and preferences.
In recent decades, research has validated the effectiveness of regular exercise as a way to reduce and/or prevent age-related functional decline and reduce the risks of a sedentary lifestyle43. Most medical groups recommend regular physical activity44. People over age 65 carry the highest load of chronic disease, disability, and healthcare utilization45. Though many of these problems are preventable, primary care physicians rarely provide their older patients with an appropriate exercise recommendation that includes an individualized motivational message, a pre-participation evaluation to ensure a safe exercise program, and a tailored exercise prescription46.

The first step in a pre-participation evaluation by your physician is to be evaluated for reasons not to be involved in exercise testing and training and to identify any risks or limitations relevant to an exercise program. An efficient screening questionnaire addresses previous exercise programs; present activity (frequency, duration, and intensity); existing chronic or acute disease(s), especially chronic obstructive pulmonary disease, cardiovascular disease, and extreme motor limitations because of severe arthritis; family history of cardiorespiratory disease; and coronary artery disease risk factors.

Though most of the risk of exercise-related morbidity and mortality is associated with preexisting cardiac conditions, contraindications to exercise testing and training are the same for older and younger adults. Absolute contraindications to formal exercise testing include recent electrocardiographic changes or acute myocardial infarction, unstable angina, third-degree heart block, and acute congestive heart failure47. Relative contraindications to exercise testing include elevated blood pressure, cardiomyopathies, valvular heart disease, complex ventricular ectopy, and uncontrolled metabolic diseases.

Physical Examination and Lab Tests

The physical exam and laboratory tests focus on a patient’s functional abilities and/or limitations. A medical assistant, nurse, or other midlevel practitioner under a physician's supervision can usually accomplish most of the steps of the pre-participation exam. The average office-based evaluation takes about 20 minutes, though additional time is required if treadmill testing, bone mineral density scans, or respiratory function tests are needed. The physical examination should include vital signs and cardiorespiratory and musculoskeletal evaluation.

Cardiovascular fitness. The American College of Sports Medicine (ACSM) recommends cardiac treadmill stress testing before commencing vigorous exercise (exercise intensity greater than 60% of maximal oxygen uptake) for men over age 40, women over age 50, and all patients who have cardiac risk factors with or without symptoms47.

Treadmill tests, which can be used to estimate the patient's aerobic capacity, are useful for prescribing exercise intensity. If a treadmill test is unavailable, the Kasch pulse-recovery test can be performed in the office to give physicians a general idea of a patient's functional and aerobic capacities. The test is based on the principle that the better one's level of fitness, the sooner the heart rate returns to baseline after exercise. The patient's pulse and blood pressure are measured at rest and 1 minute after he or she has stepped up and down (with both feet) a 12-in. step 24 times per minute for 3 minutes48. To help patients adhere to this pace, setting a metronome to 96 bpm may be helpful. Respiratory function can be determined simply by measuring the patient's forced vital capacity and forced expiratory volume in 1 second.

The Role Physicians Play in Prescribing Exercise Programs

Medical students spend a year learning about pharmacology and they receive instruction on drug prescribing throughout their training. Often, the drugs they study will no longer be recommended by the time they are in practice. On the other hand, medical students are not instructed on how to prescribe exercise (or, for that matter, nutrition)—the best medicine of all.

Physicians need more training in how to make best use of this powerful therapy. Physicians can successfully encourage increased activity by giving their patients a written exercise prescription along with printed advice on how to design a safe, enjoyable routine.

Prescribing exercise is like prescribing medications, surgery, or other therapy—It is a thoughtful compromise between potential benefits and side effects. After careful consideration of these factors, the physician and the patient reach an agreement on the most effective plan. Important considerations include the goal of exercise (e.g., osteoporosis prevention, weight loss, strength improvement, marathon training) and patient preferences. Expanding on his or her current exercise habits is a good starting point because choosing activities the patient already enjoys improves adherence.

Setting goals. The ACSM recently published separate position statements on exercise for healthy adults56 and older adults57. Kligman et al.58 have adapted these recommendations, combined with those from the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH)59, into a very helpful chart that outlines basic exercise prescriptions for a range of health and fitness goals.

