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From the Townsend Letter
July 2012

briefed by Jule Klotter
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Fatherhood and Hormones
Having children changes everything – including the father's testosterone level, according to a September 2011 longitudinal study. Previous cross-section studies had shown that men with children tend to have lower testosterone (T) levels than men without children, but the cross-section design cannot clarify whether fatherhood lowers T or whether men with lower T are more likely to become fathers. This study, which followed 624 young Philippine males, found that young men with higher T levels were more likely to marry. (465 of the subjects were single nonfathers at baseline.) Moreover, T levels dropped significantly when they became fathers. Evidence that higher testosterone corresponds to successful mating is unsurprising. But the decrease that occurs with fatherhood – reducing competitive and aggressive urges – indicates that dads are biologically designed to care for their young.

The young men in this longitudinal study were part of the Cebu Longitudinal Health and Nutrition Survey, a Philippine birth cohort study initiated in 1983. The research team, led by Lee T. Gettler at Northwestern University (Evanston, Illinois), collected a.m. (waking) and p.m. (before bed) salivary testosterone levels, as well as data on sleep quality and psychosocial stress for their analysis. Both sleep and stress can affect T levels. Data were collected at baseline when the men were 21.5 ± 0.3 years old (2005) and at follow-up (2009).

The researchers made three observations. First, single nonfathers at baseline with high T levels upon waking were more likely to be in a stable partnership (married or cohabitating) at follow-up (odds ratio=1.20, p=0.044). Higher T levels at baseline indicated greater mating success.

In addition, the men who were newly partnered or new fathers at follow-up showed greater declines in a.m. (median: −26%) and p.m. (median: −34%) salivary T levels than single nonfathers. This decline was significantly more than the testosterone decline in single nonfathers attributed to aging: a.m. (median: −12%) and p.m. (median: −14%; p <0.001). Fathers with newborns (1 month or younger) showed the greatest decrease in T levels, a decline that could not be linked to sleep quality, stress, or involvement in child care.

The researchers also looked at fathers' involvement in child care and T levels. Philippine men living in and around Cebu City usually help care for their children. Men who engaged in child care for 1 to 3 hours a day had significantly lower a.m. testosterone levels than fathers who reported no caretaking. Fathers who spent 3 or more hours per day in child care had significantly lower a.m. and p.m. testosterone levels than fathers who reported no child-care time.

While medical doctors know that age, sleep, circadian rhythm, obesity, and diabetes can reduce a man's testosterone levels, relationship status is "rarely" considered, says anthropologist Peter B. Gray in his commentary about this study. If testosterone levels initiate behavior (e.g., mating) and response to life events (e.g. fatherhood), what effect does testosterone supplementation have? When practitioners talk about restoring testosterone levels to that of a young man, do they mean the level of an unmarried man? A young married man? A young father? "Whether an older man using a testosterone gel or patch is more likely to form a new partnership or less likely to maintain a paternal relationship has not been studied," says Gray.

Gettler LT, McDade TW, Feranil AB, Kuzawa CW. Longitudinal evidence that fatherhood decreases testosterone in human males.
PNAS. September 27, 2011; 108(39);16194–16199. Available at Accessed April 26, 2012.

Gray PB. The descent of a man's testosterone.
PNAS. September 27, 2011;108(39); 16141–16142. Available at Accessed April 26, 2012.

Fathers and Postpartum Depression
Recognizing that fathers as well as mothers can develop depression after the birth of a child is vital for the individuals themselves as well as for the well-being of their partnership and their children. Unlike "maternal blues" (a mild depression that usually resolves by day 10 after delivery), postpartum depression (PPD) can continue for months. "Over half of all women who develop [PPD] still suffer symptoms a year later," according to Clay and Seehusen. Men whose partners suffer with PPD are more likely to be depressed themselves. Depression in both parents during a child's first years increases the risk of behavior problems and development delays that continue into adolescence.

Between 10% and 20% of US women develop PPD within six months after delivery; the rate is 25% or more in women with a history of PPD. Symptoms include unhappiness, rapid change in emotions, insomnia, confusion, significant anxiety, guilt, and thoughts of suicide. Screening tools for PPD in women include Edinburgh Postnatal Depression Scale, Postpartum Depression Checklist, the Beck Depression Inventory, and the Center for Epidemiologic Studies Depression Scale.

