Strong Medicine

Exploring the Science, Art and Practice of Sustainable Health and Strength

Archives for April 2015

Strength After Sixty – Resilience Against Frailty: Part I

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Strength After Sixty

The topics of osteoporosis, sarcopenia, and the frailty syndrome are extremely important for anyone over the age of 60 or anyone planning to be in the future. This article will look at the need for preventative measures, the means to healthy aging of the musculoskeletal system, and the steps you can take to ensure that you will live out your years on this earth strong and physically capable.

Osteoporosis is a well-known condition involving decreased bone density with aging that most people are familiar. Sarcopenia is a disease of muscle loss and weakness that is the lesser known evil-twin of osteoporosis but just as important to understand. These two conditions comprise the public health problem known as frailty syndrome, which has unfortunately become increasingly common in aging adults.

Frailty syndrome is technically defined as “a decline in the functional reserves with several alterations in diverse physiologic systems, including lower energy metabolism, decreased skeletal muscle mass and quality, and altered hormonal and inflammatory functions.”

For a more user-friendly definition picture in your mind a stereotypical “old person.” You think of little gray haired men and women who are hunchbacked and have trouble walking. They are too weak to even stand, and look as if they would shatter with a minor fall. That image is what many of us now associate with the word “old.” No one wants to become the embodiment of this image as we age. We cannot slow the passing of the years, our chronological age, but we do not have to succumb to frailty. Strength training is not just for the young. You can become stronger and more resilient in your 60’s, 70’s, 80’s and even 90+. Strength training is arguably more important for the aging person and absolutely essential for healthy aging.

Frailty is what makes falls the leading cause of both fatal and nonfatal injuries among older adults.[1] Falls result in disability, functional decline and reduced quality of life. Fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation.[2]

The financial cost of frailty is huge. In a 2002 study, the cost of an individual fall averaged between $14,306 and $21,270.[3] The cost increases rapidly with age and could easily exceed most peoples retirement savings. In 2013, the total direct medical costs of fall injuries for people 65 and older, adjusted for inflation, was $34 billion, and is expected to reach $54.9 billion by 2020.[4] [5]

Fortunately there are steps we can take to avoid the bleak and costly condition of frailty as we age. Physical exercise is well recognized by both the layperson and the medical community as an essential part of a healthy lifestyle. Doctors will tell you the importance for “weight bearing” exercise when it comes to osteoporosis and sarcopenia. Unfortunately, there are only a very small percentage of physicians who actually know how to properly prescribe and program weight bearing, bone strengthening exercises.

Physicians are trained to diagnose and treat disease, but most do not have the expertise to write exercise prescriptions or coach weight training techniques. It is ironic that exercise, one of the most powerful disease-preventing modalities, is not taught in medical education.

In my opinion as a strength coach and fitness professional, that lack of basic education is why there seems to be lack of information coming from the medical community about effective weight-bearing exercise. If you look at the Surgeon General’s Report on Bone Health and Osteoporosis, strength training is underemphasized and casually mentioned along other activities such as walking, dancing and gardening. No one ever seems to mention that those who have the strongest muscles (such as weight lifters and powerlifters) also have the most dense bones, and never succumb to osteoporosis or sarcopenia.

It’s understandable why a physician who is not also a trained strength & conditioning specialist would not elaborate on such a topic, but most will confirm that loading the axial skeleton is what increases osteoblast activity, resulting in bone production. Because of the body’s hardwired adaptive response to loading, the heavier the load is, the stronger the bone. However no doctor in their right mind would tell their patient to go lift the heaviest weight they possibly can, especially if that person was already showing the signs of frailty syndrome.

I have the unique position of being strongman and a strength coach who has worked with the senior population for the last 10 years. As a young trainer, I begun my career at a retirement community, and in the same calendar year won the Maryland Strongest Man contest. I also did a stint working as a strength assistant for the Baltimore Ravens. I have since gone on to open my own gym and work with people of all ages and backgrounds. Senior fitness was my first paid position as a strength professional, and I still teach a weekly class at the same retirement community at which I started my career.

