OUR BODIES, HEAD TO TOE
Our bodies are symbolic. Think back to when you were starting high school. Did you think it was a put-down if someone said, “Kid, you are skinny” (or chubby)? For high schoolers 40 and 50 years ago, it was better to have weight than to need to gain it. Two bodily standards—muscles and fitness—still seem to define the idealized male body, as is evident on the covers of men’s health and fashion magazines. In the popular culture, as long as a man maintains sufficient fitness and isn’t thin or way too heavy, his body helps affirm his masculinity. Not everyone might think that this is true, yet our bodies are what others see and draw on to form their first impressions about us.
How much the age-related changes in our bodies affect our self-esteem is unclear.1 Sometimes men report dissatisfaction with their bodies and sometimes not.2 Only a small part of men’s comfort with themselves actually rests on their body’s size and shape.3 Almost the entirety of the image we have of ourselves is rooted in what we do—being independent, self-reliant, able-bodied, and capable. The way our body changes with aging is commonly framed in words such as “I’m in pretty good shape for my age,” even if the man’s appearance suggests otherwise. Meet a weathered-face man in his late sixties who uses a cane, and he might confidently tell you that he doesn’t feel old. You think he looks it. What you do not know is that he has been using a cane for 30 years, ever since his horse stumbled and threw him in a steeple chase, requiring several surgically implanted pins in his leg. Because he still works outdoors with horses—he is a trainer of racehorses—his skin has a distinctive weathered look. His physical appearance is consistent with his livelihood and age, and his body image is consistent with his resilience and functional ability.
Body image was traditionally considered a “woman’s thing.” This is not to say that appearance is irrelevant to men; it is as much a part of our self-image as it is for women. Men are not apathetic about looking good. Body image is how a man feels about his appearance—his eyebrows, his weight, his mustache, his skinny legs—in the context of both cultural norms and the peers he uses for comparison. Even simple things matter: think about the way you feel about your appearance when you know that you need to get a haircut and then after it is cut. Having a positive body image means feeling satisfied with the way we look, appreciating our body for its capabilities, and accepting its imperfections. Psychological in nature, our body image is forever changing, responding to the social norms of what is attractive and “manly” for our age. We were not born critiquing our own looks; rather, we judge our body based on masculinity and age norms. We are socialized to judge our male bodies in terms of wholeness, and physical strength and being fit—enough to carry the ladder, rake leaves, lift a grandchild—continue to define the cultural ideal for men.
The Person in the Mirror
Have you had “the talk” with the person in the mirror and thought, “You really are getting older”? The next day you receive an invitation to attend your high school’s thirtieth, fortieth, or fiftieth reunion. Do you smile and think, “This ought to be fun,” or do you wince?
In the rest of this chapter we examine from head to toe a variety of ways our appearance changes with aging. Typically, men’s proportion of body fat doubles between ages 25 and 75, since our metabolism slows down and our bodies need fewer calories than we usually take in and burn up. The leathery look is often evident on our hands and faces, and less hair develops as skin cells decrease in size.
As you got within shouting distance of being middle-aged, you probably noticed many ways your appearance was changing. We do notice and keep track of our aging. Men can list matter-of-factly a number of physical traits when asked about their age-related changing appearance—wrinkles, thinning hair and balding, “age spots,” stooped shoulders and hunching, thinning skin on our hands, a distinct belly, and skinnier legs with varicose veins. Even if some of the changes set off silent alarms, most bodily changes likely bring out little more than nodding recognition. Australian researchers reported that the older men they studied were less satisfied with their appearance but were not making much of an effort to improve self-presentation by using skin creams or polymers to make their thinning hair look thicker.4 What’s good to know is that our long-term partners also are less bothered with our changing appearance and are more interested in us maintaining a healthy body.5
Men consider a full head of thick hair as more important to their virility and attractiveness than their weight.6 After centuries of powerful men wearing wigs and/or growing long hair, men were persuaded to believe that as we lose our hair we become less powerful, less masculine, and less attractive.7 Recall the biblical story of Samson losing his strength and being socially castrated after his hair was cut.
But the facts are that by the time we are age 50, one-half of all men reveal moderate to extensive hair loss and some baldness.8 What causes the scalp hair loss that leads to baldness? Let’s begin with what does not cause baldness. In general, rarely is it caused by disease, nor is poor diet or strong shampoo an important factor. When we lose our hair, we tend to lose it because it’s our destiny. Men’s hair loss is caused by a combination of genetics and age-related changes in our hormones. Clinically referred to as androgenic alopecia, the “andro” refers to the androgen hormones (testosterone and dihydrotestosterone [DHT]), and the “genic” refers to the male gene necessary for baldness to occur. Each hair follicle is genetically programmed when to quit producing new hairs if we are genetically predisposed for a receding hairline and/or baldness. Our genetic inheritance makes about half of us prone to what is called male pattern hair loss (MPHL).9 This is a “condition” that both shortens the growth phase of the hair cycle and produces progressively shorter, finer hairs. Eventually these hairs totally disappear.
If your grandfathers and father showed evidence of a receding hairline and balding, and you are experiencing hair loss, you too are very likely to pass this genetic trait on to your sons and grandsons. By the way, we do inherit MPHL from either side of our family, so take a look at photos of both your mother’s and your father’s male relatives to see who had the most hair loss in your family lines. Biological aging is also an important, secondary determinant of both thinning hair and baldness. As we get older, less testosterone and more DHT are produced; when there is an excess of DHT, this contributes to our hair getting thinner and eventually to hair loss.
The Hamilton-Norwood Scale, initially created by James Hamilton in the 1950s and revised by O’Tar Norwood in the 1970s, details the way male pattern baldness (MPB) occurs. There are two variations: “anterior” and “vertex.” Anterior MPB means that the receding starts from the front of your scalp; vertex MPB begins from the crown (top). Both anterior and vertex patterns of balding end the same (stages VI and VII)—the crown of your head is bald.