Identifying PPD in fathers is more difficult because men are more likely to stay strong and just "buck up." Instead of crying and expressing anxiety, men tend to display anger when they are depressed. Neither they nor practitioners recognize that maternal PPD increases the risk of PPD in the woman's partner. Even if a father does recognize that he is depressed, he is less likely to seek help – after all, everyone's main concern is mom and baby.

A Canadian pilot study involving 11 fathers whose partners had experienced PPD self-reported several depressive symptoms: anxiety, lack of energy, irritability, feeling sad or down, changes in appetite, and thoughts of harm to self or baby. Some fathers also reported self-doubt, helplessness, frustration, anger, and fear for their partner's well-being and for their relationship. Economic worries and substance abuse can compound relationship and parenting stresses.

Men in this survey emphasized the vital importance of accessible information about PPD and the availability of supportive, knowledgeable professional helpers who listen to their concerns. Even if they can find such resources, fathers may lack time and energy to use them. At the very least, practitioners need to include dads in treatment of maternal PPD. PPD isn't just an individual problem; it affects the whole family.

The negative effects of maternal depression can be reduced if dads are available to provide social support, according to a 2010 longitudinal study involving 626 children and their families. Children whose fathers worked weekends were more likely to exhibit anxiety and behavioral problems, such as hyperactivity and aggression. Other research suggests that these problems can continue into adolescence.

Clay EC, Seehusen DA. A review of postpartum depression for the primary care physician. South Med J. February 2, 2004; 97(2);157–161. Available at
. Accessed April 25, 2012.

Letourneau N, Duffett-Leger L, Dennis L-L, Stewart M, Tryphonopoulos PD. Identifying the support needs of fathers affected by post-partum depression: a pilot study. J Psychiatr Ment Health Nurs. 2011:18:41–47. Available at CINAHL Plus with Full Text database. Accessed April 18, 2012.

Letoumeau N, Duffett-Leger L, Salmani M. The role of paternal support in the behavioural development of children exposed to postpartum depression. Can J. Nurs Res. June 23, 2010. Available at Accessed April 25, 2012.

O'Connell-Binns K. Men's mental health during the first year postpartum. J Community Nurs. July 2009; 23(7):4-8. Available at CINAHL database. Accessed April 18, 2012.

Vasconcellos D. The needs of fathers. Mother Matters. 2008. Available at Accessed April 24, 2012.

Hyperbaric Oxygen Therapy for Traumatic Brain Injury
An estimated 546,000 of the 1.64 million US soldiers fighting in Iraq and Afghanistan have been diagnosed with blast-induced traumatic brain injury (TBI), postconcussion syndrome (PCS), and/or posttraumatic stress disorder (PTSD), according to a Rand report. About 82,000 have symptoms of all three. Symptoms of TBI/PCS include headaches, disrupted sleep, short-term memory and cognition problems, irritability and mood swings, decreased hearing, tinnitus, and depression. PTSD, which affects an estimated 200,000 (18.3%) service personnel, is characterized by severe anxiety and reliving traumatic events. Mild TBI is presently treated with psychoactive medications, counseling, and adaptive strategies; but no effective treatment is available for veterans with postconcussion syndrome and PTSD.

Paul G. Harch and colleagues are researching the safety and effectiveness of 1.5 atmospheres absolute (ATA) hyperbaric oxygen therapy (HBOT) in the treatment of mild to moderate blast-induced TBI and PTSD. HBOT involves the delivery of oxygen to a patient in a pressurized tank; usual treatment pressure is 2.0 to 3.0 ATA. The researchers chose to use just 1.5 ATA to reduce the risk of negative effects such as seizure.

The Harch Phase I study involved 16 servicemen (8 active duty and 8 retired) who had TBI for at least one year. Fourteen of the 16 also had PTSD. The servicemen completed symptoms and quality-of-life questionnaires and underwent physical and neurological exams and SPECT brain imaging at baseline and within one week after treatment's end. Additional SPECT imaging was performed the day after the first HBOT treatment to document its initial effect on brain blood flow. The servicemen received 60-minute HBOT treatments twice a day, five days per week for a total of 40 treatments. Two treatments per day is not the usual or preferred protocol for HBOT, but time and financial considerations prevented the subjects from committing to a longer study period.