My work with seniors has highlighted the importance of the role strength training plays in health and longevity and countering the negative effects of frailty syndrome. I have seen people of 70, 80 and 90 years of age who, because of regular strength training, do not fit the characteristics we associate with “old.” I have documentation of post-menopausal women (those most at risk for osteoporosis) I have coached achieving increased bone mineral density measured by DEXA scans.

One of Dan’s clients, Tom (age 70) on left, and Strong Medicine co-author Marty Gallagher (age 65) on the right. Both are embodiments of strength after sixty.
One of Dan’s clients, Tom (age 70) on left, and Strong Medicine co-author Marty Gallagher (age 65) on the right. Both are embodiments of strength after sixty.

I know how to program advanced powerlifting techniques and scale them to the senior population, and as much as I’d like to say “follow this exercise program to stronger bones” there are many things to consider in exercise prescription. There are obvious things such as which exercises for how many sets and reps, but there are more complex things like needs analysis, individual body mechanics, safety and technique. Just as a doctor would not write a drug prescription to a patient he has never met, I cannot write a cookie-cutter program to cover everyone reading this blog post. That being said, in part 2 of this article, I will cover some general techniques and principles for strength training an aging population. With the proper application of resistance training our potential for strength is limited only by the number of years we have left to train. Exercise is an individual responsibility and those who strive for strength will achieve it at any age. Survival truly is, of the strongest.

Editor’s comment:

The importance of this topic cannot be overstated. Dan has done an excellent job describing the problem we are facing with frailty in our ever-growing aging population. There is an unmet need for real strength training programs for our seniors that are both effective for reversing/preventing frailty and safe. If you are a trainer looking to make a huge impact on public health, start acquiring a skill set to work with this population. Dan has considerable experience and expertise in this area and is going to lay out some general training principles in Part II of this post so stay tuned…

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Dan Cenidoza, BS, CSCS is a personal trainer, professional strongman and owner of Art & Strength in Baltimore, Maryland. He has a degree in exercise science and specializes in kettlebells and strength & conditioning. His mission is to instruct and inspire people to live stronger, healthier lives. artandstrength.com facebook.com/artandstrength

References:

[1]Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed August 15, 2013

[2]Rubenstein LZ. Preventing falls in the nursing home. Journal of the American Medical Association 1997;278(7):595–6.

[3]Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorston K, Chan L. Falls in the Medicare population: incidence, associated factors, and impact on health care. Physical Therapy 2009.89(4):1-9.

[4]Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006a;12:290–5.

[5]Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of Forensic Science 1996;41(5):733–46.trial. The Gerontologist 1994;34(1):16–23.

Eight Mental Health Benefits of Regular Exercise

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Human brain x-ray view

I’m a psychiatrist and a huge fitness enthusiast. It is gratifying to be able to incorporate exercise, something that I am passionate about in my personal life, as a powerful component in the treatment of my patients with depression.

Depression is a disease of the brain. It affects around 20 per cent of people men and women in their lifetime. It’s associated with a significant reduction in functioning and provides a large economic burden on society.

Most treatment consists of a combination of medicines and therapy. In addition to this conventional approach to depression, treatment can be supplemented or augmented with physical exercise with significant benefits. This is supported by my experience as a doctor treating depression and some evidence from scientific studies. The benefits of exercise in the treatment for depression are many:

Stress reduction: It’s been well documented in science that exercise improves the ability of the body to handle stress. Exercise acts to reset and strengthen the body’s ability to handle stress. In addition, I find personally that after a stressful day, fully immersing myself in a workout tends to bring me out of my head. While I’m working out I actually don’t even think about everything that was on my mind earlier in the day. After the workout, I use the calm to think through some of the problems that may have seemed without solution earlier in the day.

Improved self esteem: Many of my patients often have a negative view of themselves. They feel that they can’t do anything right. Regular exercise brings about improvements fairly rapidly. There are mental benefits of calm and stress reduction. Often there are improvements in body image or the joy of working through a progression and achieving a skill. Nothing boosts self esteem like being able to accomplish a goal through regular training.

 Socialization: My depressed patients tell me they find it hard to leave the house. Some of them have significant social anxiety. Their world becomes closed in. Workouts rarely happen alone. Generally, people are going to the gym to begin to workout. Interaction with other people can occur at the gym. There are trainers who can provide help, group classes, and friends that can improve socialization. Even if the workouts are happening at home, often people will post their workouts on social media drawing support and encouragement through social media.