Figure 8.1. The Hamilton-Norwood Scale of male pattern baldness
Knowing that hair loss is caused mostly by genetics and aging ought to dispel most myths about men’s baldness. Have you heard that wearing hats, helmets, or baseball caps makes you bald? If this were true, the hat (or helmet) would have to literally choke each hair follicle for weeks on end. Think about it: how many baseball players in the Baseball Hall of Fame still have a full head of hair, and many are old men when inducted. Was their cap loose fitting, whereas the guys with MBHL wore tight-fitting caps? Another set of wild tales market “cures” for hair loss and baldness caused by poor circulation. Blaming receding hairline on the amount of blood flow to hair follicles opens the door to all sorts of “doctor-recommended” products that purport to improve blood flow and/or nutrients to the blood and vitamins to the scalp. Ever heard the one about getting a cow to lick your head? Men faced with a receding hairline may try nearly anything, and research tells us that the typical man who seeks medical treatment for his MPHL has already engaged in considerable efforts to self-treat.10 No matter what advertisements may claim about a treatment, receding hairlines and MPB are almost always genetic.
You might also have heard that stress will cause you to go bald. Stress does not cause baldness, but like chemotherapy, it can cause temporary hair loss. The chemotherapy involved in cancer treatment is designed to attack fast-growing (cancer) cells, and because hair roots are fast-growing cells, they too are attacked. Chemotherapy causes temporary hair loss all over the body, not just the scalp. Stress can stop hair growth. If you have overwhelming stress, the buildup of stress hormones causes the hair shaft to stop growing and forces a large number of hairs into a resting phase. In effect, your hair growth goes dormant. Within a few months, the affected hairs may fall out suddenly when washing or brushing your hair; they typically grow back 6–9 months later.
Under normal circumstances, the hair follicles on the scalp do not continuously produce hair. After 2 or more years, they revert to a resting stage for several weeks, up to 2 months, before beginning to grow new hair. At any time on a healthy human scalp, about 80–90 percent of the hair follicles are growing hair, which leaves up to 10–20 percent of scalp hair follicles in a resting state. The average life span of a single hair is 4½ years; the hair then falls out and is replaced within 6 months by a new hair. The average guy will lose 50–100 hairs from his head each day (about 0.1%). If you are among the small group of men in their sixties and seventies with a full head of hair, this process of shedding and growing new hairs remains unaffected.
Alopecia areata is an autoimmune condition where white blood cells attack the hair follicles and produce small, patchy areas of hair loss. It usually starts as a small circle of perfectly smooth baldness, and the hairs in the (bald) patches will usually regrow within 3–6 months without treatment. The hair that grows back may be white, leaving a small patch of white hair. Alopecia can affect hair on other parts of the body, too, such as the beard.
A recent study treated mice that had been genetically altered to overproduce the stress hormone called corticotropin-releasing factor (CRF). The study was designed to assess if a stress hormone inhibitor called astressin-B would diminish the effects of stress on the colon, yet what the researchers accidently found was that the stress hormone receptors in the skin and near or within the hair follicle were affected. If this hormone inhibitor proves to be reliable, there may someday soon be a treatment to prevent alopecia areata and the hair loss caused by stress.
No conditioner, shampoo, vitamin, or other product reverses baldness. Yet there are some medications that slow down hair loss and may stimulate hair growth when hair follicles still exist. When the hair follicles are gone, the hair is gone for good. Traditional methods of stimulating hair growth include minoxidil and finasteride, and surgical transplantation is also available to treat baldness.
The two basic U.S. Food and Drug Administration (FDA) approved options to slow down the rate of hair loss are minoxidil (Rogaine) and either finasteride (Propecia; not Proscar) or dutasteride (Avodart). The topical minoxidil can be purchased at any drugstore without a prescription, and if the product works, it works slowly, requiring 2–4 months before any noticeable results. Studies have confirmed that a twice-daily application of this topical cream can stimulate the growth phase of hair for some men. It seems to be most effective on the crown, rather than the frontal region, and if it works, it encourages live hair follicles to regrow a hair. Even so, applying Rogaine is basically a treatment for preserving what hair is already there. The drawback is the requirement to rub the topical onto the scalp twice daily, for as long as you want the result. It is necessary to continue to use the product for as long as you wish to keep the regrown hair.
The use of finasteride and dutasteride for hair loss involves a much lower dose of the same drugs that shrink an enlarged prostate. Both require a prescription. Taken once daily, the drugs are only effective for “fertilizing” and thickening existing scalp hair. Both have the same drawbacks: they are more costly, and they may lower sexual drive and (temporarily) cause erectile dysfunction. These side effects are reversible shortly after the drug is stopped.
Contemporary surgical treatment involves hair transplantation—surgically taking hair (several hundred plugs) from the side or back of the scalp and implanting it in the front. For reasons not fully understood, the hair on the side of the head seems to be “naturally resistant” to the hair-damaging hormones. Transplant procedures have improved greatly and produce much more natural-looking results than older surgical plug methods, which often left a checkerboard of hair stalks and bald spots. Many transplant patients also take Propecia (finasteride) to keep what they’ve transplanted. If you are considering a hair transplant, it is critical to triple-check the surgeon’s credentials and experience treating other men.
Currently, there are countless new, controversial and experimental treatments marketed to address men’s hair loss. One treatment recently approved by the FDA is low-level light therapy (LLLT). Advertised as a nonchemical, noninvasive treatment for hair loss, it seems that men who have more hair (perhaps in early stages of hair loss) tend to have better results. Low-energy laser light travels several layers into the scalp tissue without harming the skin and scalp, and the therapeutic light energy is absorbed by the cells, beginning the process of cell repair. One theory is that the laser light stimulates the cellular production of energy. There is minimal clinical evidence of the efficacy of LLLT, although most experts agree that it is safe.
Another “treatment” is to purchase a pair of hairpieces. A good hairpiece is custom made for you (taking into consideration the shape of your skull, your skin and hair color, the amount of your remaining hair). If properly cared for, a custom hairpiece can provide you with years of a self-presentation that reflects some receding hairline but no evidence of balding on the crown. By contrast, a bad hairpiece is a red flag that points to your concerns with balding. Good hairpieces are not inexpensive, and you will need two identical ones so that you can alternate their use while you clean one of the pair.