The researchers reported " … significant improvements in self-reported symptoms, physical exam changes, PCS symptoms, perceived quality of life questionnaires, affective measures (general anxiety, depression, suicidal ideation, and PTSD), cognitive measures (memory, working memory, attention, and FSIQ score), and SPECT brain blood flow imaging." Fourteen of the 15 who completed treatment reported improved cognition. Thirteen of 15 had fewer problems with headaches, energy level, and mood swings. A majority also had improved sleep and short-term memory, and less depression and irritability. In addition, PTSD scores decreased by 30%. Improvement was sustained for at least six months after treatment in 11 of the 12 servicemen who reported improvement on the majority of their symptoms. In addition, one person, who did not experience major improvement after treatment, reported during the six-month phone follow-up that most of his symptoms had improved.

Negative side effects to HBOT were temporary. Four of 16 experienced temporary worsening of headache, mood swings, or depression before improving. Another 4 developed upper respiratory infections, which the researchers attribute to the accelerated treatment protocol and HBOT's mild immunosuppression effects. These 4 plus a fifth servicemen developed mild reversible middle ear barotraumas (MEBT), which led to postponement (or termination in one case) of HBOT treatment.

This study is the first to use HBOT for TBI and PTSD. Its results are promising. Larger studies are needed.

Harch PG, Andrews SR, Fogarty EF, Amen D, Pezzullo JC, Lucarini J et al. A phase I study of low-pressure hyperbaric oxygen therapy for blast-induced post-concussion syndrome and post-traumatic stress disorder. J Neurotrauma. 2011;28(1).

US Department of Veterans Affairs. What is PTSD? [Web page]. January 1, 2007. Accessed May 6, 2012.

High-Intensity Focused Ultrasound and Prostate Cancer
High-intensity focused ultrasound (HIFU) uses high-frequency sound waves to raise tissue temperature to 80 to 90 ºC (176–194 ºF) and destroy cancer cells. This noninvasive treatment is being promoted as a possible alternative to "watchful waiting" for older men with localized, low-grade prostate cancer or as a salvage treatment when prostate cancer recurs after radiation therapy.

The purported advantage of HIFU is reduced risk of incontinence or impotence compared with surgery or radiation therapy. A 2012 Lancet Oncology study, involving 41 men, reported that none of the 41 were incontinent at a 12-month follow-up and 4 of the 41 (10%) were impotent. A 2010 retrospective study of 65 patients (55 first-line HIFU treatments, 10 salvage therapy after radiotherapy), led by Thomas Ripert, is less positive. This research team reported a 36.4% early complication rate (< 1 month) after the procedure. Complications included urinary retention, dysuria, urinary infection, hematuria, and urethral stenosis. Urethral stenosis or dysuria affected 12.7% of the 65 patients one month or more after HIFU treatment. According to Ripert and colleagues, "The long-term urinary incontinence rate was 20% and the de novo erectile dysfunction rate was 77.1%." The wide disparity in complication incidence may partially depend upon practitioner expertise and the quality of the device used to perform HIFU. Patients, however, need to realize that HIFU is not risk free.

Few long-term studies have been performed, so HIFU's efficacy as a cancer treatment is still uncertain. A 2012 South Korean study, led by Hyun Hwan Sung, reported that 5-year disease progression-free survival rates were 73.5% for low-risk patients, 46.0% for intermediate risk, and 29.2% for high-risk (p = 0.008). Xavier Rebillard and colleagues reviewed 37 articles and abstracts for their 2008 BJU International article on HIFU safety and efficacy. They found a five-year actuarial disease-free state of 60% to 70%. They state that most patients who received HIFU treatment were older men with low-grade, localized prostate cancer who would normally be candidates for watchful waiting/deferred treatment. In comparison, 10-year cancer-specific survival rates for watchful waiting patients have survival rates of 85% to 87%, according to Rebillard and colleagues. Clearly, more research on HIFU's efficacy is needed.

Meanwhile, the push is on to gain FDA approval for HIFU prostate cancer treatment in the US so that it will be covered by health insurance.

HIFU procedure awaiting approval in US [online article]. May 17, 2010. Prostate Cancer Treatment Report. Accessed April 18, 2012.

HIFU success depends by surgeon's experience [online article]. Prostate Cancer Treatment Report. January 22, 2010. Available at Accessed April 18, 2012.

Hyun HS, Byong CJ, Seong IS, Seong SJ, Han-Yong C, Hyun ML. Seven years of experience with high-intensity focused ultrasound for prostate cancer: Advantages and limitations. Prostate. January 17, 2012. Available at Accessed May 4, 2012.