Basic Exercise Prescriptions for a Range of Health and Fitness Goals for Older Persons, Adapted From Federal Exercise Guidelines
Fitness Dimension Disease Prevention Basic Health Fitness Performance
Cardiovascular capacity Accumulate 30 min of physical activity most days Large-muscle repetitive exercise or equivalent sports activity, 20 min, 3x/wk Aerobic exercise or equivalent sports activity, 40-60+ min, 4-6x/wk Add competition and/or interval training
Strength Include weight-bearing activity "Core four"* or equivalent program, one set, 8-12 or 12-15 repetitions at challenge weight,** 2x/wk, Pilates work*** Balanced whole-body free weights or machines, 1-3 sets, 8-12 repetitions reaching functional failure,++ 2-3x/wk, Pilates work Add ascending and descending pyramids+++ and muscle endurance or power training, Pilates work
Flexibility Maintain range of motion by bending and stretching in daily activities 2-4 stretches after activity, 1 repetition, hold 30 sec 6-10 whole-body stretches before and after activity, 1-2 repetitions Add yoga, Pilates, and/ or facilitated stretches with a partner
Body composition
Men -- >5%-<25%>125-150 lb 12%-20% fat; maintain lean body mass at >125-150 lb 8%-15% fat
Women -- >14<38%>90-110 lb 20%-30% fat; maintain lean body mass at >90-110 lb 17%-25% fat
Balance and agility -- "Act like a child"; balance line; "Don't step on a crack"; brush teeth while standing on one foot Recreational sports (eg, tennis, biking); tai chi; social dance; therapy ball training Agility or skill sports (ie, surfing, skiing, skating); martial arts; performance dance; agility drills
*Core four: double-leg press, chest press, latissimus dorsi pulldowns, abdominal crunch.
**Challenge weight: the lift is difficult but can be accomplished.
***Pilates: a series of stretching and strengthening exercises performed on a mat without equipment, developed by Joseph Pilates in the 1930s.
++Functional failure: unable to complete another repetition without sacrificing form.
+++Ascending pyramids: more weight is added to each set to cause fatigue with fewer repetitions; descending pyramids: weight is removed from each set to allow more repetitions until fatigue.

Like the pre-participation medical evaluation, the exercise prescription should address the five major fitness components: cardiovascular fitness, muscle strength and endurance, flexibility, body composition, and balance and agility. Many older patients have low muscle mass and/or decreased strength, underscoring the importance of strength training. The ACSM recently added formal strength training recommendations to its exercise guidelines for adults56.

Within the five categories, an individual and his or her physician should select the desired fitness level. The objective is to allow people to indefinitely maintain their current level of function and, ideally, help them reach the next category. The types and dosages of exercise will change as the patient's physiologic function changes.

Selecting activities. An exercise program prescribed by your physician should address the type, frequency, duration, and intensity of physical activity for each fitness component. Though the type of exercise is often determined by available facilities and equipment, your preference should carry considerable weight. For example, if you enjoy golf you should be encouraged to occasionally substitute this activity for a treadmill and resistance training session. Your physician should balance the benefits of each exercise mode with the your health goals and physical limitations. For example, walking, bicycling, and swimming provide excellent cardiovascular benefits, but the weight-bearing nature of walking provides a greater stimulus for bone mineral deposition than cycling or swimming does. On the other hand, swimming is better tolerated by people who have joint limitations.

Cross-training is an effective compromise among several appropriate options. You can mix exercise modes within any given week or within a single session. Cross-training programs help prevent boredom, condition more muscle groups, and reduce the risk of overuse injury.

Determining frequency, duration, and intensity.

Exercise variables can be manipulated to enhance compliance, but the dose-response relationship must be considered. Though exercising more often, longer, or harder affords greater conditioning, the relationship between effort and outcome is rarely linear. The point of diminishing return is often reached even before individuals approach levels that pose a risk of excessive fatigue or injury.

Surprisingly little exercise is required to meet the recommendations for disease prevention (CDC-NIH recommendations)59. Physicians and exercise physiologists often make frequency and duration recommendations at minimal and optimal levels, with instructions to perform the minimal exercise during the busiest weeks and meet the optimal criteria on all others.

Exercise intensity is always prescribed as a range (e.g., a target-heart-rate range of 120 to 145 beats per minute or muscle fatigue in 8 to 12 repetitions). Using an age-predicted target heart rate has limited value and is often misleading, especially as patients age, because 70% to 85% of age-predicted maximal heart rate is often off by 15 to 20 beats per minute. Physiologic change occurs when the body is exposed to stimuli greater than it can currently handle, a concept called “teasing the physiologic threshold.” The concept is useful even in balance and agility training.

Many people underestimate their exercise capacity, considering physical activity to be uncomfortable, hazardous, or medically unwise. However, Fiatarone et al60 demonstrated the safety and effectiveness of a strength training program even for nonagenarians. The quantity and load of an exercise should be adjusted as function improved. An exercise prescription should involve monitoring or teaching patients to assess their own progress.

