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Latest Advances in Men’s Health

           Nelson Vergel
          PoWeRUSA.org
     TestosteroneWisdom.com




        Copyright © 2011 by Nelson Vergel
Objectives
n   To Review:
    – The most common causes of erectile
      dysfunction (ED) and its treatment options
    – Best ways to diagnose and treat
      testosterone deficiency
    – Best ways to increase lean body mass and
      decrease fat
    – Supplements backed by data
    – Nutrition and Exercise tips


n   Questions and answers
This information (and any accompanying printed
material) is not intended to replace the attention or
advice of a physician or other health care professional.
Anyone who wishes to embark on any dietary, drug,
exercise, or other lifestyle change intended to prevent
or treat a specific disease or condition should first
consult with and seek clearance from a qualified health
care professional.
Copies of these slides
 are available free online at


TestosteroneWisdom.com
 on the “Lectures” page
Men's Health Lecture by Nelson Vergel
Testosterone and Aging
Signs and Symptoms of Low
          Testosterone
       Loss of muscle mass and strength
       Loss of libido and erectile dysfunction
       Depression
       Lethargy (fatigue, lack of focus)
       Bone loss
       Some regression of secondary sexual
        characteristics (body hair loss, etc)
       Low or no sperm count

Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987
Petak SM, et al. AACE Clinical Practice Guidelines. Available at: http://www.aace.com/clin/guides/hypogonadism.html
Testosterone Deficiency
                (Hypogonadism)

• Normal levels in blood:

   Men...    Total test. 300-1100 ng/dL,
             Free test. 5 - 21 ng/dL

   Women... Total test. 10-50 ng/dL
            Free test. 0.10-0.85 ng/dL
Testosterone
Replacement Benefits                           Mental
                                               focus




                            Stamina and Bone Strength
   Sexual function


                     Lean
                     Body
                     Mass
Testosterone and The Body
The HPT Axis
Men's Health Lecture by Nelson Vergel
Testosterone Fractions in the Blood
          Bioavailable T   Free T
                            2%
   Albumin-bound T
        38%




T = testosterone
Only 2% is free
                             Sex Hormone Binding Globulin
testosterone                        SHBG-bound T
and 98% is bound                        60%
Finasteride




Anastrozole
Tamoxifen
(binds   testosterone)
Conditions associated with alterations in
           SHBG concentrations
Conditions associated with decreased SHBG
  concentrations
  –   Moderate-severe obesity
  –   Hypothyroidism
  –   Type 2 Diabetes mellitus
  –   Nephrotic syndrome
Conditions associated with increased SHBG
  concentrations
  –   Aging
  –   Hepatic cirrhosis
  –   Hyperthyroidism
  –   Use of anticonvulsants
  –   HIV infection
             Bhasin, S. et al. J Clin Endocrinol Metab 2006;91:1995-2010
Men's Health Lecture by Nelson Vergel
Potentially Approved in the Next 12-24 Months
Men's Health Lecture by Nelson Vergel
Men's Health Lecture by Nelson Vergel
Effects of Physiologic Testosterone
Supplementation on Fat Mass and
Distribution in HIV-Infected Men
with Abdominal Obesity
CM Shikuma1, RA Parker2, F Sattler3, B Alston4, R
Haubrich5, T Umbleja2, S Bhasin6, for the AIDS
Clinical Trials Group Protocol A5079 Study Team
1 University of Hawaii, Honolulu, HI; 2 Harvard School of
Public Health, Boston, MA; 3 University of Southern
California, Los Angeles, CA 4 Division of AIDS, NIAID,
Bethesda MD; 5 University of California, San Diego, San
Diego, CA; 6 Boston University, Boston MA
Percent Change over 24 weeks
        in CT Measures (ITT)
        10
                                     P<0.001
          8                                    *
          6                                              P=0.04
                   P=0.76
          4                                  8.1%
                                                                4.3%
          2              3.1%                                               Active
          0       0.3%                                  -1.5%               Placebo
        -2                           -7.2%
        -4
        -6
        -8                              *
                    VAT                SAT            Total Abd Fat
Entries within bars are median values of change; *Change in within arm differences p<0.05
Percent Change over 24 Weeks
          in DEXA Measures (ITT)
        6      p=<0.001                          p=<0.001
                         *         P<0.001                  *
        4
                        4.6%                                       p=0.02
        2
                                                          4.5%
                                          3.8%                       *
                                                                   1.3%
        0
                                                                          -0.3%
       -2                                                                            Active
                                                  -7.9%
       -4                        -10.1%
                                                                                     Placebo
                -9.9%
       -6
       -8
                                                    *
     -10                           *
                 *
     -12        Trunk            Extremity              Total         Lean
                 Fat               Fat                   Fat          Tissue
Entries within bars are median values of change; *Change in within arm differences are p<0.05
Side Effect: Gynecomastia (breast enlargement in men)