Maybe the best “treatment” is to let nature take its course. Nearly every man’s hair thins with time; it’s part of our bodies’ aging. Our receding hairline can be a celebrated sign of our earned status as older men. As much as the vast majority of men with hair loss do not seek treatment for their hair loss, studies consistently reveal that men are upset by their hair loss.11
Whether wanted or not, graying hair slowly takes over. Gray hair once was considered the ideal in politics and business, and white or gray powdered wigs were all the rage in the eighteenth century among U.S. colonists, who gravitated to gray because they equated older age with respect, power, and prosperity.
The onset of graying hair is relatively predictable. Scientists are not completely sure why it happens. Nor is there certainty how our hair grays. The consensus opinion is that getting gray hair is a natural part of growing older. It results from a progressive loss of pigment (melanin) cells, whether it is our scalp, face, armpit, chest, or pubic hair.
The rate of our hair’s graying is related to both aging and heredity. Each shaft of hair is basically colorless, and melanin (or the pigment) is produced by melanocyte cells inside the follicle. Each hair is made up of two parts—a shaft, which is the colored part we see growing out of our heads, and a root. The root of every hair is surrounded by tissue called the follicle, and it is the hair follicle that contains the pigment cells. These pigment cells continuously produce the melanin to give each hair its color. Once a hair follicle stops producing pigment and the hair shaft turns gray, there is nothing that can make it start producing pigment again.
For a long time medical researchers assumed that with age the melanocyte cells simply became less efficient at making pigment—they got old and tired, and we got gray. However, recent studies have shown that growing older brings about a steady decline in the number of new pigment-producing cells, and the stem cells within hair follicles responsible for color are the most impacted by irreparable DNA weathering that comes from our exposure to ultraviolet light, chemicals, and ionizing radiation. Our genetic makeup and heredity also play some role, since premature graying tends to run in families. There are racial differences, too. Among white men, hair starts turning gray often in their midthirties, but among Asians it begins in the late thirties and for African Americans in the midforties. About half of 50-year-olds are at least 50 percent gray.
Legend has it that some men’s hair turns white virtually overnight as a result of a traumatic event. Although extremely unlikely, stress may accelerate the pace of our natural graying process. Stress hormones may impact the survival and the number of new pigment-producing melanocytes; however, no clear link has been found between stress and gray hair. Gray hair is simply a sign of biological aging, and once the graying starts, the proportion of (remaining) hair turning gray increases by 10–20 percent each decade.
Becoming Gray
Leo M. Cooney, professor and chief of geriatrics at the Yale University School of Medicine, argues that “people with premature graying of the hair don’t die any sooner than anybody else … gray hair has something to do with your genetics and very little to do with premature aging.”
Source: Parker-Hope, T. (2009, Mar. 10). Unlocking the secrets of gray hair. New York Times, Section D, p. 5.
Graying hair contributes to people’s notions about our health and well-being. They presume we are less physically active, tire easily, and are less sexual.12 The messages conveyed through television and magazines are rarely pro-gray. Americans are ambivalent about gray hair in the workplace or among middle-aged men, and even Presidents Ronald Reagan and George H. W. Bush preferred coloring their hair.
There are probably hundreds of other folk remedies (e.g., in Chinese medicine, fo-ti is a longevity tonic that is used to treat graying hair); people believe that a deficiency in folic acid (vitamin B9) causes graying, which can be prevented by eating foods high in folate, such as leafy greens, beans, and grain products that have added folic acid, but the sure way is to hide the gray by using hair coloring. Some men use a temporary dye, which coats your hair with distinct color molecules and is quick and easy to apply. Temporary dyes contain no ammonia and may result in less damage to the hair. Most of these commercial self-applied dyes characteristically begin to wash away after a half dozen morning shampoos, which means that you have to reapply the dye several times a month. An alternative is called progressive coloring. This is the “Grecian Formula” strategy that colors the hair gradually, and the change is not as noticeable as overnight regular dyes. Progressive hair colorants (and there are many, such as GrayBan, Grecian Formula, and Youthair) use lead acetate and sulfur as the active ingredients and cause the treated hair to darken when exposed to air. Several applications are needed to gradually color your hair, and you can decide how dark of an effect you want. The colorant both coats and penetrates the hair shaft.
A third option is a tone-on-tone semipermanent color. This method of coloring uses peroxide to permit the color molecules to penetrate the hair shaft and creates a more permanent color. This strategy to “remove the gray” usually takes 10–15 minutes to apply and will last nearly twice as long as direct dyes. But expect to invest time and money.
As we age, the texture of hair changes—it becomes coarser. At the same time you are dealing with the graying, thinning, and slow loss of scalp hair, the hair that remains has become bristly. You recognize that your hair doesn’t lie down as well as it used to when brushed. You also notice that you have some coarse, fast-growing bristly new hairs in all sorts of places—your eyebrows, ears, nostrils, and tops of the toes. You are dealing with the biology of aging. You are not suffering from “hypertrichosis,” which is a medical condition that involves excessive growth of hair in areas where hair does not normally grow (e.g., palm of your hand), and for a very few cases excessive enough to be informally called werewolf syndrome.
If your eyebrows become bushy, and if your nose, toes, and ears sprout these bristly, coarse hairs, you are dealing with genetics and hormone changes, not a medical condition. The nose and the ears contain thousands and thousands of hairs. Most are so small you can’t see them. For about three-quarters of men, the tiny little hairs inside the nose and ear canal and on the outside of the ear will eventually become thicker and coarser as they age. Similar to how science doesn’t fully understand why our hair grays, we understand too little about why hair follicles in and around men’s ears and nose begin growing coarser.
You can manage most of this new hair growth quite easily. Plucking the distinct, extra hairs on the tip of the nose or above the bridge of the nose with tweezers is an easy way to remove unwanted individual hairs on the face. But using tweezers isn’t recommended for most other places—such as your ears and nose. There are electric trimmers that you or someone else can use (consider asking your wife, partner, or barber) to trim the length of the hair on your eyebrows and the outside of your ear. There also are inexpensive, battery-powered trimmers that safely cut down nose and ear hair and have external combs to protect the skin from being pinched or nicked.
