Men: It's Time to Make Health a Priority

Raza Ahmad, MD, discusses the importance of men’s health. Dr. Ahmad practices at Delancey Internal Medicine, now located at Penn Medicine Washington Square.

Raza Ahmad, MD

When it comes to taking care of the house, men will clean the gutters, cut the grass, fix leaky pipes and do many other things to make sure it “stays in good shape”. But, when it comes to their own well-being, they are sometimes less motivated to put the same amount of effort into it. Perhaps this sounds like your dad, brother, son, husband or, even, yourself?

The summer is a great time to remind the men in your life about the importance of getting annual check-ups, proper screenings and taking a look at their overall approach to good health. Make sure that they look as good from the inside as from the outside.

Even if feeling healthy, it’s important to have annual check-ups. This gives your physician the opportunity to obtain a detailed medical history and a thorough physical exam. Additionally, we will collect baseline blood work, including cholesterol, and refer you for proper screening tests, if needed.

With these wellness checkups, potential problems can be identified before they become serious. This also gives you and your physician an opportunity to build a relationship, which will help you and your care team stay ahead of any issues. Should a health situation arise, these previous interactions will help your care team develop a personalized and focused treatment plan.

Your doctor can also provide advice on a proper diet and the best ways to exercise by taking into account your age, weight and family history.

Timetable for Maintaining Good Health

Below is a basic guide providing general medical evaluations for adults. This guide does not take into consideration any existing symptoms, chronic conditions or family history.

If you have any specific questions, your regular well checkup would be the time to ask. Playing catch up in the bottom of the ninth inning with two outs is not a position you want to be in when it comes to your health. Preventative medicine is the best medicine!

Take the next step to good health.

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Top Research in Bipolar Disorder: Reading Links

In June I will be looking for some of the top recent research advances in bipolar disorder.

Although less common than unipolar depression, bipolar disorder is a serious disorder with high rates of disability and hospitalization.

I will try to cover the spectrum of important areas in bipolar disorder during the month including: epidemiology, risk factors, biomarkers, genetics, brain imaging, neuropsychology, psychopharmacology and psychological interventions.

Here is a starting group of important studies. Some will be covered in more detail in a future post. Click on the study title to be taken to the full abstract and the free full-text manuscript.

Suicidal behavior in bipolar disorder with antidepressant use

This study examined participants in the Collaborative Depression Study, a naturalistic longitudinal study of bipolar I, bipolar II and unipolar depression. The study found a 54% reduction in suicidal behavior in bipolar I subjects receiving antidepressant therapy and a 35% reduction in bipolar II subjects receiving antidepressants. Of note, use of antidepressants in unipolar depression was not linked to change in suicidal behavior frequency. 

Anti-inflammatory markers in bipolar disorder: Effects of celecoxib (Celebrex)

Mood disorders are commonly linked to elevated markers of inflammation including serum cytokines. In this study, subjects with bipolar disorder receiving electroconvulsive therapy were randomly assigned to the anti-inflammatory drug celecoxib versus placebo. Celecoxib treatment was linked to reduced levels of tumor necrosis factor-alpha but not to reduced levels of two interleukin levels and c reactive protein levels.

Biomarkers in bipolar disorder

This manuscript is a review of the literature in biomarker research for bipolar disorder. The authors found support for several brain structural markers including reduced gray matter volumes in the prefrontal cortex. Serum measures of neutrophic factors, oxidative stress and inflammation also hold promise as biomarkers in bipolar disorder.

Brain connectivity in bipolar disorder vs schizophrenia vs controls

A study of resting state connectivity using functional magnetic resonance imaging targeted a group of subjects with bipolar disorder, schizophrenia and healthy controls. The study found significant differences in connectivity between bipolar subjects and controls although these differences were less pronounced than the differences between a group of schizophrenics and controls.

Genome-wide association studies of schizophrenia, bipolar disorder and unipolar disorder

This study examined results from 60,000 subjects in the Psychiatric Genomics Consortium. The study found evidence for common pathways across the schizophrenia, bipolar and unipolar groups that involve neuronal, immune function and histone methylation.

Follow me on Twitter for updates in neuroscience research. @WRY999

Photo of orangutan is from the author's files.

Conduct Disorder as a Substance Abuse Risk Factor

In this series of research reviews on conduct disorder several important findings are evident.