Treatment: Estrogen Blocker Medications or surgery (in worst cases)
What Increases Estradiol?
n   Antiandrogens. These include cyproterone, flutamide, and
    finasteride.used to treat prostate cancer and some other
    conditions.
n   HIV medications. Sustiva, Atripla, and Videx have been
    associated with gynecomastia.
n   Anti-anxiety medications such as diazepam (Valium).
n   Tricyclic antidepressants. These include amitriptyline.
n   Glucocorticoid steroids.
n   Antibiotics.
n   Ulcer medication such as cimetidine (Tagamet).
n   Cancer treatment (chemotherapy).
n   Heart medications such as digitalis and calcium channel
    blockers.
n   Anabolic steroids
Substances that have been reported to
  cause gynecomastia include:
n   Alcohol
n   Amphetamines
n   Marijuana
n   Heroin
n   Soy and flaxseed- There are conflicting studies but it
    is something to keep in mind
n   Exposure to pesticides and byproducts of plastic
    processing has also been linked to increased
    estrogen and decreased sperm count in men.
Side Effect: Increased number of red blood cells (polycythemia)




                                   Watch out for
                                   hematocrit over 52 !




Solution: Donate blood
or therapeutic phlebotomy
  (4-5 units every 3-4 months)
Side Effect: Testicular Shrinkage (atrophy)



                                 Dosing protocols vary




Treatment:
Human Chorionic Gonadotropin
(hCG) – It mimics LH to jump
start testicles
Side Effect : Increased prostate size
            (benign prostatic hypertrophy)



                                     Potential treatments:
                                     Finasteride,etc
                                     Or alpha blockers to increase
                                        urinary flow




Prevention:
Digital Rectal Exam (DRE)
Prostatic Specific Antigen (PSA)
 blood test
Side Effect: Acne




Treatment: Bezoyl Peroxide, salicilic acid lotions, soaps,
showering after exercising, 20 min of sun a day, Zinc supplements
Men's Health Lecture by Nelson Vergel
Oral Steroids : Oxandrin
              (Oxandrolone)
 Only anabolic approved for weight loss
 Mild - can be used by women and children
  (low virilizing)
 Does not stunt growth in children
 Several studies in HIV/AIDS
 Men need higher doses - 20 -40 mg/day with
  testosterone; women 5 - 20 mg/d
 Potential liver burden over 20 mg (adults)
 Expensive - $1100/month at 20 mg
Exercise Oxandrolone in Patients
on HAART
Anabolic Steroid Use in HIV
 Over  17 HIV studies show they are effective to
  increase muscle mass and strength in men and
  women
 Orals: Anadrol, Oxandrin
 Injectable: Testosterone Cypionate and Enanthate,
  nandrolone decanoate
 Steroids should be given with testosterone since
  they tend to lower the body’s own testosterone
  production
 Side effects: acne, high blood pressure, prostatic
  inflammation, liver dysfunction (orals), polycythemia
  (too many red blood cells), sleep apnea, etc
 Illegal for those with no medical conditions
 More information in www.medibolics.com
Anabolics Used in HIV
                          Anabolic       Androgenic
     Steroid                                              Reported Doses              Side Effects
                         Properties      Properties
Nandrolone Decanoate
   Deca Durabolin                                          Men 100-200 mg/wk         Some water retention,
                             High        Low to Medium
      (injections)                                          Women 25 mg/wk                  HTN
 Available in the U.S.