Improved Sleep: My depressed patients often have trouble falling asleep, or they wake up in the middle of the night and find it difficult to get back to sleep. It’s well known that regular exercise improves sleep hygiene. People begin to know and understand their bodies. If they stay up late watching TV, they won’t be able to perform optimally during their workouts the next day.

Elevated energy: It may seem backwards that you have to expend energy to get energy. In depression, patients have lost energy and motivation. The anergia (lack of energy) of depression kills motivation and people find themselves sleeping all day, staying up all night. Regular exercise improves the production of catecholamines (energy producers) in the body that help sustain energy throughout the day.

Mobility/Pain Reduction: Depression kills energy. Loss of energy leads to less movement. Once you stop moving, joints become stiff. Muscles ache. This leads to less movement and more pain. Movement loss leads to weight gain. The additional weight and pressure on the joints in the body, the low back, the knees, the hips compound pain. As you begin to exercise, mobility increases, reducing joint pain. As weight drops, pressure on the joints diminishes further reducing pain.

Improved eating habits: My depressed patients tell me they aren’t hungry, yet many of 
them are overweight or have gained weight. In a misguided attempt to improve mood, patients often turn to the wrong types of food: foods laden in sugar, salt and fat. The result is weight gain and further reduction in self-esteem. The journey to physical fitness is often accompanied by a change in diet. Very often people get interested in a diet that compliments their fitness regimen. Foods that fuel exercise are often healthier: fruits, vegetables and protein. Many of my patients cannot treat their depression strictly through exercise alone. Depression is a disease and many of my patients will need medicine in order to feel better. Unfortunately, a side effect of many of the medicines I prescribe for depression is weight gain. Some of the stronger medicines worsen glucose tolerance and can lead to problems in metabolism of fats leading to elevated cholesterol. If I could add exercise to their prescription I know I could lessen this effect.

Joy : Accompanying depression is something called anhedonia. Anhedonia is the inability to feel joy. It’s one of the core symptoms of depression. Depression not only saps your motivation but it also saps your ability to feel happiness. My patients often look at me incredulously when I encourage them to engage in more activities. The act of engaging in activities may be difficult at first, but as they begin to consistently add activity like exercise back into their lives, the emotional shackle of anhedonia starts to disappear. Regular exercise will aid in reclaiming the joy in life.

There are different levels and severity of depression. It is important to understand that exercise tends to work best in patients with mild to moderate depression. Severe depression is a very serious condition and should be treated under the care of a mental health professional. There is not much evidence to suggest that exercise is beneficial to patients in the midst of a severe depression.

Depression is a disease and while exercise can be a very effective treatment, it has its best effect when used as an addition to traditional treatments such as medicine and therapy.

The benefits of exercise listed above are not just seen in people in the grip of mild to moderate depression. Exercise is a powerful preventive strategy for mental health. It’s well known that regular exercisers are happier, have more energy, sleep better, have more sex and are better socialized then non-exercisers. We often focus on the physical transformation that exercise can bring – the mind and the body are connected and as the body improves so does the mind.

Exercise is good for the brain

Editor’s comments:

This week I am privileged to introduce Bradley Sadler, M.D. to the Strong Medicine community. Dr. Sadler is a Johns Hopkins trained psychiatrist as well as an avid student of physical culture. As a practicing psychiatrist he is in the clinical trenches daily, working tirelessly to improve the mental health of his patients. Anxiety and depression are huge public health problems and often are not addressed effectively due to social stigma and incorrect beliefs that they are products of mental weakness or some other type of character flaw.

It is hard for me to take seriously any recommendations for nutrition and exercise given by an out of shape physician who looks like he would be winded from walking up a flight of stairs. Dr. Sadler practices what he preaches. I think we can all take exercise recommendations seriously from a psychiatrist who is coming close to a legit front lever!

Dr. Brad showing his PCC skills
Dr. Brad showing his PCC skills

Dr. Sadler has constructed an excellent overview of the positive benefits of regular exercise for mental health. His article an example of excellent public health messaging. It is clear, concise, and easy to comprehend for the layperson.