MET levels are useful for setting exercise goals. A list of common physical activities classified by intensity in METs is available61. I have attached this article at the end of my article to help you design your exercise program.

The Borg perceived exertion scale, http://www.cdc.gov/nccdphp/dnpa/physical/measuring/perceived_exertion.htm,
is frequently used to evaluate aerobic exercise intensity; it can also be used to rate the intensity of resistance training and stretching. Maximal exertion on the Borg Scale is 20. Exercise physiologists often recommend aerobic exercise in the moderate to heavy range (13 to 15 on the Borg scale) for healthy young adults, and may modify their recommendations to light to moderate (11 to 13 on the Borg scale) for older adults.

As function improves, increasing the intensity or duration of exercise should raise the challenge. In strength training, a common recommendation is to lift to muscle fatigue (inability to complete another lift while maintaining good form) in 8 to 12 repetitions. For older adults, 12 to 15 repetitions using slightly lighter weights may be more appropriate. Weight is increased when the patient can consistently complete 13 repetitions; then he or she repeats the process. The rate of improvement varies among individuals and may be slower in older adults.

We have no control over our genetics and very little control over environmental factors, but the things that we can control—diet and exercise—can profoundly affect our longevity and quality of life. Exercise may be the closest thing we have to the fountain of youth. All we have to do is to

“just do it.”

The Importance Of Exercise and How To Incorporate It Into Your Lifestyle

a

by Jeffry S. Life, M.D. Ph.D.