      Stanozolol                                                                    Slight chance of virilizing
                                                            Men 6-18 mg/day
  Winstrol™ (Oral)           Low           Very Low                                  for women. Watch liver
                                                           Women 4-12 mg/day
 Available in the U.S.                                                                       function.

                                                                                   Slight chance of virilization
Oxandrolone Oxandrin™                                       Men 15-20 mg/day
                                                                                     for women. Watch liver
        (Oral)           Low to Medium     Very Low        Women 10-40 mg/wk
                                                                                    function. Women report
   Available in U.S.                                       Children 2.5-5 mg/day
                                                                                         water retention.


                                                                                   Balding in men, high blood
 Oxymetholone Trade
                                                                                    pressure, water retention,
 name Anadrol™ 50                                           Men 50-100 mg/day
        (oral)
                           Very High       Very High                               body hair growth in women
                                                                                   and breast enlargement in
 Available in the U.S.
                                                                                   men. Watch liver function.


     Testosterone                                                                  Water retention, balding in
Cypionate or Enanthate                                     Men 100-200 mg/wk           men, acne, breast
      (Injections)
                             High        Medium to High     Women 25 mg/wk         enlargement in men, may
 Available in the U.S.                                                                  virilize women.


      All can cause (depending on the person and if not managed properly):
      increased hematocrit, acne, BPH, gynecomastia, increased blood pressure/edema
Compounding Pharmacies
• Make customized pharmaceuticals and nutraceuticals with
  expired patents or abandoned by pharmaceutical companies
  (i.e. nandrolone,etc)
• Most products require a prescription
• Depending on the state, many can ship products to your home
• Products are usually 2-10 times cheaper than buying
  commercially available pharmaceutical medications
• Products can be formulated in different delivery forms
• Common products related to hormone treatments, erectile
  dysfunction, pain gels/creams, hair growth gels, side effect
  management products, and quality of life related formulations.
• Most do not take insurance but provide info for your own filling
• I have been using APSMeds.com for the past 4 years since
  they have the best pricing and a specialized patient support
  person for HIV+ and HIV- patients.
For More Information:
TestosteroneWisdom.com
Protecting Your Sexual Function
Causes of ED
                 Risk Factors
        Massachusetts Male Aging Study¹


 Treated   heart disease                 39%

 Treated   diabetes                      28%

 Treated   hypertension                  15%

    ¹Feldman Ha, J Urol 1994; 151:54-61
Causes of ED
Medications (cont.)

 Anti-hypertensive   drugs
  – All capable
  – Common: thiazides and beta blockers
  – Uncommon: calcium channel blockers,
    alpha-adrenergic blockers, and ACE
    inhibitors
Causes of ED
Medications (cont.)
 CNS drugs:
  – Antidepressants, tricyclics, SSRIs
  – Tranquilizers
  – Sedatives
  – Analgesics


 H1   and H2 receptor blockers
Causes of ED
 Organic   Causes
  – Cardiovascular disease
  – Diabetes mellitus
  – Surgery on colon, bladder, prostate
  – Neurologic causes (lumbar disc, MS, CVA)
  – Hormonal deficiency
Cause of ED
 Psychogenic   Causes:
  – Anxiety
  – Depression
  – Fatigue
  – Guilt
  – Stress
  – Marital Discord
  – Excessive alcohol consumption
  – Street drugs
How to Treat Sexual Dysfunction
• Avoid excessive alcohol and smoking
• Balance your testosterone- injection/cream /gel/patch
• Viagra, Levitra, Cialis
• DHEA - men 50 - 500 mg, women 25 - 100 mg
• Trimix (prescription)- Injection of 0.1-0.2 cc in the penis. Less
  expensive than Caverject. See an Urologist. Visit
  apsmeds.com, gotocompoundingshop.com, etc
• Yohimbe - stimulant, concerns about hypertension
  (Prescription: Yocon)
• Counseling may help those with psychologically induced
  sexual dysfunction
• Talk to an Urologist for other tests!
Sexual Dysfunction Oral Drugs