Years of the pull of gravity, adding a bit more facial body fat,13 and loss of skin’s elasticity—put these three together, and you have the basic ingredients to why wrinkles begin to appear, why men’s ears and noses get bigger, why the cheeks look more sunken, and why “double chins” slowly emerge as we age.14 The actual pace of the changes is affected by sun exposure, smoking, diets, and when men “turtle up” and have less active lifestyles.15
Facial anatomy is composed of three things: the skin; the underlying soft tissue, muscle, and fascia; and the bony, cartilaginous skeletal structure. With aging, the elasticity of skin declines, there is a weakening of the underlying soft muscular tissue over the cheek and jaw bones, and there is bone resorption. The more noticeable result is the sagging appearance of skin in the midface and nose and the likely formation of jowls. As the skin thins, becomes dryer, and loses elasticity, eyelids may begin to droop and the lower eyelids may begin to appear “baggy.” Wrinkles develop on the brow, around the eyes, in cheeks, and next to the mouth. With age, the height/length ratio of the nose and ear progressively decreases, which means a lengthening of the ears and the prolongation of the nose and “drooping” of its tip. At the same time, the hairline moves upward, further making the upper part of the face look elongated, and the skin under the jaw sags down, making the skin fold and the man appear to have a second (or double) chin. Our once smooth, fuller face has slowly morphed to become more leathery, weathered, wrinkled, thinner, and longer, with occasional “age spots” to boot (discussed below).
Similar to graying hair, these facial changes may well make some men not appreciate getting older, nor feel good about their changing appearance. There are two basic kinds of strategies to manage the expected age-related changes in facial appearance. Upstream strategies prevent; begin by reducing your exposure to the factors that hasten facial aging—avoid cigarette smoking, reduce exposure to ultraviolet sunlight, and hydrate to reduce water loss that stiffens skin and weakens the facial musculature. Upstream strategies involve other forms of prevention, including engaging in jaw and neck exercises, eating well, and maintaining fitness. Men who are more sedentary slowly add weight by not burning enough calories through exercise, and this increases the risk of the double chin. The downstream strategies are treatment-oriented, ranging from noninvasive techniques such as skin care products that may tighten and firm skin to the more invasive cosmetic surgery that might remove wrinkles, tighten facial skin, remove the double chin, or restructure the nose. Do recognize that cosmetic moisturizers merely cover the skin with a water barrier to slow the loss of moisture from the skin and give the skin a temporary appearance of plumpness and fullness.
Know the Nose
Like other organs, the nose changes as the body ages, and we become increasingly vulnerable to nasal problems and complain of nasal obstruction, nasal drainage and sneezing, coughing, nosebleeds, snoring, olfactory loss, and nasalsinus pain. An especially notable age-related nasal change is the reduced efficiency of the nose for breathing.
Source: Edelstein, D. R. (1996). Aging of the normal nose in adults. Laryngoscope, 106 (9), suppl. 81, 1–25.
Skin is our body’s largest organ. It is our principle organ of touch, sensuality, pleasure, and appearance. It varies in thickness, ranging from the soles of the feet (the thickest) to the thinnest areas under the eyes and on the eyelids. One square inch of skin on a healthy middle-aged man contains nearly 3 million cells, 75 feet of nerves, 600 sweat glands, at least 100 oil glands, and many hair follicles. Imagine what 1 square foot contains, and then consider that a male body is covered by 15–20 square feet.
The structure and function of skin change as we age. It loses some of its elastic quality and becomes looser. It loses its ability to retain water, resulting in drier skin. It becomes thinner. It heals more slowly. It is less able to resist being damaged. These changes bring about normal things like wrinkles and, for about two-thirds of adult men, skin problems.
Skin “thins”16 with aging—more accurately, the epidermis (or outermost layers of cells) comes to involve fewer layers. The epidermis is composed of two basic levels that collectively measure little more than 1 millimeter in a healthy middle-aged man. The living cells of the epidermis aren’t the very top layer; rather, they are just below several layers of near-dead or dead cells. Skin cells routinely move upward, replacing the 50–100 million dead, top-layer cells we “shed” daily. Dermatologists refer to the time it takes cells to move upward as “transit time,” and the process is called desquamation. You are more apt to notice the “shedding” during the winter as you remove your socks and see white specks clinging to them. As we get older, the transit time slows down; the entire process of replacing skin cells takes as much as 40 days rather than 14–20 days, and without the faster rate of replacement we once experienced as young men, the skin thins.
Just beneath the surface skin is the thicker “dermis.” This middle layer of skin is loaded with glands, nerves, blood vessels, hair follicles, fibrous proteins (called collagen and elastin) that determine the skin’s elasticity and structure, and proteins that hold water in the skin and serve as skin moisturizers. The dermis also becomes thinner with age because of slower cell reproduction. Fibrous protein cells diminish in number at an annual rate of about 1 percent, causing the skin to become (and appear) looser and sag.17 With less fibrous protein cells, the thinner and more flaccid dermal tissue also produces fine wrinkles all over the body surface.
Wrinkles. The best advice is to put on sunscreen and wear a hat. Compare the skin on your face and hands with the skin on your butt. Your hands and face haven’t been hidden from the sun. Because it is the sun’s radiation that largely determines the pace of developing wrinkles, most wrinkles appear on the parts of the body where sun exposure is greatest. There are two types of wrinkles: fine surface lines and deep furrows. Squinting your eyes when too vain to wear your glasses or when not wearing sunglasses, scowling all the time, or puckering your lips thousands of times a day while smoking cigarettes—all of these habits accelerate the pace of facial wrinkle formation. The skin has memory (called mnemodermia), and its memory is like an elephant’s. When it is repeatedly pushed into the same folds with each frown, smile, or facial contraction, fine wrinkles become deep furrows.
For men who are troubled by their emerging facial wrinkles, there is some evidence that fine wrinkles can be delayed and reduced by using wrinkle creams that include retinoids, which are derived from vitamin A. There are lotions and creams that are able to reduce skin roughness. You are also encouraged to use “detergents” such as Dove soap, rather than (Ivory) “soaps” that contribute to dry skin because they are alkaline soaps. To manage deep furrow wrinkles, there are a variety of treatments, such as chemical peels, laser treatment, and dermabrasion, which involves an intense scrubbing and leaves the treated area sensitive and red for about a week.