The United Nations, the World Health Organization, and 37 countries including the United States have proclaimed 2000-2010 as the Bone and Joint Decade to promote the importance of a healthy musculoskeletal structure for a lifetime. The number of people older than 50 will double between 1990 and 2020. Advances in medicine continue to make it possible for more people to live longer, but today most want to live stronger and maintain their quality of life. Each year, musculoskeletal conditions and injuries account for about 102.3 million visits to physician offices, 10.2 million hospital outpatient visits, 25 million emergency department visits, 3 million hospitalizations, and 7.5 million procedures, and they cost an estimated $300 billion.1 As the baby boom generation ages, people in their 50s begin to notice more aches and pains after performing the same activities that were painless in their 40s, and those in their 60s can't do as much as they did in their 50s. Roy Shephard, MD, PhD, professor emeritus of applied physiology at the University of Toronto, points out that, "Both aerobic power and muscle strength decline by as much as 10% for every decade of adult life, but a progressive exercise prescription can enhance function by 10% to 20%; thus, in terms of functional capacity, conditioning can reduce biological age by 10 to 20 years."2 In 1998, the American College of Sports Medicine issued its first position statement on aging and exercise,3 in which it recommended strength training for frail older people. Petrella says, "We now know that older patients can perform to very high levels, so exercise prescription does not differ for older and younger persons, and training effects for the elderly can exceed those of younger people at the upper end of VO2max." Exercise is the key to maintaining quality of life, as well as extending the number of years of life expectancy. It's never too late to start, and an early start is better. Even 90- and 100-year-olds can do strength training. Exercise is really a form of medicine that can prevent or treat many disabling or fatal diseases. Seventy percent of deaths (1.5 million) each year in the United States are a result of eight killers: heart disease, cancer, stroke, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, and osteoporosis4. Other diseases treatable with exercise--obesity, arthritis, depression, and dyslipidemia--contribute considerably to disability and premature death The health rewards of exercise extend far beyond its benefits for specific diseases. Exercise reduces blood clotting, enhances self-image, elevates mood, reduces stress, improves appearance, increases energy, gives the feeling of well-being (probably by stimulating endorphins). It reinforces other positive life-style changes, such as healthier eating habits and smoking cessation5. It also stimulates creative thinking 6. Furthermore, the ability of exercise to restore function to organs, muscles, joints, and bones is not shared by drugs or surgery. Paradoxically, conventional medical practice favors physical rest and inactivity during recovery from illness. Aerobic Exercise vs. Resistance Training For many years doctors have advised middle-aged and older people to get plenty of aerobic exercise—that is, exercise that requires the rhythmic movement of their arms and legs. This form of exercise, which includes walking, jogging, swimming, bicycle riding and so on, has always been thought to be the best exercise to help prevent and/or treat heart disease. Doctors have traditionally discouraged people with heart disease or older people from engaging in strength training with weights or exercise machines because they believed that this would put dangerous stress on their hearts. Recently, an expert panel of scientists, organized by the American Heart Association, has finally put to rest that age-old myth that weight training and other forms of resistance exercise are bad for the heart. In fact, this committee has advised doctors to actually start recommending this form of exercise for their healthy older patients, as well as those with heart disease, including some people with recent heart attacks as long as they are closely monitored and supervised by experienced health professionals. Aerobic exercise and resistance training clearly work hand-in-hand to prevent, reduce, or even eliminate heart disease by preventing or controlling diabetes, high cholesterol and high blood pressure. Aerobic exercise does a great job lowering systolic blood pressure, and both aerobic and resistance exercise help reduce diastolic blood pressure. This makes it much easier for the heart to do its job of pumping blood throughout the body. Both forms of exercise also strengthen the heart muscle making it work much more efficiently. Obviously, this is great news. Now doctors can encourage their patients with healthy hearts (no matter what their age or gender) and those with unhealthy hearts (under medical supervision) to start using resistance training along with their aerobic training as an integral part of their heart-disease prevention and/or treatment program. The following table, by Pollock and Vincent, from The President’s Council on Physical Fitness and Sports Research Digest, is found in my article entitled “Why Everyone Should Lift Weights” in this website. This table helps us better understand the differences in aerobic (cardio) training and resistance training. Comparison of the Effects of Aerobic Endurance Training to Strength (Resistance) Training on Health and Fitness Variables Variable Aerobic Exercise Resistance Exercise Increases Bone Density Decreases Body Fat Increases Muscle Mass very little effect Increases Strength Decreases Insulin Response to Glucose Decreases Basal Insulin Levels Increases Insulin Sensitivity Increases HDL very little effect Decreases Resting Heart Rate very little effect Increases Stroke Volume of the Heart very little effect Decreases Systolic Blood Pressure very little effect Decreases Diastolic Blood Pressure Improves Cardio/Vascular Fitness Increases Endurance time Improves Physical Function Increases Basal Metabolism Dr. Kenneth Cooper, who coined the term aerobics in 1968 and a staunch advocate of aerobic exercise, now believes a mix of aerobic conditioning and strength training is the best exercise program for aging adults. He proposes an “aerobic-strength axis” with the balance changing depending on how old you are. At age 40 and younger, he suggests 80% aerobics and 20% strength; age 41 to 50, 70/30; 51 to 60. 