                    Drug     Onset of      Duration
                             Action       of Activity
                   Viagra    60 minutes   4-5 hours
                   Levitra   30 minutes   4-5 hours
                   Cialis*   15 minutes   36 hours
* No food effect
Medication Side Effects
       (PDE Inhibitors)
Side effects:
 Headache
 Flushing
 Dyspepsia
 Nasal congestion
 Visual disturbances
 Back ache (Cialis)
Penile Injection Therapy
    Caverject, Edex, Tri/Bi-Mix
 Mechanism of action: smooth muscle
  vasodilator
 Monotherapy (protaglandin E1) or combination
  of 2 or 3 agents (Papaverine+ Phentolamine +
  Alprostadil )
 Administration: 10, 20, 40ug
 Inject directly into corporeal bodies of the penis
 Results: 70%-90%
 Dropout rates: 25%-60%
 Side effects: pain (36%), priapism (4%),
  fibrosis
Trimix
      (Papavarine+ Phentolamine + alprostadil)
Available by prescription from compounding
                pharmacies
Men's Health Lecture by Nelson Vergel
Stages of Change




© 2010 Pro-Change Behavior Systems, Inc.
COMPREHENSIVE APPROACH TO
         WELLNESS

              Stress Reduction


Medications                      Nutrition


               Exercise
Protecting Your Heart
Men's Health Lecture by Nelson Vergel
How To Minimize Heart Disease
   Do not smoke!
   Exercise and low animal fat/sugar diet
   Lose weight if you are overweight
   Manage stress and keep blood pressure in check
   Decrease triglycerides with Omega 3 fatty acids (cold
    water fish oils), low sugar intake, exercise.
   Improve HDL with Niacin 300-500 mg 3 x day. Start with
    lower dose to minimize “flushing” and take an aspirin 20 min before
    (Niaspan is the prescription grade)
   Soluble Fiber (oats, fiber supplemengts, etc)
    If everything else fails, use prescription lipid lowering
    agents (statins, fibrates, etc)
   A baby aspirin a day (81 mg)
   Keep healthy blood levels of testosterone and thyroid
    hormones.
Insulin Resistance: A Silent Health Threat




                      Pre diabetes




Keeping a healthy weight, exercising, low glycemic load diet, certain supplements
and medications can decrease Insulin resistance and glucose intolerance
Visceral Fat and Health
Potential Interventions for Decreasing
    Abdominal Fat (visceral adipose tissue-VAT)
   Diet- Lower carbohydrate diets, Mediterranean diet
   Exercise- cardiovascular and resistance training- Some pilot
    data with good results
   Anti-diabetic drugs: Metformin (Glucophage)- conflicting
    and inconclusive data
   Testosterone gel- subcutaneous fat loss only
   Anabolic steroids- Oxandrin, nandrolone?- limited VAT
    data
   Human Growth Hormone
   Human Growth Hormone Releasing Hormone- Sermorelin
    and Tesamorelin- Approved for the treatment of HIV
    related visceral fat accumulation
   Surgery- Liposuction of visceral fat very difficult and risky
How to Increase Lean Body Mass
 Higher  protein intake (whey, egg white protein
  supplements, lean meats, nuts, fish, eggs, etc)
  and more frequent snacking with right balance.
  More in nutrition section
 Resistance exercise. More in exercise section
 Testosterone Replacement if needed
 Growth Hormone replacement
 Medical use of oxandrolone and nandrolone
 Creatine Supplementation
 Healthy sleep habits
Supplements- Snake Oil?
Supplements- What Works?
 Niacin   1000-3000 mg/day
  – Increases good cholesterol (HDL). Caution with
    “flushing”. Take a baby aspirin 20 min before taking
    niacin
 Selenium
  – Glutathione production (anti-oxidant.) A study
    showed people who took 200 mcg/day had better
    immune function
 Calcium   Carbonate- 500-2000 mg/d
  – Bone protection, diarrhea control
 Vitamin D- Bone protection and other emerging
  benefits (2000-4000 IU/d)
 SAMe (S-Adenosyl-L-Methionine) – energy,
  depression, liver detox
Supplements -Any data?

