Diary Of A Mid-Life Checkup

By CHRISTOPHER HALLOWELL

I am 52 years old. I think I've taken care of myself pretty well. I exercise regularly--jogging or swimming for an hour or so three times a week. I eat fairly healthfully--a lot of fruit and vegetables. I have a loving family and a stimulating job. But I am at about the age when human bodies, no matter how well cared for, begin to lose the youthful vitality most of us at one time thought would be with us for the duration. Besides the obvious changes like hair loss and wrinkling, the lungs' capacity declines; joints start to wear out; bones, especially in postmenopausal women and older men, lose density and weaken; cholesterol levels begin angling upward; the walls of the heart thicken, reducing its ability to pump blood by 25% over the life-span; the eyes' pupils diminish, making it harder to see in dim light. And more serious things can sneak up. Around age 50, polyps in the lower intestine, precursors to colorectal cancer--the second leading cause of cancer death for men and women taken together--are more likely to appear. With each passing year, a man's risk of developing prostate cancer rises. It is that time of life when the reckoning for whatever we have borrowed in bad eating habits or inadequate exercise comes due.

Which is why I am at the Cleveland Clinic Foundation. Today I will undergo an all-day physical examination designed to ferret out the body's early warning signs, nascent failings and pending catastrophes. Dozens of similar executive health programs have sprung up around the country, prompted by the proliferation of HMOs, which generally restrict physicals to bare-bones essentials, and by a rapidly aging population in need of greater care. The cost of these thorough examinations can run high--from $1,200 to $2,500--and is generally not reimbursable by insurance companies. Rather, employers often insist that their executives have an examination, and pick up the tab on the theory that an unhealthy executive can drag down corporate productivity. About 3,000 people, mostly upper-echelon managers, take the Cleveland Clinic physical each year.

8:00 a.m. My blood pressure measures unexpectedly low, 112/74, a long way from 140/90, where hypertension, the condition most responsible for the strokes that kill more than 160,000 Americans every year, begins. And my resting heart rate, 60 beats per min., has not changed since college days. I feel almost euphoric and briefly entertain the naive notion that perhaps the aging process has overlooked me.

Like most of the middle-aged men and women being examined today, I appear entirely healthy on the outside. Yet, warns internist Dr. John Campbell, a staff member of the clinic's personal-health-management program, which administers the physical, "no one who comes through here is really healthy." That vague feeling of foreboding, that they will discover something seriously wrong with me, returns.

8:30 a.m. After many vials of blood have been taken from my arm, I am dressed in my patient's uniform--white polo shirt sporting the Cleveland Clinic logo and loose blue trousers--and seated across a desk from Dr. Richard Lang, section head of preventive medicine at Cleveland Clinic and my internist for the day. With unexpected deliberation, given the harried pace of American medicine, he spends the next hour questioning me--work, family, stresses, satisfactions, diet, diseases, sex life--progressing from the general to the specific. The goal of his detective work is to elicit hints of any underlying conditions. "Most of my patients are male executives," he explains. "They don't share; they don't ventilate. This is an opportunity for them to get out a lot of health issues that worry them."

He asks me about my medical concerns. I tell him about the two kidney-stone attacks over the past five years that sent me writhing in pain to hospital emergency rooms. I happen to mention an increased sensitivity to salt in my diet, resulting in a parched mouth, information that he dutifully jots down in my chart while observing, "Maybe your body is talking to you." Then he tells me that salt tends to precipitate calcium, a common component of kidney stones, out of the bloodstream into the kidneys. He informs me that excessive vitamin C can do the same thing. I note that my kidney specialist in New York City never told me about these two contributing factors.

I mention my concern over my frequent need to urinate, which I have assumed to be related to my prostate. As in many men my age, the status of my prostate is top priority, the site of the most common cancer in males. If I were a woman, breast cancer would be of similar concern. In a 25-year-old male, the prostate gland is the size of a grape; in a 50-year-old, it is the size of a chestnut because of its thickened walls. The enlarged gland constricts the urethra that it encircles, diminishing the ability to urinate fully. As the prostate continues to swell with increasing age, malignancies may develop; they are thought to be induced by hormonal changes. Prostate cancer is a slow-moving disease in elderly men, but in younger men it can metastasize rapidly to other tissues.

"I'll tell you just what I think of your prostate in a few minutes," says Lang in the course of his probing, listening and thumping that follow our conversation. He announces that it is in fine shape, meaning that it revealed no lumps, bumps or hardness that would indicate a malignancy. The results of one of my blood tests--less than 0.2 on the prostate-specific-antigen screen, commonly known as a PSA--corroborate his finding.