Mandal A. High intensity focused ultrasound to treat prostate cancer shows initial success [online article]. April 17, 2012. Medical News. Accessed April 18, 2012.

Rebillard X, Soulié M, Chartier-Kastler E, et al. High-intensity focused ultrasound in prostate cancer; a systematic literature review of the French Association of Urology. BJU International. 2008;101:1205–1213. Available at Accessed April 8, 2012.

Ripert T, Azémar M-D, Ménard J, et al. Transrectal high-intensity focused ultrasound (HIFU) treatment of localized prostate cancer: Review of technical incidents and morbidity after 5 years of use [abstract]. Prostate Cancer Prostatic Dis. June2010;13(2):132–137. Available at Accessed May 4, 2012.

What is HIFU? [Web page] Prostate Cancer Treatment Report. Accessed April 18, 2012.

Alternative Therapies for Chronic Prostatitis
Prostatitis, characterized by pelvic discomfort, urinary symptoms, and/or sexual dysfunction, affects an estimated 9% of US men. Bacterial infection is the most prevalent cause of prostatitis; however, a case report from India shows that fungal infections can also cause the condition. When conventional treatment – typically antibiotics and/or anti-inflammatory drugs – fails to resolve the problem and other conditions such as cancer have been ruled out, conventional doctors have nothing more to offer. Men either continue to suffer or look for alternative therapies. Research studies support the use of pelvic floor muscle therapy and acupuncture for chronic prostatitis (CP), also known as chronic pelvic pain syndrome (CPPS). In addition, some doctors have had clinical success with elimination diets.

For some men, chronic pelvic discomfort is due to spasms of pelvic floor muscles. Biofeedback helps patients gain awareness and control over these muscles. In a 2011 review article, Lara K. Suh and Franklin C. Lowe present a 2005 study in which 31 men with CP/CPPS took part in 6 to 8 weeks of biofeedback physical therapy. Mean score on the National Institutes of Health Chronic Prostatitis Symptoms Index (NIH-CPSI) fell from 23.6 to 11.4 (p < 0.001). In addition, the research team, led by E. B. Cornel, used a rectal electromyography probe to measure pelvic floor muscle tonus. Mean pelvic floor muscle tonus fell from 4.9 mV to 1.7 mV (p < 0.001). Normal resting tone is <2mV. Myofascial trigger point release can also reduce pain caused by pelvic floor muscle spasms.

Acupuncture is another option for reducing CP/CPPS pain, according to Suh and Lowe. They cite a 2010 study, led by V. Tugcu, in which men with chronic pelvic pain syndrome were given weekly acupuncture sessions for six weeks. Total NIH-CPSI scores for 92.5% of the participants (86 of 93) declined by over 50% from baseline. Suh and Lowe report that the response rate "was unchanged" at the 12-week and 24-week follow-ups.

Although an elimination challenge diet has not been tested (to my knowledge) as a therapy for CP/CPPS, Mark W. McClure, MD, and Eric Yarnell, ND, have found the technique clinically useful for identifying foods that trigger pelvic pain. McClure says, "I often see a connection between some gastric malfunction, whether it is irritable bowel syndrome or a mild case of Crohn's disease, and prostatitis. So, I try to do an elimination-challenge diet to see what foods might be culprits in causing gastric problems and, directly or indirectly, causing pelvic discomfort."

When antibiotics (or antifungals) fail to help a patient with CPPS, it may be time to consider an alternative.

Srivastava SC, Srivastava AK. Homoeopathy a resonable [sic] alternative for treatment of fungal prostatitis-a case report. J Recent Adv Appl Sci. 2010;25:25–27. Available at Accessed April 25, 2012.

Suh LK, Lowe FC. Alternative therapies for the treatment of chronic prostatitis. Curr Urol Rep. 2011;12:284–287. Available at Accessed April 25, 2012.

Tugcu V, Tas S, Eren G, et al. Effectiveness of acupuncture in patients with category IIIb chronic pelvic pain syndrome: a report of 97 patients [abstract]. Pain Med. April 2010:11(4):518–522. Available at Accessed May 6, 2012

Yarnell E, Espinosa G, McClure MW. Roundtable discussion – focus on men's health. Altern Complement Ther. April 2010;16(2):77–82. Accessed from CINAHL database. April 18, 2012.