   Whey Protein 20-100 grams/day
    – Popular with bodybuilders. HIV study found compensatory response.
      People ate less food and no increased LBM was found
   Creatine 5-15 grams/day
    – Muscle voluminizer, strength enhancer. Caution with diarrhea
      and kidney overload.
   Omega 3 oils (fish oils) 3000- 6000 mg/day
    – Decreases cholesterol/triglycerides, anti-inflammatory, mood
      stabilizer?
   L-Carnitine 1000-3000 mg/day
    – Helps use fat for energy, cell protection, lowers lipids, anti-
      catabolic, heart muscle protection, N-Acetyl Carnitine may
      restore nerve damage in neuropathy
   B Vitamins (100 mg each/day)- whole body processes,
    possible prevention of mitochondrial toxicity
Great Web Site to Find Out
What Supplements to Trust

   ConsumerLabs.com
Men's Health Lecture by Nelson Vergel
What Your Plate Should Look Like….
Men's Health Lecture by Nelson Vergel
The
                  ZONE
                  &
Modified Atkins   South
                  Beach
                  Diets
Low- Fat vs Mediterranean vs Low-Carbohydrate
        Diets- Effect on Weight Loss
More Nutritional Tips
 • Shop the perimeter of the store
 • Do not skip breakfast (keep an eye on sugar and
   refined flower products!)
 • Try to eat several smaller meals or snacks instead of
   2-3 large ones
 • Eat more almonds, walnuts, pecans and pistachios
   (good cholesterol lowering fats)
 • Eat fruits and vegetables of all colors
 • Avoid sweet drinks and fruits juices. Eat the fruit!
 • Eat a high protein, complex carbohydrate- rich meal
   after work outs
 • Get a slow cooker
 • Cook for the week and freeze
Nutritional Considerations
• Reduce saturated (animal) fats, fried foods
  and hydrogenated oils
• Eat omega-3 fish oil-rich foods- salmon, tuna,
  sardines or flax seed oil (alternative)
• Use good fats: olive oil, nuts, avocados,
  flaxseed
• Minimize sugar, fructose (sweets, sodas,
  foods with high fructose corn syrup )
• Eat adequate amounts (0.7-1 gm/lb/day) of
  protein (fish, eggs, cottage cheese, lean
  meats, chicken, whey, yogurt, nuts, etc)
Best Protein Sources
 Building  block of muscle mass and food for the
  immune system
 Dairy proteins - best is cottage cheese (casein),
  whey, yogurt… made to make mammals grow
  bigger . Be careful with milk allergies/lactose
  intolerance
 Whole eggs are better than egg white
 Fish - cold water fish like salmon and tuna
 Lean beef
 Chicken (no skin)
 Natural almond butter (no added hydrogenated oils
  and fillers)
 Beans, rice - vegetarian diet requires good
  knowledge of protein sources
Good Carbohydrates
     Bad Carbohydrates