9:30 a.m. Happy in the continued evidence of my good health, I am off to my sigmoidoscopy. I don't like what I see in the examination room: a black, jointed, snakelike creature with two little eyes and a mouth that squirts jets of air and water. This thing, under the guidance of gastroenterologist Dr. Edgar Achkar, is about to explore the lower third of my colon for polyps. After enemas are administered, I am in position. A congenial nurse named Debby clutches my hand reassuringly. Achkar wonders if I would like to see the proceedings on a video monitor. Suddenly a world I never imagined existed lights the screen. I am awestruck, feeling the amazement that a spelunker might experience upon discovering a similarly rose-colored passage deep in the earth. But my wonder is quickly tempered; the exploration I am witnessing is in my own bowels, not the earth's. Also, it is painful, and I gasp as the creature squirts water and air to clear the passage. Debby squeezes my hand and tells me to breathe deeply; I am barely able to breathe at all. The reward for my five minutes of suffering is Achkar's announcement that my colon is in "perfect condition." It does not feel that way: all that air pumped inside me has brought on cramps that contort my gut. Debby counsels me to let it out. "This is one time to forget everything your grandmother taught you about good manners," she tells me.

10:00 a.m. I toot my way over to audiology for a hearing test, a waste of my time, I expect, because I am certain my hearing is excellent. In the soundproof booth where different tones are squeaked through earphones, I dutifully push the button at each to affirm for audiologist Mary Ann Karnuta that I have heard the sound. Two minutes later, I am incredulous when she shows me a printout of my responses. Having failed to hear a range of high-toned pitches, I learn I have mild symptoms of presbycusis--"old-age hearing," Karnuta informs me--caused by gradual loss of the 30,000 tiny hairlike cells in the inner ear that respond to sound by signaling the auditory nerve to send electrical impulses to the brain. The noise of daily life, from loud music to jet planes to machinery, contributes to presbycusis, but the condition goes hand in hand with aging.

10:30 a.m. Humbled by the first tangible evidence that the passing years do indeed have me in their grip, if only a gentle one, I am not made to feel better in dermatology. I tell Dr. Kenneth Tomecki, a dermatologist who is also in his 50s, that I am concerned about dry facial skin. He seems unfazed. "Young people are greasy, we're dry," he sums up. He checks me for moles with the potential for turning cancerous, and finds none. But he does discover a handful of tiny red dots on my torso, another sign of aging. "Hey, these things just happen," he says, and explains that as collagen, the matrix of supportive tissue under our surfaces becomes brittle, skin wrinkles and veins shoot off in odd directions. While flaking skin, itching, red spots and sun spots--sometimes called liver spots--are an inevitable part of aging, especially among light-skinned Caucasians, skin cancer is not. People who baked away on a beach during their youth are most prone to skin cancers 20 years later. "The sun can do them in," Tomecki notes. Warning signs are new hard bumps on the skin that grow larger, and rough and irritated skin patches that do not heal; sometimes they have a pinkish border. Most moles are harmless, but if they grow crust or bleed, you should see a dermatologist.

11:00 a.m. I have just discovered that my hearing is compromised, red spots are beginning to decorate my parched skin, and now Cindy Moore, the clinic's dietitian, informs my that my total cholesterol is too high. It has jumped to 222 from the previous year's 195. Cholesterol, the fatty substance crucial to cell functioning, contributes to atherosclerosis, a narrowing of the arteries, which is a major cause of heart disease. My level is not alarmingly high, but vascular disease is rampant among males in my family, resulting in generations of heart attack and stroke.

Most worrisome, my LDL level (the so-called bad cholesterol, but actually low-density lipoprotein, which helps maintain cholesterol in the blood) is high at 148 compared with my "good" HDL (high-density lipoprotein, which helps clear cholesterol), which is 54. Moore assures me I can lower my cholesterol without medication and asks about my diet. While I generally stay away from red meat and eat mostly fish, chicken, vegetables and salads, I confess a weakness for cheese, potato chips and butter on all sorts of things. Moore wonders if I am ready to "commit"--as she says--to eliminating cheese and chips and cutting down on butter. Reluctantly, I say yes.

11:45 a.m. After taking a deep, deep breath, I blow like crazy into a wide white tube connected to a spirometer that measures my lung capacity. And when there's nothing left to blow, Anne Spellacy, a registered nurse, tells me to keep blowing. The results are good; the volume of air, known as forced vital capacity (FVC), expelled by my lungs measures 5.16 liters per sec., 109% of what is predicted for a man my age, weight and height. Pulmonary capacity goes down with age, which is why older people tend to get out of breath faster than the young. A typical 30-year-old man of my height and weight would have an FVC of 5.63. Even two years makes a difference; at 50, my number would have been 5.20.

