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Why Men Die Younger (transcript)
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(Dr. Peter Salgo) 
Welcome to Second Opinion, where each week our healthcare team solves a real medical mystery.  When we close this file in a half an hour from now, you'll not only know the outcome of this week's case, but you'll be better able to take charge of your own healthcare and doctors will be able to listen to patients more effectively.  I'm your host, Dr. Peter Salgo, and you've already met our special guests, who are joining our primary care physician today, Dr. Lou Papa.  Lou, welcome back.

(Dr. Lou Papa) 
Thanks, Peter.  How you doing?

(Peter)  
Nice to see you again.  No one on this team knows the case, so let's get right to business.  I want to tell you a little bit about Vera.  And, Lou, you know she's in her primary care physician's office.

(Lou)   
Beautiful.

(Peter)
Vera's ninety-four years old.  She considers herself healthy, and she has some arthritis.  That's her major complaint.  She takes medicine for a slightly elevated blood pressure.  It doesn't say here in the chart which medicine she takes.

(Lou)   
Mm-hmm.

(Peter)
But that's not why she's in her primary care physician's office.  She's here to discuss end of life care for her eighty-year-old brother, who has severe dementia.  Now, I'm going to tell you a little bit about the family history here, because it's in the chart.  Vera is the oldest sibling.  She moved in with her two younger brothers when her third husband died twenty-six years ago.  One of the two brothers died a few years ago of lung disease at the age of eighty-two.  Not only has she been running the household for all of these years, she's also been doing all of the bookkeeping for the family-owned printing business.  All right.  I mean, I got to tell you, this sounds a little weird, but she's ninety-four years old, she's planning end-of-life care for her brother, who's fourteen years her junior, and I guess the weird part to some people is she's already buried her other brother and three husbands.  I can hear people out there saying she's a black widow.  I mean, you see people in your office every day. 

(Lou)  
Mm-hmm.

(Peter)
 
Is this a common thing to see?

(Lou) 
Oh, sure.  I mean, it's not uncommon at all, where you see older individuals taking care of younger siblings or spouses or, you know, even children.

(Peter) 
But is it more men doing this or more women doing this?

(Dr. Lou Papa) 
Oh, it's clearly more women.

(Dr. Peter Salgo) 
How come?  And is this - how come - what are the - what's the data here in the United States, men, women life expectancy?

(Tom) 
Among the oldest old, women are very much the winners of the longevity marathon.  So, generally, for the oldest, a hundred years old and older, eighty-five percent of centenarians are women, but from age sixty, seventy on, women just progressively get more and more of the proportion of the population.

(Peter) 
But we keep hearing that certainly in America people are living longer and longer.  Is this not true for men?  I mean, what's the average life span of a woman, the average life span of a man?

(Tom) 
Men, generally, in the United States, around seventy-eight, seventy-nine, women maybe eighty-two, eighty-three.  The gap is shortening, and one of the reasons that men were living a shorter amount of time compared to women is a lot more of them smoked, but as they stopped smoking that gap is shortening.

(Peter) 
There's one chromosome difference, right?  It's an X versus a Y.  What is it about that Y chromosome, or is it chromosome?  Is it genetic?  Does anybody know the answer to that?

(Dr. Tom Perls) 
The women have - may have a little bit of an advantage with regard to having that extra X chromosome compared to the men.  Men are XY, women are XX, and if there's a certain genetic variation on one of those Xs, that isn't so good for you.  The cells actually can rely upon the better version, and so that may be a bit of an advantage.

(Kathy) 
Is that because we have estrogen?  Is that what -

(Lou) 
Estrogen -

(Peter) 
We meaning women?  I'm assuming it's you.

(Kathy) 
Yes, yes, yes, and the other women in the panel.

(Lou) 
Men have a little bit of a -

(Peter) 
You mean the two on this panel that are going to outlive all of us put together.

(Dr. Royda Crose) 
Well, actually - actually, up until mid-century, last - the last century, the life span was about equal.  Men and women were equal, and then the second half of the century women started living longer than men.  And interestingly, it correlated with the women's movement in many ways that women started creating more options in their lives and really looking at options and expanding who they were as people, and medical advances, too, saved women in childbirth and things like that.

(Lou) 
But, I think, if you look at a lot of that original data, a lot of that was skewed because of the childbearing and the childbirth.  A lot of women would die in childbirth, and that really skewed the mean age for survival down quite a bit.

(Tom) 
There's another very important point, and that is at the turn of the last century, the 1900's, average life expectancy was forty-six years.  And that was with major changes in public health, clean water supply changes and other aspects of public health that allowed the population to suddenly go from forty-six to, say, average life expectancy of sixty around 1960.  And then when the population generally had a much greater opportunity to live to older age, then we started to see women showing some advantages over men that were otherwise kind of hidden.