Have you noticed “age spots,” or what some people call “liver spots”? The spots (or lentigines) are brownish and appear over time on your face and body, similar to freckles. The spots are no more than distinct clusters of epidermis cells and the uneven pigmentation most prominent in sun-exposed areas of skin. All epidermis cells make the melanin (or pigment) responsible for freckles, skin color, birthmarks, and moles. As our skin ages, the melanin-producing cells will at times mass together to cause dark(er) patches; aging skin also has lesser ability to fend off UV rays from the sun, and this UV exposure is largely responsible for the dermal changes that lead to the development of so-called age spots.
Fungal skin infections (called tinea) such as athlete’s foot and “jock itch” in the groin are noticed by others if you are constantly scratching the itch. Most of these infections are superficial, whether it is skin cracking between the toes, a scaliness over the sole of the foot, or red, raised scaly patches in the skin folds in the groin area. Beyond the itching and the unpleasant odor, the infections can be controlled with a daily application of an antifungal cream or powder for 4–6 weeks. Risk factors include sweating heavily, walking barefoot on damp public floors, weak immune systems, and smoking.
By contrast, a fungal nail infection is more difficult to treat and will continue indefinitely if left untreated. Nails are essentially hardened skin cells and made mostly of keratin, which is the same protein found in hair. The living cells begin in the hidden (half moon) area under the cuticle, and as new skin cells grow, the older cells are pushed forward, harden, and form a visible nail. As we age, nails thicken and become more susceptible to infection. The infection frequently begins as a white spot just under the tip of the toenail or fingernail, and as the fungi spread deeper into your nail, the nail discolors, thickens, becomes dull, develops crumbling edges, and has dark, smelly debris. It can be unsightly and is sometimes painful. Oral antifungal medication (e.g., griseofulin, terbinafine) works about 50–75 percent of the time. Unlike most antibiotics, it often takes 6–12 months to see if the treatment worked or not, because it takes that long for a nail to grow out.
Cellulitis is a bacterial infection involving a sudden, red skin rash. Microorganisms are always living on skin and can enter the body when there is a small crack or cut. Though cellulitis can occur anywhere on the body, it is more likely found on the legs and arms, starting on a crack in the skin, especially between the toes. The inflamed, infected area becomes red, hot, and irritated, and because you have an infection, other symptoms can include muscle aches, chills, fatigue, fever, and sweating. Men with compromised immune systems are at greater risk of a cellulitis infection, and those with a fungal infection are also at increased risk of cellulitis coming back multiple times. Typically, treatment involves a 7–10 day regime of oral antibiotic medication.18
Eczema is a common problem in the skin that involves itching, redness, and scaling. Less often, you might also have to deal with edema, or the accumulation of fluid beneath the skin. The actual cause of eczema is unknown. The most common form of eczema is dry skin (or xerosis), which is likely caused by dehydration and vitamin A deficiency. Sometimes called “winter itch,” dry skin is more common in northern winter climates with low humidity and cold temperatures. It usually manifests as itchy, scaly, cracked, red plaques on the arms and, more commonly, the lower legs and shins. Dry skin can be prevented by reducing the effects of (harsh) soaps that remove too much of the skin’s natural oils and keeping the skin hydrated via liberal and frequent use of skin care emollients and moisturizers.19
Psoriasis is an autoimmune, chronic inflammatory disorder of the skin (and, at times, joints) which occurs in many forms and is more common as we get older. It affects millions of men, has no known cure, and is not contagious. The most widespread form (plaque psoriasis) produces reddish, scaly lesions or thick lesions covered with thick silvery white scales that can erupt anywhere on the body. It commonly appears on the elbows, scalp, knees, ankles, groin, or torso, and the lesions may be itchy. Although the cause of psoriasis is unknown, it can break out as a result of psychological stress, an infection, a skin abrasion, or the side effects of prescription drugs, especially among men using multiple prescription and over-the-counter medications (called polypharmacy).20 The prescription drugs most often associated with psoriasis are the nonsteroidal anti-inflammatory drugs (NSAIDs) we use to treat headaches, arthritis, and sports injuries; antibiotics such as penicillin; and diuretics.
Treatment aims at managing the symptoms. Corticosteroid creams and other topical products are usually the first line of treatment. Your doctor might recommend one of several forms of photo or light therapy in combination with a topical cream that might include synthetic forms of vitamin D or anti-inflammatories like corticosteroids. For severe psoriasis, there are biological therapies that have been approved by the FDA within the past 5 years. Unlike medicines, which are a combination of chemicals, biologics are primarily made up of proteins that are made from or taken from living cells and tissues, and they act as inhibitors to specific molecules thought to be essential in causing psoriasis inflammation.21 The treatments can be taken orally or by injection (e.g., Enbrel, Stelara, and Humira). Because these biologics attack T-cells within your immune system responsible for causing skin problems, these new treatments do carry the risk of reducing the ability of your immune system to fight potentially serious and even life-threatening infections.
Shingles is a type of painful, blistering skin rash caused by the herpes zoster virus, which is the same virus that causes chickenpox. It is more likely to develop after age 60, especially if you had chickenpox when you were very young. Once you have had chickenpox, the virus remains dormant in certain nerve cells. Exactly what triggers the onset of the rash isn’t known. The initial signs are little grouped blisters that cause pain, tingling, or a burning sensation; the tingling, burning discomfort usually begins before the blisters are noticeable. For most people, the blisters are clustered together and sit on a line of reddened skin that may begin on the back and will run around the ribs to the front of the belly. The line of blisters can be thin or as wide as your fist. Sometimes shingles are located on the neck, hands, and cheek. On rarer occasions, the rash may involve the eyes and mouth. Should an itching, painful rash develop in your eyes, see a physician immediately; blindness is one of the complications. Wherever shingles is located on your body, it can cause considerable pain because it involves an inflammation of spinal nerves, and there might be lingering pain after the flare-up.
