Is the Runner’s High a Quick Buzz or a Long-Term Benefit?

Methinks that the moment my legs began to move, my thoughts began to flow.

- Henry David Thoreau

Every day I have patients who come to me asking what they should take to help prevent memory loss or to treat depression or “brain fog” – a loss of ability to concentrate fully. I have several supplements that can help those things, but there is one prescription that is more proven, consistently helpful and accessible than any pill – prescription or over the counter supplement. It’s called exercise.

Evidence is mounting that physical exercise is good for the brain as well as the body. Of course we know that vigorous cardiovascular exercise, like running, elicits an increase in endorphin production, those feel-good chemicals made by our brain that elevate our emotions. But we also know that there are other, longer term, neurologic benefits of exercise.

It turns out that aerobic exercise slows the loss of gray matter, the part of the brain that atrophies as we age. This is one way in which exercise keeps us mentally young. Gray matter makes up the cerebral cortex, the part of the brain that allows for processing of information. Research shows that the more dense the gray matter is in a particular region of the brain, the more intelligence or skill the brain's owner is likely to have.

While such aerobic exercise like running or using the elliptical machine prevents brain aging, scientists have found that anaerobic exercise, such as working out with weights, stimulates the creation of new brain cells in the part of the brain responsible for memory and learning – the dentate gyrus (part of the hippocampus). Many people think that the brain stops growing by adulthood, but new nerve cells continue to be generated in the hippocampus throughout our lives. Exercise can help stimulate the growth of such cells, which are essential to learning.


On the flip side, stressful events have been shown to destroy these newly developed nerve cells in the hippocampus, making it harder to retain new lessons learned or memories created. This is how those stress-reducing endorphins that get stimulated by vigorous exercise can help protect your brain.

There are other ways in which exercise is neuroprotective, meaning it builds up our ability to defend ourselves against neurologic decline. Exercise causes levels of a substance called Brain Derived Neurotrophic Factor (BDNF) to increase. BDNF has been called “Miracle-Gro for the brain” by Harvard Psychiatrist John J Ratey, MD in his book Spark: The Revolutionary New Science of Exercise and the Brain because it helps nerve cells transmit information better. In fact, low levels of BDNF are associated with depression; so increasing BDNF through exercise can be a natural anti-depressant in a more permanent way than that surge of endorphins.

One more way that exercise helps the brain is by preventing brain damage from stroke. Many studies attest to the benefit of cardiovascular exercise in preventing or minimizing atherosclerosis, the process by which arteries get clogged with plaque. Strokes occur when such plaque-ridden arteries interfere with blood flow to the brain. One recent study showed that men engaging in intense physical activity had less than half the risk of stroke as those who did not engage in such activities. Furthermore, for those who did have a stroke, the ones who had been exercising before the stroke recovered greater and faster than those who were not physically active. So, exercise was like a great insurance policy that protected people from having stroke and helped them get better even if they did have one.

People spend enormous resources investigating and purchasing supplements that have far less evidence supporting their use in preventing neurological decline than does simple exercise. It may be easier to pop a pill than to go for a run, but the benefits – both short and long term – are more predictable with the running than with the pill.

Testosterone: Friend or Foe?

“He's a guy. They don't talk, they fight. It's all that crazy testosterone.”
Kim Cattrall as Samantha Jones on Sex in the City

If testosterone is responsible for all of the negative behaviors among men, wouldn’t that mean that men with lower levels are healthier than those with normal or high levels of testosterone?

Most people know that testosterone (T) is responsible for sexual development in men and is important for libido and sexual function. However hormones, by definition, have effects throughout the body. There are testosterone receptors in nearly all tissues in the body, so this primary male hormone impacts nearly every organ system. We know that testosterone impacts hair growth in some areas (face, chest) and loss in others (scalp). It is also especially important in muscle and bone growth, impacts cardiac function and affects the central nervous system. Truth be told, it is linked to behaviors such as aggression, risk-taking and territoriality.

As a counter-point, the central nervous system effects of testosterone are not all negative. Testosterone has positive effects on mood, energy levels, feelings of well-being and vitality. Low T is associated with depression and with poor brain function on tests of memory and comprehension. Testosterone also has been shown to be an important anti-oxidant, protecting nerve cells against oxidative damage. In fact, low levels may make diseases like Alzheimer’s worse. http://www.medicalnewstoday.com/articles/5553.php

Most testosterone is produced in the testes with stimulation from hormones secreted by the hypothalamus (GnRH) and pituitary glands (LH). The adrenal gland also produces some testosterone as well as other androgens (male hormones) such as DHEA. These other androgens are also important for libido and energy.

More and more, we are finding low T in our male patients. This does not appear to be only because we are checking levels more often. A large study showed that average T levels have fallen from 1987 to 2007. Among 1532 randomly selected men at three time periods between those years, there was a slow, steady decline in T levels such that a 65 year old in 2007 had 15% lower T than a 65 year old in 1987 – even correcting for being over weight or smoking.