60/40; and at 61 and older, 55/45. So he still favors aerobics, but the bias practically disappears after age 60. “A good rule of thumb, “ says Cooper, “is that you should always include at least 50 percent aerobic/endurance work in your personal fitness routine, regardless of your age and sports interest.” As individuals age they need more strength training. In Regaining the Power of Youth At Any Age, Cooper writes: “Up to age 50, people lose about four percent of their strength and muscle mass per decade. After that, the loss increases to about 10 percent per decade.” “By age 60”, he goes on to say, “the average man will have lost about one third of his muscle mass—unless he makes an effort to reverse the process through weight training.” Women have a similar decline as they age. Cooper still leans toward aerobics because he believes the supporting evidence at this time is stronger. He cites a number of impressive studies showing that endurance training slows the steady erosion of oxygen uptake capacity with age that appears to occur for both trained and untrained individuals. He cites one study, which indicates that it may even be possible to stop the decline with hard consistent training. That study, reported in the Journal of Applied Physiology, followed a group of track athletes, age 50 to 82, who remained highly competitive for 10 years – and found that their aerobic capacity remained unchanged during the entire time. Individuals who aren’t satisfied with a moderate level of fitness can take heart from a study published March 14, 2002, in the New England Journal of Medicine. The researchers concluded that exercise capacity is perhaps the most powerful predictor of mortality. They found a direct relationship between greater fitness and longer survival. Most previous studies have emphasized that the least fit have the most to gain from exercise, that the most striking reduction in mortality results when one becomes active and moves out of the poor fitness category. An earlier study reported in 1989 by the Institute for Aerobic Fitness in Dallas highlighted that those in the high-fitness group were only slightly less likely to die than those in the medium-fitness groups, but this study shows that people benefit in proportion to their level of fitness. As in other studies, the researchers found a "striking difference" in mortality rates between the least fit 25 percent and the next quintile of fitness. "This observation concurs with the consensus," the researchers wrote, "that the greatest health benefits are achieved by increasing physical activity among the least fit." They also demonstrated that there is a nearly linear reduction in risk with increasing quintiles of fitness. With each 1-MET increase in exercise capacity there was a 12 % improvement in survival. Participants whose exercise capacity was less than 5 MET were roughly twice as likely to die as those with exercise capacity of more than 8 Met. Absolute exercise capacity measured in METs predicted risk of death better than percentage of age predictions. In both healthy participants and those with cardiovascular disease, peak exercise capacity was found to be a stronger predictor of death than risk factors such as hypertension, diabetes, obesity, heart arrhythmia, high cholesterol, and even smoking. Poor fitness proved to be the deadliest risk factor of all. Lead author Jonathan Myers, a professor of medicine at Stanford University, told the Washington Post "No matter how we twisted it, exercise came out on top." Exercise pays big dividends. It’s even more important than smoking in its impact on life span. Greater fitness means longer life. What could be a bigger dividend than that? Doctors who don’t encourage their patients to exercise are missing the boat. Gary J. Balady, M.D., summarized the message in an editorial which accompanied the report: "The data from the study compel the clinician to go beyond the identification of risk to the initiation of interventions, such as the prescription of increased physical activity and exercise, in order to modify risk, particularly in patients with low levels of fitness." Benefits of Exercise Therapy for the Common Serious Diseases Coronary artery disease7-11. Coronary artery disease (CAD) is our number one killer, responsible for 2,000 deaths in the United States each day. About twice as many heart attacks occur every day. CAD claims many people who are at the peak of their career. Exercise combined with diet therapy can reverse established heart disease. Furthermore, exercise improves heart function, reduces several coronary risk factors (hypertension, high cholesterol, low high-density lipoprotein (HDL) cholesterol, and obesity), enhances psychosocial wellbeing after a heart attack, and improves survival. In summary, exercise is an effective strategy for preventing heart disease, and it is a beneficial, low-cost, pleasure-giving treatment without the side effects of drugs or the risks, pain, and expense of surgery. Cerebrovascular disease12-14. Vigorous exercise in early adulthood confers considerable protection from strokes in later life. This effect is independent of other risk factors. Furthermore, exercise is essential for restoring function following a stroke--again, a benefit not shared by drugs or surgery. Hypertension15-19. Substantial evidence shows that exercise is an effective treatment for mild and moderate high blood pressure and is a useful adjunct for the treatment of severe hypertension. Many patients who adhere to a regular, specifically prescribed aerobic exercise program can reduce their blood pressure without taking drugs. Thus, they avoid the potentially toxic effects and considerable expense of long-term drug therapy. Drug and exercise compliance are reported to be similar. Postexercise blood pressure reduction in normal and hypertensive patients disappears 2 weeks after exercise stops. The degree of blood pressure reduction depends on the type, duration, and intensity of the exercise, as well an individual's genetics. Therefore, the prescription must be carefully individualized. Among non-pharmacologic means for lowering blood pressure, physical activity provides better patient compliance and quicker results than