MEN: THE FORGOTTEN PATIENTS - The challenges facing men in adequately dealing with health and lifestyle issues – and what doctors need to do about it
By Dr George Janko - Medical Director, McKinnon Sports Medicine  Men have to be tough in our society and so it's not surprising that men tend not to think about health but about survival. Even though we are becoming more egalitarian, men often feel that the bottom line responsibilities of life still lie with the male. As a result men are impatient with discussion about preventive medicine, about stress and mental health, about depression, about impotence, about smoking, about drinking, about prostate and about rectal examinations.
At the same time the medical profession and the Government have neglected men's health issues. This has been the result of lack of community interest and inadequate understanding by doctors and politicians - most of whom were men. The lobbying that has driven political interest in women's health issues such as pap smears for cervical cancer prevention and mammography for breast cancer has up till the present time not existed for men.
Yet believe it or not more men die from prostate cancer than women die from breast cancer. The difference is that women tend to develop breast cancer at an earlier age than men get prostate cancer. So breast cancer tends to be a more emotive issue for those left behind to grieve. Heart disease on the other hand hits men a lot earlier than it does women. Both sexes however are affected. Surprisingly only about 41% of women die from breast cancer but 44% die from heart disease. Women however die from heart disease later in life because up to menopause they are protected by high estrogen levels. So again, the attitude of our society has tended to be if you die over sixty or sixty-five you die from old age. Today most younger and adult people tend no longer to think that way.
Footy Quarters
In fact I have developed my own Modern Age Classification along the lines of the four quarters of a footy match:
- Teenager till 25 years (confirmed by psychologists)
- Adult - 25 to 50 years
- Middle age - 50 to 75 years
- Mature adult - 75 to 100 years - the final siren
I am sure you will all agree this is what we should aim for. How do we achieve it? Education must be the answer! And so this is where you all come in.
Scientific studies show again and again the importance of genetic endowment on body type and predisposition to various diseases such as cardiovascular problems, immune insufficiencies and even cancers. But if genes determine 50% of the end result than the other 50% must be determined by the environment - by lifestyle management issues - diet, stress, smoking, alcohol, exercise, self esteem, marital status, hygiene and exposure to infectious diseases. All people need to learn the way to manage these issues to avoid the pitfalls they form for the uninformed. Fitness trainers are in a position to deliver some of this information but must be aware of the dangers of spreading misinformation. Sometimes a little knowledge can be a dangerous thing. Unscrupulous promoters will too often target fitness trainers. They will make their particular product seem to be the newly found fountain of youth. Be aware of this because in reality there are no simple solutions to the complex area of health.
RelationshipsRecently in the "scientific" publication Cosmopolitan I came across a list of what men and women supposedly want from a relationship. Women tend to want to be loved and cherished. Men on the other hand want the following:
- To feel adequate just the way they are
- To feel that they are in charge
- To be respected
- To know their partners are their confidantes
- To have companionship
- To feel appreciated
- To be sexually fulfilled
So men need to feel they are OK, they are in control, they are respected, they are contributing. To help men we need to be careful not to be too dictatorial. For doctors, this means we need to let our clients feel that they are being involved in the decision making processes. Often though it may be the women in their lives (or significant others) who alert men to the need to look at health issues. Let's look at some ways doctors can help our male clients.
Importance of testing Exercise is of course most important but let's make sure our Exercise Prescription is safe and efficient. Male clients over 35 years old and females over 45 years old should have a maximal exercise electrocardiograph (ECG) before starting an exercise regime. Other clients of concern are those with significant health problems such as heavy smokers, obese clients, symptomatic clients (chest pain, high blood pressure, dizzy spells, shortness of breath, etc), and clients with diabetes, asthma, high blood lipid levels and other health problems.
Those with a family history of heart attacks, high blood lipid levels, strokes or other artery diseases must also be a concern. All these clients should have an ECG under exercise conditions to maximal heart rate before commencing an exercise program.
What does an ECG tell the fitness trainer?
- The resting ECG is a template of the electrical impulses in the heart-muscle that will remain the same for the individual unless a problem arises in the heart. It looks at the form, regularity and rhythm of these electrical impulses.