Within his article are some very important concepts. Among these is the statement “Depression is a disease of the brain.”   This is actually quite a profound point that is a departure from previous paradigms looking at depression as a “psychological” condition. Depression and anxiety are the end results of structural and functional changes within the brain. As we have a very sophisticated readership in the Dragon Door community, many of you will want to know what is going on “under the hood” in the brain with exercise and depression.   I will team up with Dr. Sadler to write a future post covering the latest theories on the underlying mechanisms behind the observed benefits of exercise for mild to moderate depression. We will also take some of his points outlined above and put them in the context of concepts covered in the Strong Medicine book such as allostasis (“Stress Cup”), neuroplasticity, and chronic inflammation.

Depression has a profoundly negative impact on the quality of life for so many people and is seldom talked about openly. Many thanks to Dr. Sadler for contributing this post on a topic that is not often addressed effectively, and certainly not given the attention it deserves in public health discussions.

Maximizing the Health-Span: Introduction

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Strong Medicine Maximizing Health-Span: Introduction

Mortality is the great equalizer. It is the single characteristic all human life has in common. As Jim Morrison said, “No one here gets out alive.” Although some embrace our mortality as a defining aspect of what it means to be human, the specter of death has haunted many since the origin of our species. We are now at a point in our technological development that some think that the ability to cheat death will soon be within our reach.

Over the past couple of years, Silicon Valley billionaires have collectively invested billions of dollars toward the quest for immortality. Research into finding the molecular equivalent of the fountain of youth is proceeding at a feverish pitch fueled by this massive influx of funding. Whether you agree with this goal from a moral or philosophical perspective, the scientific pursuit of extending the human life-span will likely result in new medical advances with carryover benefit to the treatment of devastating afflictions such as cancer and neurodegenerative diseases. On the other side of the coin, there would be significant downstream effects on world-wide society by extending the human life-span, including problems with overpopulation and dwindling natural resources just to name a few.

I am not posing the question for whether we should pursue life-span extension or not. That is a philosophical argument with many valid points of view. I do question the amount of money and resources that are being allocated for life extension research when most of us are not living even a normal human life span in good health. The majority of us have not maximized our health-span. This is readily apparent by even a cursory examination of the current state of public health with respect to chronic disease. Two-thirds of us are obese or overweight and preventable diseases such as diabetes have become the equivalent of modern plagues, spreading despite our best attempts at intervention. Our children are the most at risk, as the current generation is projected to be the first not to outlive their parents.

The Strong Medicine book was written with the aim of increasing the health-span of the general public through prevention. We aimed to empower people to live a life largely free of disease and with high physical function into old age. Even with the level of detail and breadth of subject matter in the book, they were still broad brush strokes and certainly not the end of the story for maximizing the human health-span.

There are many challenges to implementing an individualized program of “health-span optimization.” It is easy to tell someone to eat more locally-sourced organic fruits and vegetables, but hard for them to implement if they live in the “food deserts” found in many of our major cities. Regular intense exercise can be difficult for those with limited time due to seemingly endless demands of daily modern life, or for those impaired by injury or disability. There are also countless “techniques and tactics” on the Internet purported to be the magic bullet for achieving your health and fitness goals.

We will use the Maximizing the Health-Span (MHS) series to address challenges in individualized health-span optimization. We will also use the MHS series to put some of the latest and most popular health/fitness techniques and tactics to the test by looking under the hood and uncovering biologically plausible mechanisms and evidence of effectiveness.

In keeping with the mission of this blog, I not only welcome your comments, but encourage you to submit potential subjects of interest for future posts in the Maximizing the Health-Span series.

Stay tuned for the first post in the MHS series when we will examine the practice of intermittent fasting as a potential tactic for increasing the health-span. Start doing your own research on intermittent fasting now so we can have an informed discussion about the potential benefits and risks when the post goes live…

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Chris Hardy, D.O., M.P.H., CSCS, is the author of Strong Medicine: How to Conquer Chronic Disease and Achieve Your Full Genetic Potential. He is a public-health physician, personal trainer, mountain biker, rock climber and guitarist. His passion is communicating science-based lifestyle information and recommendations in an easy-to-understand manner to empower the public in the fight against preventable chronic disease.