weight reduction or alcohol and salt restriction. Diabetes20-22. Exercise can prevent or delay the serious complications of diabetes, namely, the vascular disease of the brain, heart, kidney, eyes, and legs that commonly occurs in diabetics who are under age 40. The same benefits of exercise are seen in those who develop the disease in later life. Exercise improves the abnormal blood lipid pattern and reduces the high blood pressure common in people who have diabetes. In addition, exercise increases insulin effectiveness and the metabolism of sugar, thereby reducing the insulin requirement, which in turn reduces the risk of vascular disease. Elevated blood insulin has been implicated in the pathogenesis of arteriosclerosis. The complexity of diabetes treatment requires a combination of methods to achieve healthy blood sugar levels and to prevent or reduce the serious complications of the disease. An exercise regimen, properly taught and followed, helps accomplish this goal and allows diabetic patients to lead healthy, active lives. Arthritis23-26. In patients who have rheumatoid or degenerative arthritis, exercise improves endurance, strengthens muscles, and increases joint flexibility and range of motion. These, of course, are benefits that drugs or surgery cannot achieve. Osteoporosis27-29. Osteoporosis affects 20 to 24 million postmenopausal American women and an unknown number of men over the age of 80. It results in musculoskeletal weakness, loss of height, bone fractures (primarily spine and hip), and painful disability. Two hundred fifty thousand hip fractures occur each year in the United States, resulting in 12,000 deaths and $11 billion in medical expenditures. Research indicates that regular exercise can prevent and control the disease. Dyslipidemia30-32. Abnormalities of blood fats (high total cholesterol and triglycerides and low HDL cholesterol) are major risk factors for vascular disease of the heart, brain, kidney, eyes, and legs. Regular exercise reduces total cholesterol and triglyceride levels and raises HDL cholesterol. Obesity33-36. The amount of body fat is a useful indicator of health and fitness, as well as an early warning signal of many serious diseases. Excess body fat is a risk factor for heart disease, hypertension, diabetes, many cancers (breast, prostate, colon, uterus, and gall bladder), and premature death from other causes. It appears that being overweight aggravates a very wide spectrum of diseases and is also a handicap to getting a job, obtaining admission to a university, and forming social relationships. The magnitude of the problem in the United States is greater than in any other country. Estimates of the number of overweight Americans range from 50 million to 200 million. The average American is said to have 20 to 30 lb of excess body fat. Daily, lifelong exercise is an essential strategy for achieving and maintaining optimal weight. Diet, though essential, cannot be relied on exclusively for successful weight loss and maintenance. Depression37-39. Depression, the most common mental disorder in America, affects approximately 5% (about 12 million) at any given time. Psychologists have observed that walking or running has both physiologic and psychological benefits for people who are depressed. These forms of exercise reduce depression and anxiety, increase feelings of wellbeing, improve tolerance to everyday stress, and improve the self-image of depressed patients. It is difficult to sustain depressed feelings while one is physically exercising. Furthermore, exercise stimulates the release of the "feel good" hormones (endorphins). One report38 concluded that walking or running while talking with depressed patients was more effective than talking and listening to them in an office because (1) the walking approach is non-confrontational--the patient and therapist are side by side, looking ahead rather than looking directly at one another; (2) the talking is being done in a less threatening setting; and (3) the patient is actively experiencing life rather than passively observing it in a chair. Cancer. There is evidence that physical activity reduces the risk for cancer of the left side of the colon40 and the breast41. COPD. Recent data42 suggest that adding an exercise component to the rehabilitation program for patients who have COPD results in physiologic as well as psychological benefits, even for those with severe air flow obstruction. A Plan for Therapy To be maximally effective for therapy or health enhancement, an exercise program must fulfill certain basic requirements: It must be a daily activity (7 days a week), it must be fun, not painful or excessively fatiguing, and it must fit an individual's preferences5-6. The selected activities must be readily available, not distant or difficult to reach, and preferably be close to the home or workplace. The clothes, equipment, and/or club membership associated with the activity must be inexpensive. Ideally, the activity should not depend on other people (team, class, or partners), but should permit group participation if desired. And finally, the activity must be suitable for lifelong participation. The major form of aerobic exercise should be (walking, running, cycling, swimming, or cross-country skiing). Variety is an important part of the prescription: At least two or preferably three different activities are recommended, for example walking-running-tennis or walking-cycling-swimming. The choice of exercise should be guided by individual preference and previous experience. Walking and running are most often recommended because they do not require special training or skills. They are inexpensive, readily available, safe, and suitable for doing alone or with others. The acronym DF ALIVE is helpful to guide one’s exercise program: Daily, Fun, Available, Lifelong, Independent, Variety, & Endurance. Encourage Lifelong Habits The daily goal is to exercise for at least 30 to 60 minutes (2% to 4% of the day) and to make a conscious effort to do body movement throughout 16 hours of the day (i.e., doing household chores, working, shopping, gardening, running errands, visiting, or socializing in an active manner5-6). Everybody should have an individualized lifelong exercise program designed to fit his or her lifelong situation and preferences. In recent decades, research has validated the effectiveness of regular exercise