Symptoms of low Testosterone
Low libido
Decreased morning erections
Low energy or fatigue
Depressed mood
Irritability
Osteoporosis
Shrinking testicles
Loss of muscle mass or failure to gain muscle despite working out

Low testosterone may be caused by diseases of the hypothalamus, pituitary gland or testicles. Usually, however, low levels are the result of a natural decline with age (after the age of 40 or so) and/or lifestyle factors such as stress, physical inactivity, chronic illness, poor sleep or substance abuse (including tobacco and alcohol). To some degree this decrease in testosterone due to stress is evolutionary. The body’s production of sex hormones is exquisitely sensitive to stress – be it physical or emotional. Testosterone in men drops in the face of chronic stress or anxiety, partly because the primal role of the sex hormone system is to drive reproduction. If the body senses an inability to care for itself, the last thing it wants is to produce a child needing to be taken care of in the face of such external stress. This system can’t differentiate attack by tigers from the daily grind in an unhappy job – it is all translated chemically in the body and ends in low testosterone production.

Coming back to the initial question – is it better for men to have low T so that they will talk more and fight less? Unfortunately, such a trade-off has its cost.

Cardiovascular disease is the number one killer in men in the United States. Men with subnormal T levels have higher cholesterol and an increased risk of diabetes, both of which are significant risk factors for heart disease. Obesity also increases the risk for diabetes and heart disease, and men with low T have more body fat. In fact, the obesity-low T link manifests as a vicious cycle. Body fat causes an increase in the conversion of testosterone into estrogen – yes, men have estrogen. In fact, a 50-year-old man has, on average, more estrogen than a post-menopausal 50-year-old woman. The more T that gets converted, the lower is the ratio of testosterone to estrogen and the more muscle mass is lost and fat is gained. This gets to be self-perpetuating.

So, it appears that while testosterone is associated with riskier health behaviors, low T is associated with serious diseases like osteoporosis, Alzheimer’s, depression, diabetes and heart disease. Therefore it is unhealthy to leave low T untreated. While elevating levels of T above physiologic levels, as is done by some body builders and athletes, has been associated with enlarged hearts (cardiomyopathy) and higher risk of heart attacks, high blood pressure and stroke, replacing low testosterone to achieve normal values has not been associated with such negative outcomes.

Men over 40 should have their levels of testosterone checked regularly, especially if they are experiencing any of the symptoms listed above. That level may be as important to overall health as cholesterol number or blood pressure. There are many proven ways to treat low T, under a doctor’s supervision. Testosterone may make us fight more and talk less, but it also keeps us going in many healthy ways.

We Cannot Abandon Health Care Reform

Michael, a struggling actor, came to see me at the free clinic yesterday. He had been in a car accident many years ago and has suffered with chronic neck and back pain ever since. He has had physical therapy, chiropractic care and acupuncture, but still he suffers. For 8 years his pain has been under control with a combination of Vicodin, Xanax and Soma prescribed by a chronic pain specialist. This combination allows him to continue to work and to function. But, Michael doesn’t have insurance. The visit to the doctor is $100 a month. His medications (all of them, generic) costs $140 a month. He has finally reached a point where he cannot continue to afford them. He had two Vicodin left when I saw him last night – he had been taking less in order to make his bottle last a while longer, but now he was in severe pain and needing some help.

We don’t carry any of his medications at the free clinic. Our policy is to not carry narcotics. I could refer him to the county hospital pain management program, but that takes about 9 months to get an appointment. In the meantime, Michael will be suffering from extreme pain plus withdrawal and not be able to work or function.

During the same shift, Elizabeth came in. She is a professional dancer and had a fall while rehearsing. Her knee has been in pain for 7 months, limiting her ability to dance, so she has not been able to get any gigs since the fall. She had an x-ray and physical therapy, but needs an MRI to see if there is a tear. We have no ability to order MRI’s at the free clinic. I can refer her to the county orthopedics specialist, but that takes about 12 months before they will send her an appointment.

Ken sees me in my private clinic. He has high blood pressure and high cholesterol. He takes his medications regularly, but has a strong family history of heart disease. He needs routine blood tests to check his cholesterol, his kidney (make sure the medications aren’t causing any problems there) and general chemistries. His deductible with his insurance is so high, that he can’t afford to have his labs done. I have to decide between continuing his medications (for which he pays a reasonable copay not affected by the deductible) and potentially causing harm to his system that I can’t detect because he can’t have the blood work OR I can insist that I cannot prescribe refills unless he gets the labs done, in which he case he will probably just stop his meds.

Meanwhile, in my private practice, I can’t afford to stay in network. I want to see patients for 30 minutes, not for 10. I want to get to know my patients and discuss what they are eating, how much exercise they are doing and what might be bothering them at home or work that could be contributing to ill health. I want to discuss prevention and treatment options. I can’t do that in 10 minutes. Insurance reimbursement is based on a full billing staff and a high volume of patients booked every 10-15 minutes. The amount they pay cannot support a practice that allows for 30-minute visits.

This is our health care system. It is not working for Michael or Elizabeth or Ken. It is not working for my colleagues or me. It is not working for people with insurance (because of huge deductibles an copays) or people without insurance.

We cannot give up on reform.

Earthquake in Haiti

As a former volunteer and baord member with Medecins sans Frontieres/Doctors without Borders (MSF) , I assure you they are doing an efficient and masterful job at helping with the huge need for medical care in Port au Prince. I encourage you to support their efforts if you can.

Just click on the photo below to donate.

MSF has hospitals up and running and is providing surgical and emergency care now. They need your help to ramp up the efforts.

In gratitude and prayer for those suffering,
Myles Spar, MD