Ironically, shingles usually gets better on its own; however, your physician can prescribe antiviral medication (e.g., acyclovir, famciclovir, valacyclovir) to fight the virus, and the medication typically shortens the course of the inflammation and helps reduce the discomfort. You can also soak the inflamed areas with a wet cloth to ease the discomfort or soak yourself in a colloidal oatmeal bath. The goal is to keep the blisters dampened until crusting occurs. Finally, a herpes vaccine is available (Zostavax, approved in 2006) and has been shown to reduce the risk of getting shingles by half, as well as reduce the pain associated with this condition if you still get it. The vaccine is recommended for adults 60 years and older.22
Have you noticed that your once-chiseled chest seems to have sunk into your belly? That your waistline has expanded? Chances are you weigh more now than you did when you were younger, and even if you weigh the same as you did 25 years ago, your muscle/fat ratio has likely changed. Physiological aging causes muscle to diminish and fat to increase. In addition, as we get older, our bodies simply need fewer calories to maintain our weight and good health, so if you are still eating like a teenager and do not regularly exercise, you’ve probably put on pounds. If these added pounds are belly fat and you are now “pear” shaped, you are living with more than just a change in your appearance—there is a serious health risk.
For my sixtieth birthday, I asked my wife to surprise me. She said, “Ahhh, give me some hints.” So, I gave her two hints. I’d like something sleek and polished, and something that goes from zero to 200 in seconds. She gave me a scale!
—Source unknown
The surgeon general argues that there is an “obesity epidemic” among middle-aged and older men in the United States.23 Whether or not this claim is true, three-quarters of men age 40 and older have already added enough abdomen weight that they can be officially classified as overweight. Clinical studies have found that the size of a man’s belly (waist circumference) is actually a better predictor of heart disease and mortality than general obesity.24 The Mayo Clinic proposed a good way to measure your waist. Use a flexible tape measure—not one of the metal tape measures from your workbench. Pull the tape around your bare abdomen just above the hipbone until it fits snugly. Relax, exhale normally, and measure your waist without sucking in your belly. What’s your waist size? Generally speaking, if your waist size is greater than 40 inches, you need to pay attention to things you do (and do not do) that will increase your risk of type 2 diabetes and heart disease.25
Even though the most common weight-related change for men is the accumulated fat around the abdomen, which makes men in their sixties and seventies look a tiny bit pregnant, too frequently men do not fret much about their weight. Nearly two-thirds of men age 50 and older in a Gallup poll reported that they rarely worry about their weight, and in a later Gallup poll nearly two-thirds of the men also described their weight as “about right.”26 As a result, men who are overweight (but not obese) are not likely to perceive themselves as overweight or think that their eating and exercise habits are unhealthy.27
On occasion you will see a guy at the mall, workplace, or beach who sports a bulging beer belly. Unlike women’s experiences, his largeness has long been accepted and has even been considered evidence of being powerful and “manly.” Americans have normalized large breakfasts of steak and eggs, the “man-sized” frozen dinners in Hungry-Man advertisements (with 1,700 calories), and 300-pound, very fit professional footballers. Being large is accepted, so long as you are fit. This could be why men whose weight is roughly 10–20 pounds more than their ideal weight are rarely judged by other people as “heavy” (though women are), and this lack of judgment could be why there is such a disconnect between the large percentage of men who are overweight and the small percentage who recognize themselves as such.
Middle age is when your age begins to appear around your middle.
—Bob Hope
Even should we concede that our weight is higher than the ideal, barely more than half of adult men in the United States have ever tried to lose weight in their lifetime.28 Men prefer to use exercise and going to the gym as a way of “correcting” an overweight body, rather than dieting.29 As one 54-year-old man observed about men and dieting,
It’s not normally vanity. The men don’t seem to worry that they are overweight, whereas the women are more inclined towards the sort of vanity of being overweight, y’know. Most of the men that I know up here were doing it for some sort of medical reason. Cause, y’know, something pushed them into it; otherwise they wouldn’t have come [to the slimming club].30
Men who work out 30–45 minutes and burn off 200 calories are unaware that the athletic drink they downed right after working out added 130–300 calories right back.
All in all, by the time we are 60, most of us tend to be heavier than we were at 40. We might pat our flabby-looking stomach after a morning shower, think a moment about it, and then do nothing. That is the problem.
As our bodies age, there are two appearance changes in men’s legs. One is the slow loss of muscle mass in the thighs and calves, or what is thought of as the onset of age-related “skinny legs.” The other is the arrival of varicose veins.
Have you discovered a ropy, blue, gnarled, and sometimes painful vein winding down your leg or ankle? If so, you are among the 20–50 percent of men who are likely to live with varicose veins or the milder spidery veins.31 Varicose veins are most common in the surface veins of the skin. They tend to be inherited from either side of your family, and aging increases the risk. In normal veins, one-way valves keep blood moving toward the heart, but the wear and tear of aging causes weakened valves to no longer open and close properly, allowing blood to remain in or flow back into the vein. This pooling causes the vein to enlarge. As you get older, your veins also can lose elasticity, causing them to stretch, which can affect valve functioning.
Risk is increased by being overweight, being physically inactive, smoking, and having a poor diet, which are the same poor health habits that are linked to heart disease. Additionally, leg veins are subject to the effects of high pressure when standing, and men who run outdoors on hard surfaces can hasten the onset of varicose veins. Though varicose veins may be perceived as unattractive, they usually are not a sign of a serious problem. They are mostly a cosmetic concern. However, for some men varicose veins can be achingly painful.
Treatment begins by self-care—such as wearing compression stockings, elevating your legs at night, exercising, losing weight, and avoiding long periods of standing. Do you have a recliner with an extending footrest (or “easy chair”) to elevate your legs? Compression socks (or stockings) ought to be your first effort to deal with varicose veins before you begin other treatments. They can be worn from morning to night, and as they steadily squeeze your legs, they help veins and leg muscles move blood more efficiently. Medical therapies include sclerotherapy, which entails injecting the small- and medium-sized varicose veins with a solution that causes the vein to absorb the solution and close. No local anesthesia is needed, nor is there a recovery time. You can immediately return to your planned activities for the day. After a few weeks, the treated varicose veins should fade. The same vein may need to be injected more than once. Other effective treatments are laser surgery, vein stripping, and catheter-assisted procedures where a physician inserts a catheter into an enlarged vein, heats the tip of the catheter, and pulls the catheter, leaving the heat to destroy the vein and causing it to collapse and seal shut.