as a way to reduce and/or prevent age-related functional decline and reduce the risks of a sedentary lifestyle43. Most medical groups recommend regular physical activity44. People over age 65 carry the highest load of chronic disease, disability, and healthcare utilization45. Though many of these problems are preventable, primary care physicians rarely provide their older patients with an appropriate exercise recommendation that includes an individualized motivational message, a pre-participation evaluation to ensure a safe exercise program, and a tailored exercise prescription46. The first step in a pre-participation evaluation by your physician is to be evaluated for reasons not to be involved in exercise testing and training and to identify any risks or limitations relevant to an exercise program. An efficient screening questionnaire addresses previous exercise programs; present activity (frequency, duration, and intensity); existing chronic or acute disease(s), especially chronic obstructive pulmonary disease, cardiovascular disease, and extreme motor limitations because of severe arthritis; family history of cardiorespiratory disease; and coronary artery disease risk factors. Though most of the risk of exercise-related morbidity and mortality is associated with preexisting cardiac conditions, contraindications to exercise testing and training are the same for older and younger adults. Absolute contraindications to formal exercise testing include recent electrocardiographic changes or acute myocardial infarction, unstable angina, third-degree heart block, and acute congestive heart failure47. Relative contraindications to exercise testing include elevated blood pressure, cardiomyopathies, valvular heart disease, complex ventricular ectopy, and uncontrolled metabolic diseases. Physical Examination and Lab Tests The physical exam and laboratory tests focus on a patient’s functional abilities and/or limitations. A medical assistant, nurse, or other midlevel practitioner under a physician's supervision can usually accomplish most of the steps of the pre-participation exam. The average office-based evaluation takes about 20 minutes, though additional time is required if treadmill testing, bone mineral density scans, or respiratory function tests are needed. The physical examination should include vital signs and cardiorespiratory and musculoskeletal evaluation. Cardiovascular fitness. The American College of Sports Medicine (ACSM) recommends cardiac treadmill stress testing before commencing vigorous exercise (exercise intensity greater than 60% of maximal oxygen uptake) for men over age 40, women over age 50, and all patients who have cardiac risk factors with or without symptoms47. Treadmill tests, which can be used to estimate the patient's aerobic capacity, are useful for prescribing exercise intensity. If a treadmill test is unavailable, the Kasch pulse-recovery test can be performed in the office to give physicians a general idea of a patient's functional and aerobic capacities. The test is based on the principle that the better one's level of fitness, the sooner the heart rate returns to baseline after exercise. The patient's pulse and blood pressure are measured at rest and 1 minute after he or she has stepped up and down (with both feet) a 12-in. step 24 times per minute for 3 minutes48. To help patients adhere to this pace, setting a metronome to 96 bpm may be helpful. Respiratory function can be determined simply by measuring the patient's forced vital capacity and forced expiratory volume in 1 second. The Role Physicians Play in Prescribing Exercise Programs Medical students spend a year learning about pharmacology and they receive instruction on drug prescribing throughout their training. Often, the drugs they study will no longer be recommended by the time they are in practice. On the other hand, medical students are not instructed on how to prescribe exercise (or, for that matter, nutrition)—the best medicine of all. Physicians need more training in how to make best use of this powerful therapy. Physicians can successfully encourage increased activity by giving their patients a written exercise prescription along with printed advice on how to design a safe, enjoyable routine. Prescribing exercise is like prescribing medications, surgery, or other therapy—It is a thoughtful compromise between potential benefits and side effects. After careful consideration of these factors, the physician and the patient reach an agreement on the most effective plan. Important considerations include the goal of exercise (e.g., osteoporosis prevention, weight loss, strength improvement, marathon training) and patient preferences. Expanding on his or her current exercise habits is a good starting point because choosing activities the patient already enjoys improves adherence. Setting goals. The ACSM recently published separate position statements on exercise for healthy adults56 and older adults57. Kligman et al.58 have adapted these recommendations, combined with those from the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH)59, into a very helpful chart that outlines basic exercise prescriptions for a range of health and fitness goals. Basic Exercise Prescriptions for a Range of Health and Fitness Goals for Older Persons, Adapted From Federal Exercise Guidelines Fitness Dimension Disease Prevention Basic Health Fitness Performance Cardiovascular capacity Accumulate 30 min of physical activity most days Large-muscle repetitive exercise or equivalent sports activity, 20 min, 3x/wk Aerobic exercise or equivalent sports activity, 40-60+ min, 4-6x/wk Add competition and/or interval training Strength Include weight-bearing activity "Core four"* or equivalent program, one set, 8-12 or 12-15 repetitions at challenge weight,** 2x/wk, Pilates work*** Balanced whole-body free weights or machines, 1-3 sets, 8-12 repetitions reaching functional failure,++ 2-3x/wk, Pilates work Add ascending and descending pyramids+++ and muscle endurance or power training, Pilates work Flexibility Maintain range of motion by bending and stretching in daily activities 2-4 stretches after activity, 1 repetition, hold 30 sec 6-10 whole-body stretches before and after activity, 1-2 repetitions Add yoga, Pilates, and/ or facilitated stretches with a partner Body composition Men -- >5%-<25%>125-150 lb 12%-20% fat; maintain lean