  Provide energy and nutrients
 Bad carbs can worsen insulin resistance and
  triglycerides
 Bad: Avoid/reduce high glycemic, high calorie
  carbs – refined flour, especially milled grains,
  sugar, high fructose corn syrup
 Good: Eat more fiber, nutrient, and fluid-rich,
  low calorie, low glycemic carbs like: oatmeal,
  multi-grain breads, vegetables, fruits, roots,
  greens, wild rice and beans
Fat is not a Four Letter Word
 Fats are needed for energy, immune
  function, vitamin absorption, and hormones
 Good Fats- monounsaturated- Olive Oil
  Essential Fatty Acids- polyunsaturated
  Omega 3’s- cold water fish (salmon)
  Omega 6’s- high oleic sunflower oil, walnuts,
   almonds, pecans, avocado
  Omega 3’s and 6’s- Flaxseed meal
 Bad Fats-processed/hydrogenated
 oils,margarine, artificial creamers, any man-
 made oil, burned oils, rancid oils, lard
Grocery Shopping List
   Almonds and other nuts
   Beans and other legumes
   Spinach and other green leafy vegetables
   Low fat dairy, yogurt
   Hummus
   Whey protein
   Oatmeal
   Eggs
   Lean meats
   Whole grain breads and pasta
   Peanut, almond , cashew butters
   Olive oil and avocados
   Raspberries and all berries. Fruits (avoid fruit juices)
   One or two glasses of red wine per day (optional)
   Flaxseed , pumpkin and sunflower seeds
   Sweet potatoes and wild rice
   Green tea (optional)
Exercise, the Best Therapy for Most Health Problems
Exercise: The Best Medicine
Benefits:
         total and abdominal fat
        improves insulin sensitivity
        improves glucose tolerance
        increases HDL cholesterol
        triglycerides and LDL
        increases muscle mass
        improves endurance
        improves strength
        improves bone density
        improves mood
EXERCISE FOR BEST RESULTS
Aerobic (Cardiovascular)
        Exercise
 Start with a brisk walk every day if tired
 Concentrate in low impact or no impact
  exercises (e.g. Elliptical Trainers)
 Do what you enjoy (bicycling, roller
  skating, etc)
 Good for burning fat, triglycerides, blood
  sugar, but it may decrease muscle mass
 20 - 30 minutes 3-4 times a week is
  enough for many people
Resistance Exercise

 Exercise   using weighs, machines, your own
  body
 Warm up by doing a light set
 Lift maximum weight for muscular failure
  (exhaustion) at 8-12 repetitions
 One body part per week
 One hour sessions 3-4 times a week
 Three sets per body part
 If no access to a gym, start with crunches,
  push ups, and squats at home
Resistance Exercise Principles
 Safety First - Stop if if hurts!
 High Intensity - Momentary muscular
  failure to stimulate growth
 Recovery = Rest, nutrition, and time
 2 - 3 warmup, 2- 3 heavy sets per
  exercise
 45 to 60 minutes per session, 3 - 4
  sessions per week.
              DO NOT OVERTRAIN!
Resistance Exercise Principles
              (continued)

 Major  muscle group first when energy is
  highest
 Do compound exercises first while energy
  is up. They affect the most tissue/mass
  for quickest growth (squats, bench press)
 Secondary/ancillary muscles follow
 Important: Full range of motion -
  recruits/builds the most muscle mass
Resistance Exercise Principles
             (continued)

 Warm    up sets: 50 - 60 % of the
  heavy weight you can lift 6-12 times
 Heavier sets: Weight you are capable
  of lifting 6 - 12 times to momentary
  muscular failure
 When strength increases so you can
  do 12 reps, increase weight 5 – 10
  lbs so you can only lift about 6-8
  reps to momentary muscular failure
Best Exercise Sites with
      videos, etc
      www.exrx.net
      www.MyFit.ca
Ipod exercise routine downloads:
   http://www.menshealth.com/download/
Final Words
   There are several life style modifications in your control
    to stay healthy and in shape as you age to prevent
    lean body mass and bone loss, sexual dysfunction, and
    heart disease.

   You do not have to accept sexual dysfunction as a
    reality of aging. There are several treatment options!

   Find out your free testosterone and thyroid function if
    you have fatigue, sexual dysfunction, etc. Supplement
    if needed. Readjust the dose if you do not achieve
    optimum levels.
Final Words
   Do not waste your money and risk liver or medication
    interaction problems with unproven supplements. Support
    the New York buyers’ club.

   Combat loss of lean mass and increased fat with resistance
    and cardiovascular exercise 3 to 4 times a week for an
    hour

   Diet: Avoid sweets, hydrogenated oils, high fructose corn
    syrup, animal fats and consume more fruits, vegetables,
    fish, lean meats, yogurt and nuts.