(Dr. Royda Crose)
Breaking out on sex roles.

(Dr. Peter Salgo) 
Raises the obvious question; what are men dying of?  What is everybody dying of, and specifically men, that makes them die earlier than women?

(Dr. Ganesh Palapattu) 
Well, the commonest causes of death in men in this country are heart disease, cancer, prostate cancer is the second leading cause of -

(Peter) 
Women don't have a prostate.

(Dr. Ganesh Palapattu) 
That is correct, but of course they get breast cancer.

(Peter) 
Right.

(Dr. Ganesh Palapattu) 
And men can get breast cancer, although much less commonly.  The third leading cause of death in this country is cerebral vascular disease or complications from strokes.  Fourth leading cause of death, then, for men in this country would be related to lung disease, most commonly the outcome from smoking.  Fifth leading cause is accidents, and then diabetes is a close sixth.  So, I think, if you look at these, we have a combination of genetic predispositions as well as environmental factors and risky behaviors, which are unfortunately more common among men.

(Kathy) 
But isn't that different in terms of age groups?  So those numbers will shift -

(Dr. Ganesh Palapattu) 
They certainly do.

(Kathy) 
- if you're younger.  I mean, I happen to have a son who's twenty-one, so I'm very worried about the statistics for young men.

(Tom) 
That's a phenomena that we call testosterone storm -

(Lou) 
Right.

(Tom) 
- where there's just too much testosterone, and it does relate to these risky behaviors, not wearing your seatbelt, driving with - while drinking -

(Dr. Lou Papa) 
Right.

(Tom) 
- fighting, whatever.  So the testosterone storm definitely -

(Peter) 
But is -

(Dr. Tom Perls) 
- causes a higher - there's another thing on the other end of the life span.  Very interestingly, among very old men, they are the highest risk of being successful at suicide. 

(Lou) 
Mm-hmm.

(Tom) 
So when an older man is contemplating suicide, you have to take that very seriously.  They're very successful at that.

(Dr. Royda Crose) 
And I think there's some racial difference in that, too.

(Tom) 
Mm-hmm.

(Dr. Crose)
Older white men are one of the highest risk of suicide in this country.  And so, there again, we look at lifestyle and what does it mean to be old in this country and what happens to men once they retire when they lose power and when they become invisible like -

(John) 
So you would recommend that I keep on running?

(Dr. Royda Crose) 
Absolutely.

(Peter) 
Who's going to get to this?  John, you've been atypically quiet.  Tell everyone how old you are.

(John) 
I'm eighty-three.

(Dr. Peter Salgo) 
Eighty-three years old.

(John) 
Eighty-three years of age, yes.  I took up running at the age of fifty-five.  And I was diagnosed with high blood pressure, and so I thought, well, I'd rather run than medicate.  And that's what I've been doing.  I've never had to take blood pressure medicine yet.  I've enjoyed my running.  I never thought that I'd become world-ranked, but over the years I've had a great time enjoying the running, beating other young - younger runners, and I feel very well and feel very fit.

(Peter) 
Now, before we go any further, we've heard people saying, well, it's genetic, you know, maybe men are genetically programmed to die earlier than women, maybe it's environmental, but we touched on environmental a bit.  You don't drive drunk.  Did you ever smoke?

(John) 
No.  I did smoke, but I never smoked very much.

(Peter) 
So that takes care, to some degree, of your lifestyle.  What about your genetics?  Tell me a little bit about your parents, your siblings, if there are any.

(John) 
Well, my father lived longer than my mother.  My mother died at eighty-nine.  She was almost ninety.  My father died at ninety-five, so we do have, in our family, a very good background for longevity.

(Peter) 
What's the difference between genetics, inheritance and environment?  How can you tease that out?

(Tom) 
From - there are various twin studies, particularly out of Scandinavia, that looked at identical twins that lived apart versus those who lived together, and from those studies, they show about seventy percent or so of average life expectancy is related to one's behaviors and exposures and thirty percent are not.  Another very interesting study is that of the Seventh-day Adventists, who have the highest average life expectancy of any group I know of in the United States, and it's primarily because of the health behaviors that that religion dictates.  So they're vegetarian, they regularly exercise, they don't smoke, maybe a little bit of alcohol.  They spend a lot of time with family and friends.  That probably relates not so much to it doesn't matter how much stress you have in your life, it's how you manage it.  That seems to be fairly important.  There are centenarians, how they manage their stress relates to a personality that - where they quite low in this testing for neuroticism.  They don't dwell on things.