body mass at >125-150 lb 8%-15% fat Women -- >14<38%>90-110 lb 20%-30% fat; maintain lean body mass at >90-110 lb 17%-25% fat Balance and agility -- "Act like a child"; balance line; "Don't step on a crack"; brush teeth while standing on one foot Recreational sports (eg, tennis, biking); tai chi; social dance; therapy ball training Agility or skill sports (ie, surfing, skiing, skating); martial arts; performance dance; agility drills *Core four: double-leg press, chest press, latissimus dorsi pulldowns, abdominal crunch. **Challenge weight: the lift is difficult but can be accomplished. ***Pilates: a series of stretching and strengthening exercises performed on a mat without equipment, developed by Joseph Pilates in the 1930s. ++Functional failure: unable to complete another repetition without sacrificing form. +++Ascending pyramids: more weight is added to each set to cause fatigue with fewer repetitions; descending pyramids: weight is removed from each set to allow more repetitions until fatigue. Like the pre-participation medical evaluation, the exercise prescription should address the five major fitness components: cardiovascular fitness, muscle strength and endurance, flexibility, body composition, and balance and agility. Many older patients have low muscle mass and/or decreased strength, underscoring the importance of strength training. The ACSM recently added formal strength training recommendations to its exercise guidelines for adults56. Within the five categories, an individual and his or her physician should select the desired fitness level. The objective is to allow people to indefinitely maintain their current level of function and, ideally, help them reach the next category. The types and dosages of exercise will change as the patient's physiologic function changes. Selecting activities. An exercise program prescribed by your physician should address the type, frequency, duration, and intensity of physical activity for each fitness component. Though the type of exercise is often determined by available facilities and equipment, your preference should carry considerable weight. For example, if you enjoy golf you should be encouraged to occasionally substitute this activity for a treadmill and resistance training session. Your physician should balance the benefits of each exercise mode with the your health goals and physical limitations. For example, walking, bicycling, and swimming provide excellent cardiovascular benefits, but the weight-bearing nature of walking provides a greater stimulus for bone mineral deposition than cycling or swimming does. On the other hand, swimming is better tolerated by people who have joint limitations. Cross-training is an effective compromise among several appropriate options. You can mix exercise modes within any given week or within a single session. Cross-training programs help prevent boredom, condition more muscle groups, and reduce the risk of overuse injury. Determining frequency, duration, and intensity. Exercise variables can be manipulated to enhance compliance, but the dose-response relationship must be considered. Though exercising more often, longer, or harder affords greater conditioning, the relationship between effort and outcome is rarely linear. The point of diminishing return is often reached even before individuals approach levels that pose a risk of excessive fatigue or injury. Surprisingly little exercise is required to meet the recommendations for disease prevention (CDC-NIH recommendations)59. Physicians and exercise physiologists often make frequency and duration recommendations at minimal and optimal levels, with instructions to perform the minimal exercise during the busiest weeks and meet the optimal criteria on all others. Exercise intensity is always prescribed as a range (e.g., a target-heart-rate range of 120 to 145 beats per minute or muscle fatigue in 8 to 12 repetitions). Using an age-predicted target heart rate has limited value and is often misleading, especially as patients age, because 70% to 85% of age-predicted maximal heart rate is often off by 15 to 20 beats per minute. Physiologic change occurs when the body is exposed to stimuli greater than it can currently handle, a concept called “teasing the physiologic threshold.” The concept is useful even in balance and agility training. Many people underestimate their exercise capacity, considering physical activity to be uncomfortable, hazardous, or medically unwise. However, Fiatarone et al60 demonstrated the safety and effectiveness of a strength training program even for nonagenarians. The quantity and load of an exercise should be adjusted as function improved. An exercise prescription should involve monitoring or teaching patients to assess their own progress. MET levels are useful for setting exercise goals. A list of common physical activities classified by intensity in METs is available61. I have attached this article at the end of my article to help you design your exercise program. The Borg perceived exertion scale, http://www.cdc.gov/nccdphp/dnpa/physical/measuring/perceived_exertion.htm, is frequently used to evaluate aerobic exercise intensity; it can also be used to rate the intensity of resistance training and stretching. Maximal exertion on the Borg Scale is 20. Exercise physiologists often recommend aerobic exercise in the moderate to heavy range (13 to 15 on the Borg scale) for healthy young adults, and may modify their recommendations to light to moderate (11 to 13 on the Borg scale) for older adults. As function improves, increasing the intensity or duration of exercise should raise the challenge. In strength training, a common recommendation is to lift to muscle fatigue (inability to complete another lift while maintaining good form) in 8 to 12 repetitions. For older adults, 12 to 15 repetitions using slightly lighter weights may be more appropriate. Weight is increased when the patient can consistently complete 13 repetitions; then he or she repeats the process. The rate of improvement varies among individuals and may be slower in older adults. We have no control over our genetics and very little control over environmental factors, but the things that we can control—diet and exercise—can profoundly affect our longevity and quality of life. Exercise may be the closest thing we have to the fountain of youth. All we have to do is to “just do it.”