- The exercise ECG measures any change in these electrical impulses when the heart muscle is being stressed - hence the term "stress test". In effect a stress test measures the integrity of the blood flow in the coronary arteries which supply the heart muscle with the required nutrients for adequate performance. Blockages in these arteries can result in changes in the character of the electrical impulses. Sometimes these changes at maximal heart rates may be associated with chest pain, shortness of breath or other symptoms but this is not always so. Any noted changes may be followed up by further investigations such as a thallium stress test, an echocardiogram, and an angiogram. If blockages are found they may lead to CABG or coronary artery bypass grafts in which the coronary artery blockages are passed by another vein or artery.
- Resting heart rates and recovery heart rates can also be indicators of fitness and are routinely measured. Spirometry or Vitallograph tests measure lung function before the stress test. Total lung capacity, expired air flow in the first second of breathing out forcefully and the maximum speed of the expired air are measured. This helps us to check for any signs of lung disease and in particular for asthma which affects about 50% of the population.
You may think that figure astounding but many people suffer from what is called sub-clinical asthma. In this condition clients do not get a wheeze and are not in obvious distress that usually requires a loss of about 50% of lung function. They may simply get a dry cough or some chest tightness and only feel unfit. Measurement of lung function again after exercise can be a predictor for exercise induced asthma (EIA).
What about blood tests? Prior to undertaking a stress test the client may be asked to have a fasting blood test. The fasting component checks for blood cholesterol and triglyceride levels as well as blood sugar levels (diabetes). Results may also check for male menopause by testing for male hormone levels, prostate test for PSA (prostatic specific antigen), liver enzymes (hepatitis and alcohol consumption), kidney function and blood for anaemia, leukaemia etc.
Prostate checks present a particular difficulty for most males as they are associated with the possible insertion of a finger in the back passage. It brings us back to the idea of being potty trained and what would happen if I suddenly want to pass wind (or worse)! Of course the prostate is also linked with SEX and typically of the male philosophy remember 'if it ain't broken don't fix it'!
Fortunately the blood test is much easier but if a finger does need to be inserted it is for only a brief second or two and may only feel a little uncomfortable. Recently Michael Schildberger who himself has developed prostate cancer at 59 years of age has been publicising prostate cancer. It is now considered reasonable for males to have a regular prostate check from the age of 40 onwards. This especially applies to those with a family history of prostate cancer. Waiting for symptoms such dribbling of urine or a reduced stream is not advised. 
Measuring aerobic fitness levels and anaerobic threshold (AT) heart rate gives the fitness trainer an insight into how to exercise the client. The highly sophisticated equipment available at a few exercise physiology laboratories such as ours at McKinnon Sports Medicine makes V02maX testing a pleasure. An easy to understand report is always provided to the client and their trainer to make the exercise program much more specific to the level at which the client should exercise at in order to improve their aerobic fitness.
Working the client at the anaerobic threshold heart rate allows muscles to be stressed in an oxygen deprived environment increasing the blood vessel supply to the exercising muscles. On the microscopic level it allows the muscles to increase the mitochondria (powerhouse) numbers in each muscle cell. This test also suggests the client's ability to work within a lactic acid load.
Diet is a complex issue and is discussed elsewhere on this site.
Stress management is also complicated for all of us. Remember stress is only the difference between the pressure in your life and how you cope with it. Many things can help us cope. Exercise for one helps us get rid of that excess adrenaline which our bodies produce when we feel trapped, out of control, rushed, betrayed, threatened etc. Having good social supports can reduce stress also. So can having good self-esteem and even utilizing some concepts of denial and rationalising of one's problems.
Men’s health is complex In conclusion, men's health is a complex issue which men need to address but which women need to understand. Recently more and more men seem to be taking up the idea that health and fitness go hand in hand. The simple fact that our bodies have been naturally selected to survive for thousands of generations by our strength and endurance as well as our brain seems to be slowly permeating parts of our society. More and more individuals are willing to pay fitness trainers to motivate them and to structure a more interesting, effective and safe program for them. The costs are still largely born by the individual and with more and more pressure to reduce the cost of health care in Australia this is likely to continue.
Unfortunately the Health Budget should really be called the Sickness Budget because government emphasis has been purely on fixing up the leaky holes in the health bucket. Discussion of preventive medicine has only been on a superficial and hypocritical scale. Only when the Minister of Health really understands the issues of prevention and really decides to push these into the public eye will the Health Budget and Men's Health stop looking so sick.
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