(Peter) 
Tell me, though, do the Seventh-day Adventists women live longer than the Seventh-day Adventists men, or does the gap close?

(Tom) 
The women still do live longer.  I suspect -

(Peter) 
It's hopeless.  It's allover.

(Dr. Tom Perls) 
Yeah.  It's not hopeless.

(Lou) 
It's not.  I think that's very important, because when you - unfortunately, the other part of this is the psyche of the male.  They're less likely to come into the doctor's office.  They're less likely - they're more likely to be kind of like it's written in stone, and I think that issue of it's genetically predetermined has to kind of be tempered knowing that seventy percent of what you do kind of contributes to your longevity.  It's very important to relay to those men.

(Tom) 
There's a number of important difference we haven't come across, and I'll tell you we came across some - a really interesting clue with the centenarians.  When we were looking early on at about a hundred pedigrees of centenarians, we found a woman who'd had a child at the age of fifty-two.  And we went back, we double-checked that, and indeed when we looked at the rest of the centenarians about twenty percent of the centenarian women had children after the age of forty, and that was compared to only about five percent of other women born around the same time.  And, if you did the math, women who had kids after the age of forty had about a four to five times greater chance of living to a hundred.  And when we started to think about that, we figured, well, that makes sense because if these women have a history of aging slowly and avoiding diseases that impact upon fertility, then having a child later in life would be a consequence of the genes that help people age more slowly, avoid age-related diseases, and get to these extreme ages.  We then thought more about, well, what's the advantage of living to extreme old age?  After reproduction, there's a, you know, forty-, fifty-year period of time where evolutionarily there doesn't seem to be any pressure to live to these older ages.  And then when we thought about that, we said, well, for women to have kids in their twenties and in their thirties and forties, through evolution, if you want to win the evolutionary game, you want to have more kids, and the way to do that is have more time to have those kids.  So you start selecting for genes that help slow down the aging, help delay or escape the age-related diseases that impact upon fertility, and low and behold now we have women having naturally kids in their forties and their fifties.  And those genes keep cooking along.  The point here, however, is interestingly from an evolutionary point of view, it's the women and their ability to have kids at older and older ages that might be the driving force behind the life spans that we have.  The men kind of don't matter. 

(Dr. Peter Salgo) 
Well, thanks.

(Tom) 
But when we start talking about X chromosomes, there's probably a whole set of genes related to reproduction and other factors that were allowing these women to have kids at older age that give the kind of advantages that we'd be looking for in Vera compared to her brothers.

(Peter) 
So let me just understand what you're saying.  You're basically, if I understand you correctly, saying that being able to have a child at an older age is not of and by itself going to prolong your life, but it's a marker, because you were able to do so, of a set of chromosomes which are consistent and correlated to the longer life.

(Tom) 
It's a marker that you are aging slowly, that the reproductive system was aging slowly and very healthy, and therefore the rest of them is very healthy, too.  By no means does it mean that women should be going and have kids in their forties because there's some kind of boost to their longevity.

(Peter) 
When you look at the literature you find iron keeps popping up as a variable in terms of living longer, that if you have more iron in your body, you tend to live less long, that women menstruate in their thirties, for example, twenties, thirties, and so they're constantly losing iron, and could that be the difference?  And, if so, how do you explain why women live longer after?

(Tom) 
One of the issues about the women who had kids to a older age, by definition, were going through menopause at an older age, and therefore they were prolonging the time during which they were able to menstruate and be iron-deficient.  And the reason that iron is probably bad for you is that our cells, the mitochondria, the energy factories within our cells require iron as a part of producing that energy, but a consequence of that is also the spewing out of free radicals, these very damaging atoms and molecules that glom onto your cell membranes, your nuclei, and probably play a very critical role in aging.  And it may be as simple, though I doubt it, that having less iron in your body means less free radical production.  And you're right, women, over a long time, have lower amounts of iron.

(Peter) 
Let's pause just for a moment here.  We've covered a lot of ground.  Statistically, men in the United States die at a younger age than women do.  There are several reasons for this including some that are genetic, others are biologic factors, and there's a lot more work to be done on this and we have to tackle the environment we live in, too.  So, let me tell you a little bit more about Vera.  Now, it's not lost on her that she's been predeceased by so many of the men in her life.  So, I have information about the deaths of her three husbands.  Her first husband was a volunteer firefighter, died in a fire.  Her second husband was a truck driver, a smoker, and died of a heart attack at fifty-eight.  Her third husband had prostate cancer and finally died, not of the prostate cancer, but of a stroke.  And the urologists I know always say that prostate cancer is often something you die with not of.  So all of her husbands had bad genes, right?