1. Conduct disorder (CD) commonly evolves into adult antisocial personality disorder
2. Conduct disorder in children often presents along with attention deficit hyperactivity disorder and learning problems
3. CD in childhood and adolescence raises risk for alcohol, drug and nicotine dependence.

Margaret Sibley and colleagues recently published a study of CD and ADHD and later initiation and escalation of the use of alcohol, cigarettes and cannabis.

In her study, 113 children with ADHD were assessed between the ages of 5 and 18 years of age. A control group of 65 children without ADHD were similarly assessed during this developmental period.

Twelve percent of the childhood ADHD later met criteria for a diagnosis of CD. This contrasts with only 1.5% of the control group. Also noteworthy was the high rate of oppositional defiant disorder in the ADHD group (59%) compared to only 5% of the control group.

Significant differences emerged in substance use. These key findings included the following:

• ADHD adolescents were more likely to have ever smoked a cigarette (47% v 28%) and were much more likely to be daily smokers (27% v 6%).
• ADHD adolescents were not more likely not more likely to have ever tried marijuana (53% v 51%) but were more likely to use on at least a weekly frequency (23% v 8%).
• There were no differences in the ADHD group compared to controls in ever use of alcohol or frequent drinking
• Maternal drinking in early childhood was the strongest predictor of adolescent alcohol use

The authors also found another important finding:

"escalating CD symptoms in childhood were viewed as a mediator of the relationship between ADHD and cigarette and marijuana use."

The authors noted in the longitudinal data analysis that increasing ADHD symptom endorsement predicted more CD symptoms. More CD symptoms was the strongest predictor of later substance use.

The take home message for clinicians is early identification and treatment of ADHD in children is important. Early identification and treatment of ADHD holds the promise for modifying later CD and substance use morbidity.

This is an important study teasing out some of the issues in ADHD/CD overlap and later substance use risk. Readers with more interest in this topic can access the free full-text manuscript by clicking on the PMID link in the citation below.

Graphic figure is an original created by the author using Canva.

Follow the author on Twitter @WRY999

Sibley MH, Pelham WE, Molina BS, Coxe S, Kipp H, Gnagy EM, Meinzer M, Ross JM, & Lahey BB (2014). The role of early childhood ADHD and subsequent CD in the initiation and escalation of adolescent cigarette, alcohol, and marijuana use. Journal of abnormal psychology, 123 (2), 362-74 PMID: 24886010

How Much Water Do You Need Each Day?

Raza Ahmad, MD, discusses the question of how much water to drink on a given day. Dr. Ahmad practices at Delancey Internal Medicine, located at Penn Medicine Washington Square.

Raza Ahmad, MD

We all know the human body is predominantly made up of water. We also know that the body thrives when it is properly hydrated. But what is "proper hydration?" Do we really need to be running to the water cooler every 15 minutes to fill up our water bottle? And, do we really need to drink so much water? Can we drink other liquids instead? The answer is…well, a bit fluid.

Why Water is So Important

Water is a vital part of your body’s overall health — because it affects every cell of your body. It is a huge component of muscle and helps you produce energy. This is why you’ll often get a cramp when you work out without proper hydration.

Water also helps the body to maintain its temperature, remove waste and lubricate joints.

“Hydration has the greatest impact on training, performance and recovery," says Dr. Ahmad. "Dehydration, even at the lowest level, can result in impaired performance.”

How Do I know I am Hydrated Enough?

Dehydration occurs when your body loses more fluids, mostly water, than it is taking in. With dehydration, more water is moving out of our cells and body than what we take in through drinking.

The signs and symptoms of dehydration range from minor to severe. Increased thirst, dry mouth, weakness, dizziness, confusion and fatigue are all signs that an individual may be lacking the proper amount of water.

Many think that dry mouth is one of the first signs of dehydration. If you are experiencing dry mouth, though, your body is likely already craving water. If you are concerned that you may be dehydrated, a good way to check is to check the color of your urine.

If your urine is anything but clear, you are lacking the water your body needs. Yellow and orange are not the colors of healthy urine. If your urine is brown, you need to speak with your physician.

Should I Only Drink Water?

It is rare, but you can actually drink too much water.

As much as you need water, too much in your system can create an imbalance between water and electrolytes. When you sweat or lose water through other ways, you lose electrolytes. Replenishing your body with just water can dilute the electrolytes that are already low in your system. This could lead to your sodium levels becoming very low. When this occurs, you could become very ill. Although this is rare, it does occur.