12:15 p.m. An electric current too slight to feel passes through my body from neck to big toe to measure body fat vs. lean muscle. The result indicates that I am slightly overweight. Fat accounts for 14.4%, or 26.8 lbs., of my total weight. I knew this, of course. I was aware that those potato chips were beginning to show up on my belly, thighs and buttocks. Yet fat is not all bad. Some studies even advocate moderate fat gain, no more than 10 lbs., every decade. The theoretical basis is that fat is an insurance policy from our distant past. For our human ancestors, it meant that when they reached old age and it was difficult to gather food, they could survive for a time off their own fat.

12:40 p.m. My heartbeat, as measured on an electrocardiogram, looks as steady as a clock's swinging pendulum. In fact, my regular internist compliments me annually on its steadfastness, which he attributes to years of aerobic exercise.

1:00 p.m. "No one beats this machine," declares cardiologist Dr. Fredric Pashkow proudly as he points to the cardiac-function lab's treadmill. I am about to test his assertion while he examines how my heart behaves under physical stress. "Many athletes have tried. It has worn them all out."

His assistants, Vanessa Heinly and Kimberly Schifko ("We're known as the bad people here. We make you work"), plaster my torso, particularly the area around my heart, with electrodes attached by wire to a complex of computerized machinery that flashes numbers and graphs across screens. I am led onto the treadmill and told to begin walking. My heartbeat on the nearby monitor is as regular as it was a few moments ago when I was lying on my back. The treadmill speeds up, forcing me into a jog, and I feel a sweat break out. My systolic blood pressure (the big number) is up from 112 to 142. The cardiac team tells me I am "doing great." I feel the treadmill tilt upward. Now I am puffing. Computers have calculated my maximum heart rate to be 168 beats per min. Though I'm approaching that goal, I don't know if I can make it.

The treadmill angles up again, and now Pashkow is telling me I can stop anytime I want to. For a moment, I want to be a hero and beat the machine. The tension in the little room is high now; one of the assistants worriedly informs me that my heart is about to exceed the work capacity of men my age. I look over at the monitor to see how my heartbeat looks. The graph looks fine, just about the way it always appears. And then something happens. A line arcs upward like a Roman candle from the otherwise tight mass of up-and-down squiggles. Pashkow reassures me, saying my heart has just skipped a beat, a common occurrence. But such a graphic exhibition of my heart rebelling chills me emotionally, and I stop. The hell with the hero stuff. I am 52, and my heart did what a 52-year-old heart is supposed to do.

1:45 p.m. Chest X ray is normal.

2:00 p.m. In a room so quiet it reminds me of a chapel, I lie on a cushioned table while an overhead machine passes over my torso down to my waist, scanning bone density. The spine and the hips tend to be the first areas to lose bone mass. Since such bone loss is relatively rare in men my age, I assume this examination, like my hearing test, is a gratuitous experience. Alas, I am wrong again. The results of the scan, immediately visible on a computer screen, show that my left hip has lost 3% of its mass, and portions of my lower spine are 20% less dense than they should be.

3:00 p.m. In an extravagantly equipped sports clinic, Donald Lu, a trainer, shows me around the resistance machines and appears somewhat disappointed when I tell him how much I already exercise. He says most patients coming through the clinic desperately need an exercise plan. He offers to design one for me, but I am so upset about my vanishing bones that I defer. He does tell me a few things I don't know, however. First, people tend to lose muscle mass, especially beginning in their 50s, not simply because they are older but because they no longer use their muscles. Maintaining muscles through resistance training, such as using barbells, is just as important for older people as cardiac maintenance through aerobic exercise. Moreover, the more muscle available, the easier it is to burn off calories.

4:00 p.m. Consultation with Lang. My systems appear to be operating within or beyond the expected range for my age, but there is the mystery of my bones. "All the doctors here feel that the bone loss and your kidney stones are connected," Lang says. Dr. Angelo Licata, a clinic endocrinologist who specializes in bone diseases, seems not at all surprised. "Twenty percent of the people who come through here with osteoporosis are men," he says, "and 50% to 60% of those have a kidney-stone problem." In most cases, the cause has to do with interleukins, proteins in the bone marrow associated with the immune system that go awry and start eating away at the bone. The released calcium ends up in the kidney, contributing to the formation of stones.

But this is a preliminary assessment. In a few days I will receive a final report and recommendations for further testing to pinpoint the origin of my bone loss. A copy of the report will be sent to my regular internist. I will have to make some decisions. The first is whether to find a replacement for the New York kidney specialist who apparently never wondered if my kidney stones were formed out of the residue of my deteriorating bones, much less warned me about salt and vitamin C.

I leave the clinic perturbed over the bone-loss finding. In fact, I leave humbled in several ways. While happy that my body is standing up to time, the day's experience has vividly revealed to me something I had intellectually known for a long time but refused to recognize: that my body--like any body--is a finite entity. At 50-plus, it is high time for me to admit that even my body will eventually wear out. The good news is that there is a lot I can do to keep it going for many years to come.