(Lou) 
Bad luck.  I mean -

(Peter) 
(Or they)

(Lou) 
Some of it is something that kind of crosses the gamut.  The first husband died in trauma, and that's an issue that's on that list, and the second husband had risk factors.  He was a smoker, he was a truck driver, I imagine he wasn't very physically active, and had a heart attack and died at a young age.  Some of that was genetic and lifestyle.  And the third husband had prostate cancer, which is a known risk factor as you get older, and a stroke.

(Peter) 
But, you know, you talk about these things as if they're predetermined, as if, well, genes had nothing to do with it, but didn't I hear earlier, maybe I didn't, that men tend to engage in different behaviors than women do statistically?  So a smoker, a firefighter.  Maybe men choose to be firefighters because they get a rush fighting fires.  Is that something that's genetic as well as ((society))?

(Dr. Palaputtu)
I think there must be definitely some interplay between the genes and the behaviors that manifest from those genes in those genes in which - that give you your predisposition to suffer from some diseases that may cause you to die earlier than women.  So it's an interplay that goes back and forth.

(Dr. Peter Salgo) 
You've got observational analysis of the human race.  What's your take on this?

(John) 
Well, I, having lived eighty-three years and most of the - last the - last half of my life, at least, has been a lot more dynamic than it used to be, but now -

(Peter) 
You grew up in London, right?

(John) 
Sorry?  I grew up in London.

(Peter) 
You grew up in London, right?

(John) 
Yes.

(Peter) 
Dirty city just like New York, where I grew up?

(John) 
Absolutely.  Yeah.

(Peter) 
Worked in a factory for a while?

(John) 
I did.

(Dr. Peter Salgo) 
And you're eighty-three?

(John) 
I'm eighty-three.

(Peter) 
So much for environment at a young age.

(John) 
Well, I think the environment has certainly got a lot cleaner, even though we're using more cars than we ever did, but I remember London and some of the smogs that they had.  It was absolutely filthy.  Everybody had coal fires, and we were breathing that nasty smog and quite often it was just - one would cough up black stuff from their lungs.

(Peter) 
Again, that's my point, John.  You were in this environment, you grew up in it, you worked in a factory.  Here you are eighty-three.  What's different about you?  Is it that you were able to glide through life better?  You weren't as neurotic, or is there something else that we don't understand and you're keeping a secret?

(John) 
I think I might've been somewhat neurotic as times, but I think I have to attribute the exercise to my longevity.

(Peter) 
Don't women integrate into the healthcare delivery system earlier than men certainly as a result of having babies?  Men, we know, statistically right just don't, and is it this early exposure to and regular access to healthcare compared to men?  Is that what causes women to live longer?

(Lou) 
It probably plays a role in the sense that there are much more to - I mean, the - you know, a lot of the insurers know that it's the women in the household that make the decision about healthcare, so a lot of their marketing is aimed at them.  But I think that clearly plays a role in keeping them engaged, making sure that they're more proactive in that sense.

(Peter) 
You know, something else that occurred to me, you mentioned that it was the middle part of the 20th Century where this diversion, women living longer than men really became more and more obvious, and yet that's the point where women entered the workforce, World War II Rosie the Riveter, exposed to industrial toxins, regular work days.  Many of them began to smoke - women that is - in that era, and yet they diverged and the men died younger.  Explain this.

(Dr. Royda Crose) 
Women have jobs that are more sporadic or they have part-time jobs - or they take time off for their family rearing.

(Dr. Tom Perls) 
One of the interesting analogies I use for why so few people, one out of ten thousand people - well, one out of eight thousand now, get to be a centenarian, and it's not because of one or two factors or some kind of holy grail that people have been searching for.  And so for me it may be not being obese, not smoking, not being a Russian male in World War I, getting my - if I had high blood pressure, getting it detected early on, and then maybe a few genes along the way that helped me age more slowly and avoid certain age-related diseases.  But it's the combination of all those factors and getting them at the right time that makes getting to such extreme old age rare, and what's so difficult in my field is that my combination is going to be different from yours, it's different from yours, can vary according to ethnicity, geographic location of occur, be different according to sex.

(Peter) 
So, if I'm - what he's telling me is you can have the genes you've got.  You can't pick your parents.

(Dr. Royda Crose) 
Right.

(Dr. Peter Salgo) 
But there's a number bullet points that men can do to try to catch up to women, and if women do that, they're going to stay ahead of us anyway, as, I guess, one of the takeaways.  Anything else you want to add to the recipe for longevity for men?