By contrast, the onset of age-related skinnier legs (smaller calf and thigh circumference) is often preventable but isn’t really treatable. Because the primary cause of smaller calf and thigh circumference is the loss of muscle mass, men who are not physically active—who prefer to ride the elevator rather than take the stairs, or motor around the golf course in a cart rather than walk or pull the clubs—do not counteract the effects of physiological aging. Their less active behavior teams up with nature’s slow decline in muscle-producing testosterone to yield “skinny” legs.
Smaller calf circumference can also be the consequence of poor nutrition. As noted in chapter 3, basic nutrition is essential to maintaining our body’s muscle mass. Calf and thigh muscles are less likely to shrink in size in your seventies and eighties if you maintain a healthy diet and are active. You ought to be aware that low leg strength and smaller calf circumference are linked to frailty and the risk of falling upon standing up. Our best defense against loss of muscle mass is an offense—to remain physically active and to eat well.
Rarely are your feet going to affect others’ judgment of your appearance, or even grab your own attention. But they surely affect your mobility, quality of life, and self-presentation, which you and others notice. All day long your feet take abuse supporting your weight, yet most of us do not think about our feet or grasp how important they are until they don’t work and we’re incapacitated. Anyone who has broken a toe or faced the symptoms of Achilles tendonitis—pain and tenderness on the back of the foot or heel—after a weekend of activity knows how little it takes to feel hobbled. An injured foot—whether caused by a painful ingrown toenail, a nagging stress fracture, or even a blister—will keep you from enjoying life. Don’t let this happen. And don’t wait for a foot problem to restrict your activities. What follows is a list of common foot problems that can be easily treated and often prevented.
Flat feet (and fallen arches). As we get older, our feet enlarge. More specifically, they flatten. With age, the feet’s tendons and ligaments lose some of their elasticity, become looser, and don’t hold the bones and joints together as compactly. These changes are the effects of decades of weight-bearing use and ordinary aging, where the muscle mass declines and tissue weakens. The constant pressure of bearing weight causes two changes: the “fat” pads on the bottoms of your feet thin, and the tendon forming the arch in the foot stretches, which lowers the arch. As the arch lowers, the front of the foot widens and the foot becomes longer and flatter. Foot flattening causes two additional changes. With tendons and ligaments becoming more flexible, this lets the ankle roll inward and increases the chance for sprains. Foot flattening also pulls the big toe up, which often causes cramp-like pain in its own right.
You might not want to admit it, but as your feet flatten, you might need to change the way you engage in physical activity. There’s no need to retire from an athletic life because of flat feet; rather, you just need to compensate for years of wear and tear. Purchasing customized insoles for your shoes is a smart decision, and being fitted for good athletic shoes is equally smart. Particularly for men who want to continue working out or whose jobs require long periods of standing and walking, insoles will very often reduce the sense of tiredness in the feet and noticeably reduce foot discomfort while working.32 Shoes should have cushioning in the heel and sole to make up for the loss of natural padding.
For most men, after age 40 our shoe size gets bigger by a half size every decade. So, if you are 50 and wearing size 10 shoes, by age 60 you need to have your shoe size measured, because the odds are that you will be buying size 10½. Your new shoe also needs to fit the widest part of the foot, usually the front, which means you might be buying a 10½ wide rather than your former medium width. But most men resist and keep wearing the wrong-sized shoes. An interesting study of veterans visiting a clinic found that only 25 percent were wearing the right-sized shoe.33 As noted next, three foot problems are related to improperly fitting shoes: calluses and corns, bunions, and ingrown toenails.
Calluses and corns. When narrow, too-tight shoes are worn, the skin of the foot will endure friction as the shoe rubs against parts of your foot. Where there is persistent rubbing against the skin, this friction causes hard bumps of skin, called calluses and corns, to form. Calluses are, in a sense, permanent blisters. They are thick, hardened layers of skin that usually develop under and around the heel area, under the ball of the foot, and under the big toe. A corn is a form of callus with a hard central core and typically develops on top and between the toes. They can be painful. Properly fitted shoes, with good support and cushioning, are an effective method of prevention. You might also consider podiatrist-developed insoles that realign your foot and reduce unnecessary pressure and friction. Both corns and calluses can be treated using over-the-counter pharmacy products that contain salicylic acid, which dissolves the protein in the thickened skin and cuts back the callus or corn. Don’t attempt to cut away a callus or corn at home, for you risk an infection.
Bunions. Not as common among men as women, bunions can develop when you compress the toes of your foot with narrow, poor-fitting shoes. A bunion is when your big toe is bent inward toward the second toe and a boney bump forms on the outside edge of the large toe. The bump begins as red (inflamed) calloused skin and over time becomes larger, boney, and more painful. Stiffness may develop, and researchers find that our quality of life suffers.34 If a bunion begins to develop, you need to wear wide-toed shoes. This alone might resolve the problem, but if it continues to get worse and causes severe pain, you are looking at surgery to remove the bunion and realign the toe.
Big toe stiffness and pain. As cartilage in the big toe joint wears away, stiffness and pain develop slowly. The big toe is one of the most common sites of arthritis, particularly among men, and has troubling consequences.35 The big toe joint (called metatarsophalangeal, or MTP) is essential for normal foot functioning, for it allows the toe to bend upward with every step you take. Limitation of motion of the big toe is only one of the symptoms arising from mild to severe degenerative arthritis. When the joint starts to stiffen, walking becomes painful and more difficult. Stiffness interferes with maintaining balance on uneven surfaces and a normal gait. Big toe stiffness is an arthritic condition where the articular cartilage between the joints begins to wear out, causing the raw end of the two connecting bones to rub one another. Untreated, a bone spur may develop on top of one of the toe bones, and this overgrowth also reduces the toe’s ability to bend. Pain relievers and anti-inflammatory medications such as ibuprofen usually reduce the swelling and ease the pain. Wearing a shoe with a wide toe will reduce the pressure on the toe. If the joint remains stiff and painful, seeking an opinion from a podiatric practice wouldn’t hurt.