   An informed man helps his doctor to give him the best care
For More Information
More details in ”Testosterone- A Man’s Guide” on
  www.amazon.com



Nelson Vergel – nelsonvergel@yahoo.com

TestosteroneWisdom.com

Mesomorphosis.com

The New York Buyers Club (supplements) newyorkbuyersclub.org
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Men's Health Lecture by Nelson Vergel

  • 1. Latest Advances in Men’s Health Nelson Vergel PoWeRUSA.org TestosteroneWisdom.com Copyright © 2011 by Nelson Vergel
  • 2. Objectives n To Review: – The most common causes of erectile dysfunction (ED) and its treatment options – Best ways to diagnose and treat testosterone deficiency – Best ways to increase lean body mass and decrease fat – Supplements backed by data – Nutrition and Exercise tips n Questions and answers
  • 3. This information (and any accompanying printed material) is not intended to replace the attention or advice of a physician or other health care professional. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with and seek clearance from a qualified health care professional.
  • 4. Copies of these slides are available free online at TestosteroneWisdom.com on the “Lectures” page
  • 7. Signs and Symptoms of Low Testosterone  Loss of muscle mass and strength  Loss of libido and erectile dysfunction  Depression  Lethargy (fatigue, lack of focus)  Bone loss  Some regression of secondary sexual characteristics (body hair loss, etc)  Low or no sperm count Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987 Petak SM, et al. AACE Clinical Practice Guidelines. Available at: http://www.aace.com/clin/guides/hypogonadism.html
  • 8. Testosterone Deficiency (Hypogonadism) • Normal levels in blood: Men... Total test. 300-1100 ng/dL, Free test. 5 - 21 ng/dL Women... Total test. 10-50 ng/dL Free test. 0.10-0.85 ng/dL
  • 9. Testosterone Replacement Benefits Mental focus Stamina and Bone Strength Sexual function Lean Body Mass
  • 13. Testosterone Fractions in the Blood Bioavailable T Free T 2% Albumin-bound T 38% T = testosterone Only 2% is free Sex Hormone Binding Globulin testosterone SHBG-bound T and 98% is bound 60%
  • 15. (binds testosterone)
  • 16. Conditions associated with alterations in SHBG concentrations Conditions associated with decreased SHBG concentrations – Moderate-severe obesity – Hypothyroidism – Type 2 Diabetes mellitus – Nephrotic syndrome Conditions associated with increased SHBG concentrations – Aging – Hepatic cirrhosis – Hyperthyroidism – Use of anticonvulsants – HIV infection Bhasin, S. et al. J Clin Endocrinol Metab 2006;91:1995-2010
  • 18. Potentially Approved in the Next 12-24 Months
  • 21. Effects of Physiologic Testosterone Supplementation on Fat Mass and Distribution in HIV-Infected Men with Abdominal Obesity CM Shikuma1, RA Parker2, F Sattler3, B Alston4, R Haubrich5, T Umbleja2, S Bhasin6, for the AIDS Clinical Trials Group Protocol A5079 Study Team 1 University of Hawaii, Honolulu, HI; 2 Harvard School of Public Health, Boston, MA; 3 University of Southern California, Los Angeles, CA 4 Division of AIDS, NIAID, Bethesda MD; 5 University of California, San Diego, San Diego, CA; 6 Boston University, Boston MA
  • 22. Percent Change over 24 weeks in CT Measures (ITT) 10 P<0.001 8 * 6 P=0.04 P=0.76 4 8.1% 4.3% 2 3.1% Active 0 0.3% -1.5% Placebo -2 -7.2% -4 -6 -8 * VAT SAT Total Abd Fat Entries within bars are median values of change; *Change in within arm differences p<0.05
  • 23. Percent Change over 24 Weeks in DEXA Measures (ITT) 6 p=<0.001 p=<0.001 * P<0.001 * 4 4.6% p=0.02 2 4.5% 3.8% * 1.3% 0 -0.3% -2 Active -7.9% -4 -10.1% Placebo -9.9% -6 -8 * -10 * * -12 Trunk Extremity Total Lean Fat Fat Fat Tissue Entries within bars are median values of change; *Change in within arm differences are p<0.05
  • 24. Side Effect: Gynecomastia (breast enlargement in men) Treatment: Estrogen Blocker Medications or surgery (in worst cases)