(Dr. Palaputtu) 
I think the answers are very simple, kind of iterated here.  There are certain things we can control and there are numerable ones we cannot.  Don't smoke, exercise, keep a vital mind, a vital body, watch what you eat, and unfortunately, in the end, you're going to play the hand that you're dealt.

(Peter) 
Your centenarian study is exactly what - and what have you learned from it to help us right here live longer?

(Tom) 
Well, one of the things that we haven't talked about that has been a very interesting thing with regard to men versus women, and it ties into your question a little bit about the interaction of women with healthcare, is that while the men are far fewer in number, they are usually in much better shape than the women.  And that sounds very paradoxical.  If they're in such good shape, why aren't there many more of them?  And it seems to us that for a man to get to these extreme ages he has to be in spectacular shape, like you.

(Peter)
Hmm.  Yeah.

(Tom) 
And if they get a - if otherwise that they get a heart attack or stroke or dementia, they much more readily die of those things, and they don't get to a hundred.  So they have to be in great shape.  The women, on the other hand, are very much the champions of aging, and the double-edged sword of that is that they can live with these age-related diseases much more readily.  They don't die of them, but then they also get the chronic illnesses.  Thus, they're also interacting with the medical -

(Dr. Peter Salgo) 
I want to get  -

(Tom) 
- system much, much more.

(Peter) 
Okay.  Let me pause for a moment and sum up what we've been discussing.  It's fascinating stuff.  External forces, such as social, cultural, marriage, for example, environmental, behavioral factors all interact with your genetic makeup and have an impact on your life span.  You can make a difference in these factors, even though you can't change your genes, and you can take active steps to live longer.  Let me tell you about Vera.  Vera decided, after discussing all of this with the primary care physician, to put her younger brother in hospice care.  Now, a lot of women, as we discussed, are simply going to outlive their families, whether it's brothers, whether it's husbands.  Is that okay?  I mean, should we be actively trying to make men live longer, or is this just the way it is.

(Dr. Tom Perls) 
I think, my grandmother lived to be ninety-eight years old, and one of the things she talked about is losing that peer group.  There's not a whole lot of future to talk about, and losing that kind of - that peer group, losing that - somebody from your peer group was a big deal to her. 

(John) 
My mother-in-law, who died at a hundred and four point eleven recently, she had the most wonderful friends in her church, and she had very young friends, too.  There was a young woman that spent so much time with her, and I think this all helped.  She was so bright at a hundred and four.

(Peter) 
Can you define the centenarian project for me, like, in one sentence?  What's the bullet on what you're doing?

(Dr. Lou Papa) 
We've enrolled about fifteen hundred centenarians since 1995, plus their family members and the kids with really the aim of trying to dissect out what factors are helpful in getting people to older age in good health.  This notion of the older you get the sicker you get has been very much disproven by the centenarian study in which what we find is there's actually a compression of disability towards the end of these people's lives.  They can have lots of illnesses and what have you, but they have some kind of resilience.  This is much more the case with the women, and the men, they don't get the illnesses, but the women, even among them, the average age of any kind of disability really is around ninety-two years of age.  So it does answer, at least from a disability point of view, the question of who would want to live to a hundred.  In fact, all of us should want to live to a hundred, if in fact what we're seeing is that they're compressing their disability towards the very end of their lives.  We're talking almost thirty, a bit more years beyond the age of sixty of being disability-free, and getting to a hundred is a very good thing.  You ask should we be trying to get more people to a very old age, particularly the men.  You can't really, with good health behaviors, add unhealthy years to your life.  You can really only add healthy years to your life.  It becomes more of the case of the older you get the healthier you've been, which is really, I think, a very positive, optimistic view of aging.

(Peter) 
John, I'm going to give you the last word.  I did - didn't escape my notice that you not only picked your parents' genes correctly but your in-laws' genes correctly.  Do you have any last - I know this is what people do as people get older, they ask you who'd you do it?  How'd you do it?

(John) 
How did I do it?  I just was happy most of my life, and I got to the point where I knew that I had to do something dynamic about staying alive and it happened to be running.  I started with students, running with students, and then just graduated and got better.

(Peter) 
Well, I want to thank you so much for joining us, and panel, I want to thank all of you because it's been a great discussion.  I want to sum up, before we go, what we've been discussing so that we sort of put a button on everything.  Statistically, men in the United States die at a younger age than women, and there are several reasons, including genetic, some of them biologic factors, external forces such as social, cultural, environmental and behavioral factors can interact with your genetic makeup and can have an impact on your life span.  You can make a difference in these factors and can take active steps to live longer.  And, of course, our final message is always this; taking charge of your health means being informed and having honest communication with your doctor.  I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

 

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