During intense physical activity where you are sweating quite a bit, you may want to grab a sports drink or coconut water rather than plain water. This will help to better replace sodium lost in sweat.

"For slower athletes, it is recommend to drink according to thirst," said Dr. Ahmad. "Elite level athletes should follow a recovery plan, which includes drinking water and carbohydrate-electrolyte drinks."

How Much Water Do I Need Each Day?

This is last for a reason. Although the question is rather simple, the answer is much more complicated.

Unfortunately, there really is no one-size-fits-all approach to the amount of water you should consume on a daily basis.

As a general rule of thumb, you should try to drink between half an ounce and an ounce of water for each pound you weigh, every day. For example, if you weigh 200 pounds, it is recommended you drink 100 ounces of water if you are performing non-strenuous activities.

If you are going to be working out or hiking, you definitely should add to those 100 ounces. It is recommended that you drink 12 ounces of water a couple hours before your activity and then another 12 ounces about 30 minutes prior to the start. Be sure to also drink throughout the activity.

Other factors to keep in mind when thinking about your daily water consumption include the environment and any illnesses or health conditions. Hot or humid air makes you sweat more and will require additional intake of fluid. If you are sick and vomiting or have a fever, you will again be losing fluid more quickly and need to replenish.

As you can tell, being properly hydrated is important but not a perfect science. The best approach is to listen to your body and look for the feedback signs.

"I can not emphasize enough the importance of hydration," says Dr. Ahmad. "It has the greatest impact on training performance and recovery. Lack of hydration can lead to severe problems, including muscle breakdown, kidney injury and electrolyte imbalances."

Keep Calm and Hydrate on!

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If The Shoe Fits…Run!

Daniel C. Farber, MD, Foot and Ankle Surgeon, discusses the importance of picking the proper running shoe and offers advice while going through the selection process. 

To avid runners, there is much more to the sport than simply lacing up any type of running shoe. They know that selecting the proper shoe is an incredibly important part of preparing for any type of competition.

Daniel C. Farber, MD

If you're wearing a shoe that doesn't fit your feet properly, you have a better chance of developing an improper gait or poor biomechanics. This added pressure on the heel or ball of the foot could lead to pain, plantar fasciitis, stress fractures, hallux valgus, (bunions) and lesser toe deformities.

When you're standing in the shoe store, most running shoes feel comfortable. Still, the true test doesn't come until you've pounded the pavement for several miles.

"Not all shoes are the same. Make sure you choose a shoe that fits your foot shape and running style," Dr. Farber recommends. "Remember that the most expensive shoe is not necessarily the best. The midrange shoes often have the more proven technology without the trendy price."

So, how do you sift through the many different brands and styles to ensure your feet stay happy and you stay pain-free?

• Try on all shoes. Sizes among shoe brands and styles tend to vary. Don’t select shoes by the size marked inside the shoe. Judge the shoe by how it fits on your foot.
• Select a shoe that conforms as nearly as possible to the shape of your foot.
• Have your feet measured regularly. The size of your feet changes with age. For women, it may change during pregnancy.
• Have BOTH feet measured. Most people have one foot larger than the other. Always fit to the larger foot.
• Get fitted at the end of the day. The best time to measure your feet is at the end of the day when your feet are largest.
• Stand during the fitting process. Standing allows you to check that there is adequate space (3/8" to 1/2") for your longest toe at the end of each shoe.
• Comfort is important. Make sure the ball of the foot fits comfortably into the widest part (ball pocket) of the shoe.
• Don’t expect them to stretch. Avoid purchasing shoes that feel too tight, expecting them to “stretch” to fit.
• Minimize slippage. Your heel should fit comfortably in the shoe with a minimum amount of slippage.
• Take a stroll. Walk in the shoes to make sure they fit and feel right.

Finally, remember that knowing when to replace your running shoes is just as important as picking the proper pair. Dr. Farber recommends that running shoes should be replaced every 3-6 months (or 300-500 miles) as they show signs of wear.

"With less activity, once a year is adequate Dr. Farber said. "If a shoe is in good condition, but has lost the cushioning of its insole, you can oftentimes simply rehab it with an over-the-counter insert."

"However, if the shoe looks and feels worn and doesn't support your foot well, replace it no matter what the age."

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Are Women Athletes More Susceptible to Injury?