Ingrown toenail. When the sharp edge of the nail grows down and into the skin of a toe, the result is pain and discomfort, redness, and swelling around the nail. You’re dealing with an ingrown toenail, and if it gets infected, you will be dealing with more pain, redness, swelling, and a very visible uneven gait as you try to walk. An ingrown toenail is usually the result of poorly fitting shoes and toenails that are not trimmed properly. As we get older and our feet get bigger, too often we keep using our older, too-small shoes. When a big toe is lifted up as a result of the arch flattening, it can rub against the top of a too-tight shoe. The skin along the edge of a toenail may become red and infected. The rubbing can also thicken the toenail and force it to grow down into the skin. The big toe is usually affected, but any toenail can become ingrown.
Heel pain and heel spurs. Heel pain is experienced with your first steps in the morning and is a common foot complaint. It is often a by-product of “fallen arches” and involves an inflammation. Usually, there is a sharp acute pain felt at the bottom of the heel area, and sometimes the pain extends to the back of the heel as you take those first steps. The pain diminishes as you walk around, because you are forcing the nerves to adapt to the discomfort. What is happening is that the band of ligaments under the foot (called plantar fascia) tightens when you are sleeping or driving and sitting inactive for a long period, and when you stand and put your body weight on your foot, the ligaments are forced to immediately stretch and lengthen. This (again) causes micro-tearing of the ligament, which causes the stabbing pain. Gently stretching your foot by standing on the ball of the foot and your toes will help. If the heel pain is ignored and left untreated, a pointed bony growth can form at the back of the heel bone or under the bone. This is a heel spur.
Since heel pain is usually caused by an inflammation, the first line of treatment is anti-inflammation medication such as ibuprofen. Equally important is to rest the injury—take a few days off from physical activity—and get shoe inserts that support your arch. Even though heel pain is most often caused by tissue inflammation, it can result from a broken bone, a tight Achilles tendon, a pinched nerve, or other problems.
Achilles tendonitis. Tendonitis involves an inflammation of the Achilles tendon, which is the large tendon at the back of the ankle that connects the calf muscle to the heel bone. Aside from an injury and inflammation, tendonitis is also related to a chronic degeneration of tissue and thus our aging-related, wear-and-tear loss of the normal fiber structure of the tendon. Fundamentally, it is an overuse injury. Whether acute or chronic, men with tendonitis will most often experience stiffness and a shooting, burning pain at the back of the ankle, just above the heel bone. This regularly occurs during the first few steps out of bed in the morning or when first walking after a long period of sitting. It is very noticeable when climbing stairs or walking up a hill. It usually develops from a sudden increase in physical activity, such as when men play weekend sports. You won’t be limping around, but you will feel the pain. It is the stress on the Achilles tendon that causes the irritation, inflammation, and pain. Treatment is much the same as managing heel pain—anti-inflammatory medication such as ibuprofen,36 icing and massaging the tendon, and adding an insole pad to raise the heel to reduce some of the strain on the tendon. If the pain is persistent, consult your physician or sports injury therapist.
Fungal nail infection (onychomycosis). Mentioned briefly as a skin infection, this topic is worth more attention. Infections caused by fungi in the toenails (and, much less often, the fingernails) become common with age. More than an embarrassing cosmetic issue involving ugly discoloration and nail disfigurement,37 fungal nail infections can cause other health problems. Like all infections, they are contagious. It is a progressive, recurring infection that begins in the skin underneath the nail (or “nail bed”) and migrates to the nail itself (or “nail plate”). Over time it causes the nail to become brittle, thicken, discolor, change in shape, and split. The outside edges of the nail crumble, and the debris of dead tissue is trapped under the nail. The fungi feed on nail tissue, leaving behind their messy debris. Untreated, the toenail can become so thick that when you are wearing shoes, the shoe presses against the nail and causes noticeable pressure, if not pain. Untreated, the collection of fungal microorganisms can spread from the toenail to other areas of the body. Wash your hands after touching an infected area.
What puts you at risk for fungal nail infection is both environmental and family history. You might be more susceptible genetically. But the fungi spores grow best in warm, moist areas. If you are living in a warm climate, wear socks made out of synthetic material that don’t breathe and don’t allow air to circulate around your foot (e.g., nylon, acrylic), regularly participate in fitness activities and end up with sweaty feet, and bathe in a communal gym shower, you are putting your toenails at risk. Prevention is the best defense: keep your feet dry, your nails short, wear socks made out of 100 percent natural material (e.g., cotton, silk, wool), select breathable footwear, and don’t plod around barefoot in the gym, in the locker room, or on the pool deck. Most importantly, don’t share toenail clippers with someone who has a fungal nail infection.
Historically, the medicines used to treat nail fungi were not very effective. But recent advances in oral antifungal medicines have made treatment much more effective, because they go through the body to penetrate the nail and nail bed within days of starting therapy. Although treatment is expensive and recurrence is very possible, the newer oral antifungal drugs require shorter treatment periods and yield higher cure rates. Usually taken once a day for at least 6 weeks and up to 3 months, terbinafine (Lamisil tablets) and itraconazole (Sporanox capsules) are the most widely used. The alternative fluconazole (Diflucan) is gaining acceptance, partly because it treats the yeast-based infections that can also cause the nail infection.38 These oral medications are quite safe, yet they are never recommended for men with liver disease or congestive heart failure. They are also more effective than the available topical agents, which seem best used if only less than half the nail is involved. Topical treatments are less effective because they cannot penetrate the nail deeply enough, so they are rarely able to kill off the fungi spores and cure the infection. But they may be useful as supplemental therapy and are not very expensive.
Foot odor. Ever dread removing your shoes for fear of grossing out anyone close by with a nasty, unpleasant, and embarrassing stench? Smelly feet result from sweat confined in a sock and/or shoe, and men who wear socks made of synthetic materials are adding risk. Actually, the odor is the result of bacteria that flourish in warm, moist areas and release isovaleric acid.39 The bottom of your foot is a perfect breeding ground for the bacteria when your foot is wrapped in an inorganic sock and embedded in a shoe or boot. It’s a condition that’s very easy to treat. Rotate your shoes, make sure you wear socks made of natural material that absorb perspiration, and don’t bother spending your hard-earned money on costly shoe powders and sprays.