Military Vets and Mental Health Care
The Veterans Health Administration is struggling – and pretty much failing – to help thousands of servicemen and -women who need mental health care. Despite widespread recognition that veterans need help, the VHA lacks trained personnel with a better understanding of posttraumatic stress disorder (PTSD) and traumatic brain injuries. One million-plus veterans sought help in 2011, according to an NPR report by Larry Abramson.

A 2012 study, led by Peter C. Britton, PhD, highlights some of the VHA's weaknesses. Data from two VHA geographic areas revealed 423 veterans who committed suicide during a seven-year period (2000–2006). Of that total, 381 veterans (90.07%) attended a VHA clinic during their last year of life. Medical records for 31.5% of those 381 soldiers contained no documented symptoms of depression, PTSD, substance abuse, or other forms of mental illness/distress. The lack of documentation points to "problems with detection, documentation, or the absence of critical variables in the chart review," according to Britton and colleagues. Veterans with documented symptoms were almost three times as likely to kill themselves within 30 days of their last visit. Clearly, more than better documentation is needed.

The researchers also found that the 10% of suicides who did not attend a VHA clinic in the last year of life consisted of a high number of racial and ethnic minorities, indicating a greater need for accessibility and outreach to minority veterans. Of course, this study cannot show how many suicides were prevented because of VHA intervention. It does point to a need for improved access to services and to an expanded understanding of factors that lead veterans to take the irrevocable step of suicide.

A 2012 study sought to understand factors that contribute to high suicide risk among vets, particularly those who have served during the Iraq and Afghanistan wars, in the hope of finding ways to help them. The study, led by Mark S. Kaplan, DrPH, used National Violent Death Reporting System data from 2003 to 2008. Suicide risk among veterans ages 18 to 64 years "was statistically significantly greater" than among nonveterans of the same ages. Relationship problems apparently contributed to suicide in about half of the veterans aged 18 to 34. In addition to partner difficulties, family and friends also mentioned that decedents faced money, job, and/or legal problems. Kaplan and colleagues say that counselors working with veterans need to "consider moving beyond the standard 'danger signs' of suicide risk (e.g. major depressive disorder or PTSD) and address the role that life crises play in triggering suicidal behavior." As an example, the authors suggest helping veterans develop interpersonal skills so that they can better navigate personal relationship crises. This study did not address how or if service in combat situations contributed to mental distress.

Every other year or so, news stories and politicians beat up the VA for inadequate health care for Iraqi and Afghanistan servicemen and -women. The brouhaha may make everyone feel self-righteous, but it hasn't helped the people who risked their lives and sanity. This problem will continue to get worse. "You don't see the real cost in human terms," says Patrick Belton, an activist with Veterans for Common Sense, "until 20–30 years after the conflict has ended."

Abramson L. VA struggles to provide vets with mental health care [online article]. NPR. April 25, 2012. Accessed April 25, 2012.

Britton PC, Ilgen MA, Valenstein M, Knox K, Claassen CA, Conner KR. Differences between veteran suicides with and without psychiatric symptoms. Am J Publ Health. 2012:102(S1):S125–130. Available at CINHAL database. Accessed April 18, 2012.

Kaplan MS, McFarland BH, Huguet N, Valenstein M. Suicide risk and precipitating circumstances among young, middle-aged, and older male veterans. Am J Publ Health. 2012;102(S1):S131–S131. Available at CINHAL database. April 18, 2012.

Vitamin E and Prostate Cancer
"Dietary supplementation with vitamin E significantly increased the risk of prostate cancer among healthy men," reads the conclusion to the October 12, 2011, JAMA report on the Selenium and Vitamin E Cancer Prevention Trial (SELECT). The group of 8702 men taking 400 IU/day of all-rac-a-tocopheryl acetate for a minimum of seven years had a 17% higher incidence of prostate cancer than the placebo group. All-rac-a-tocopheryl acetate is a synthetic form of just one of the four tocopherols (alpha, beta, gamma, delta) found in vitamin E complex. Both synthetic and natural forms of alpha-tocopherol are antioxidants, but the natural form is more powerful. Many brand-name multivitamins, made by pharmaceutical companies, contain all-rac-a-tocopheryl acetate, according to William Faloon at Life Extension.