Erik Thorell, DO, discusses if gender plays a role in individuals being more susceptible to injury. Dr. Thorell practices at Penn Medicine Woodbury Heights.

In a perfect world, every run would be completely pain-free. No soreness, no aches and no lingering effects from the previous workout. Unfortunately, many runners constantly deal with a slight disturbance. There are things that can be done by, both men and women, to reduce the risk of injury.

Regardless of how careful you are, injuries do occur. And, for women, the rate of injury is slightly higher. Runner’s knee, stress fractures, shin splints and plantar fasciitis are all injuries that are more common with female runners.

“One anatomical difference between men and women leading to greater predisposition to lower extremity injuries is the wider female pelvis, which results in a larger Q-angle,” says Erik Thorell, DO. “This results in increased stress across the knee in particular.”

Simply put, men and women are built differently. Women tend to have smaller, weaker muscles supporting their knees, as well as more lax ligaments. They typically have a larger hip width to femoral length ratio, which leads to greater hip adduction (muscles located towards the lateral portion of the thigh contract and pull the thigh away from the midline of the body). Females are also more at risk of certain injuries because there is added motion in their hips and pelvis.

When it comes to bone injuries, females are, again, more susceptible than their male counterparts. Women have smaller bone dimensions and are predisposed to lower bone density. Also, estrogen, a hormone in women that protects bones, decreases sharply as women age. All of these factors increase the risk of broken bones.

“Though gender differences do predispose women more to certain musculoskeletal injuries, attention to bone health, nutrition, core strengthening and a well-structured exercise routine can mitigate some of these problems,” explains Dr. Thorell.

Tips to Reduce the Risk of Injury

Because women suffer sports injuries more often than men, it is important they take extra care prior to playing sports or exercising. Below we offer certain exercises and other helpful tips:

• Leg lifts, back bridges and standing hip flexors help to improve motion and flexibility in the hip and glutes area.
• Weight-bearing exercises help to build and maintain bone density.  Attend dance classes, go for hikes, pick up aerobics or simply get into fast walking.
• Balance exercises, such as Tai-Chi, can help strengthen legs.
• Wear proper footwear and work out on appropriate (not very hard) surfaces.
• Don’t suddenly intensify or lengthen your workouts.

Need help coming up with a fitness plan to keep you healthy?

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Brain Imaging and Conduct Disorder: Temporal Lobe Abnormalities

Conduct disorder is a complex behavioral disorder with significant risk for later adult psychopathology.

There is increasing evidence for a biological basis for conduct disorder.

Twin studies show a significant genetic contribution to the disorder.

Brain imaging studies also point to biological factors in conduct disorder.

Gregory Wallace and colleagues recently published a structural MRI study of conduct disorder in 22 adolescents between the ages of 10 and 18. Conduct disorder subjects were compared to a group of 27 age-matched controls on imaging measures.

This study focused on measures of brain cortex thickness, brain surface area and degree of brain folding or gyrus formation.

Conduct disorder was linked to the following brain structural abnormalities:

• Reduced cortical thickness in the superior temporal lobes
• Reduced gyrus formation in the ventromedial frontal cortex
• Reduced volume of the the amygdala and striatum (putamen and pallidum) 

The research group also found a negative correlation between superior temporal lobe thickness and psychometric measures of callousness/unemotional styles.

The mechanism for the temporal lobe to be involved in the symptoms of conduct disorder is unclear. Cortical thinning in this region has been found in adults with psychopathy. 

The authors note that amygdala/temporal lobe integration is necessary for stimulus-reinforcement learning. This integration may explain some of the deficits found in the current study.

This study will be important for continuing research in the genetics and pathophysiology involved in conduct disorder. Intervention strategies will need to address potential biological deficits contributing to the behavioral and learning problems in conduct disorder.

Readers with more interest in this research can access the free full-text manuscript by clicking on the PMID link in the citation below.

Image of brain with superior temporal lobe highlighted in green is an iPad screen shot from the Brain Tutor app.

Follow the author on Twitter @WRY999

Wallace GL, White SF, Robustelli B, Sinclair S, Hwang S, Martin A, & Blair RJ (2014). Cortical and subcortical abnormalities in youths with conduct disorder and elevated callous-unemotional traits. Journal of the American Academy of Child and Adolescent Psychiatry, 53 (4), 456-650 PMID: 24655655