Why would an antioxidant lead to an increase in prostate cancer? Large doses of alpha-tocopherol (synthetic and natural) deplete gamma-tocopherol levels in the body. Men in SELECT's "vitamin E" group showed a 45% decrease in their gamma-tocopherol levels within six months – very early in the trial. The decrease continued throughout the study. Like alpha-tocopherol, gamma-tocopherol is a powerful antioxidant; but it has anticancer effects that the alpha form does not. Gamma-tocopherol scavenges reactive nitrogen species that damage proteins, lipids, and DNA, according to Faloon. It also prevents cancer cells from reproducing by "downregulating" control molecules called cyclins. In vitro experiments with prostate cancer cells showed that gamma-tocopherol caused cancer cell death by preventing the synthesis of necessary cell membrane components. Gamma-tocopherol also inhibits blood vessel formation in tumors. A marked reduction in gamma-tocopherol may not totally account for the increased prostate cancer risk in SELECT, but it could certainly be a contributor.

We are still learning about the interactions between the tocopherols and tocotrienols that make up vitamin E complex and their effects on the human body. For now, it is wisest to use mixed tocopherols when supplementing. And the next time that headlines blare news about vitamin E (good or bad), find out what the research actually used: an isolated tocopherol, mixed tocopherols, or the vitamin E complex itself.

Faloon W. Synthetic alpha tocopherol shown to increase prostate cancer risk. Life Extension. March 2012;30–43.

Klein EA, Thompson IM Jr., Tangen CM, et al. Vitamin E and the risk of prostate cancer: the Selenium and Vitamin E Cancer Prevention Trial (SELECT) [abstract]. JAMA. October 12, 2011;306(14):1549–1556. Available at Accessed April 24, 2012.

Well-Being, Health, and 'Men's Sheds'
As men in the Baby Boom generation (born between 1946 and 1964) enter their sixth and seventh decades, more attention will turn to the factors that promote health in older men. Those factors have less to do with diet, exercise, and medication and more to do with mental health and emotional well-being. Men who lack a sense of social and emotional well-being question the need for physical health, according to Gary Misan and Peter Sergeant. Without social connections and a sense of self-worth, physical health has little meaning or purpose. Yet, mental-emotional well-being in men is often ignored by society, by practitioners, and by men themselves.

Men are less likely to seek medical help than women. Despite the questioning of gender roles that accompanied the women's liberation movement, " … a traditional yet widespread view of masculinity [still] sees seeking help for health problems as a sign of being weak," writes Toby Williamson. Also, men – particularly older men – do not want to be a burden. Their self-worth depends upon personal autonomy and having control in their lives. Because men do not exhibit the same behavioral symptoms as women, practitioners may not recognize the seriousness of a man's problem when he does seek help for mental or emotion disturbance. Older men and their doctors may wrongly view depression as a natural part of aging. In fact, depression may be an understandable response to social isolation, financial stress, or other life situations.

A grassroots movement in Australia, known as Men's Sheds, is being viewed as a strategy for improving retired men's health and well-being. "[Men's Sheds] are diverse in structure and function but common in purpose; they are a space for men," write Misan and Sergeant. Specifically, they are a place for men "to tinker," to share interests, to make friendships, and to use their skills and knowledge in helping others. Misan and Sergeant explain that most men's sheds include a workshop with tools where men can work on crafts or hobbies, refurbish old computers, or repair machinery. Sometimes, participants mentor youth and unemployed men or provide support to men with disabilities. A nine-minute video at the Australian Men's Shed Association (AMSA) website ( shows how these organizations help improve health and life quality for the participants. The positive effects touch their family members and communities as well. As the AMSA slogan points out, "men don't talk face to face, they talk shoulder to shoulder." The website also has a 91-page manual on how to start a men's shed.

The Men's Shed movement reminds me of the Grandmother Project, which engages the wisdom and authority of village grandmothers in Senegal and other underdeveloped countries to improve nutrition for pregnant women and children. This movement is more autonomous, but it gives male elders a way to share their skills and knowledge, benefiting the community and increasing their own well-being.

Misan G, Sergeant P. Men's sheds – a strategy to improve men's health. 10th National Rural Health Conference (Australia). Available at Accessed April 24, 2012.

Shapiro A, Yarborough-Hayes R. Retirement and older men's health. Generations. Spring 2008:49–53. Available at CINAHL Plus database. Accessed April 18, 2012.

Williamson T. Grouchy Old Men? Promoting older men's mental health and emotional well being. Working with Older People. 2011;15(4):164–176. Available at CINAHL Plus database; doi:10.1108/13663661111191284. Accessed April 18, 2012.

Jule Klotter


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