  • 25. What Increases Estradiol? n Antiandrogens. These include cyproterone, flutamide, and finasteride.used to treat prostate cancer and some other conditions. n HIV medications. Sustiva, Atripla, and Videx have been associated with gynecomastia. n Anti-anxiety medications such as diazepam (Valium). n Tricyclic antidepressants. These include amitriptyline. n Glucocorticoid steroids. n Antibiotics. n Ulcer medication such as cimetidine (Tagamet). n Cancer treatment (chemotherapy). n Heart medications such as digitalis and calcium channel blockers. n Anabolic steroids
  • 26. Substances that have been reported to cause gynecomastia include: n Alcohol n Amphetamines n Marijuana n Heroin n Soy and flaxseed- There are conflicting studies but it is something to keep in mind n Exposure to pesticides and byproducts of plastic processing has also been linked to increased estrogen and decreased sperm count in men.
  • 27. Side Effect: Increased number of red blood cells (polycythemia) Watch out for hematocrit over 52 ! Solution: Donate blood or therapeutic phlebotomy (4-5 units every 3-4 months)
  • 28. Side Effect: Testicular Shrinkage (atrophy) Dosing protocols vary Treatment: Human Chorionic Gonadotropin (hCG) – It mimics LH to jump start testicles
  • 29. Side Effect : Increased prostate size (benign prostatic hypertrophy) Potential treatments: Finasteride,etc Or alpha blockers to increase urinary flow Prevention: Digital Rectal Exam (DRE) Prostatic Specific Antigen (PSA) blood test
  • 30. Side Effect: Acne Treatment: Bezoyl Peroxide, salicilic acid lotions, soaps, showering after exercising, 20 min of sun a day, Zinc supplements
  • 32. Oral Steroids : Oxandrin (Oxandrolone)  Only anabolic approved for weight loss  Mild - can be used by women and children (low virilizing)  Does not stunt growth in children  Several studies in HIV/AIDS  Men need higher doses - 20 -40 mg/day with testosterone; women 5 - 20 mg/d  Potential liver burden over 20 mg (adults)  Expensive - $1100/month at 20 mg
  • 33. Exercise Oxandrolone in Patients on HAART
  • 34. Anabolic Steroid Use in HIV  Over 17 HIV studies show they are effective to increase muscle mass and strength in men and women  Orals: Anadrol, Oxandrin  Injectable: Testosterone Cypionate and Enanthate, nandrolone decanoate  Steroids should be given with testosterone since they tend to lower the body’s own testosterone production  Side effects: acne, high blood pressure, prostatic inflammation, liver dysfunction (orals), polycythemia (too many red blood cells), sleep apnea, etc  Illegal for those with no medical conditions  More information in www.medibolics.com
  • 35. Anabolics Used in HIV Anabolic Androgenic Steroid Reported Doses Side Effects Properties Properties Nandrolone Decanoate Deca Durabolin Men 100-200 mg/wk Some water retention, High Low to Medium (injections) Women 25 mg/wk HTN Available in the U.S. Stanozolol Slight chance of virilizing Men 6-18 mg/day Winstrol™ (Oral) Low Very Low for women. Watch liver Women 4-12 mg/day Available in the U.S. function. Slight chance of virilization Oxandrolone Oxandrin™ Men 15-20 mg/day for women. Watch liver (Oral) Low to Medium Very Low Women 10-40 mg/wk function. Women report Available in U.S. Children 2.5-5 mg/day water retention. Balding in men, high blood Oxymetholone Trade pressure, water retention, name Anadrol™ 50 Men 50-100 mg/day (oral) Very High Very High body hair growth in women and breast enlargement in Available in the U.S. men. Watch liver function. Testosterone Water retention, balding in Cypionate or Enanthate Men 100-200 mg/wk men, acne, breast (Injections) High Medium to High Women 25 mg/wk enlargement in men, may Available in the U.S. virilize women. All can cause (depending on the person and if not managed properly): increased hematocrit, acne, BPH, gynecomastia, increased blood pressure/edema
  • 36. Compounding Pharmacies • Make customized pharmaceuticals and nutraceuticals with expired patents or abandoned by pharmaceutical companies (i.e. nandrolone,etc) • Most products require a prescription • Depending on the state, many can ship products to your home • Products are usually 2-10 times cheaper than buying commercially available pharmaceutical medications • Products can be formulated in different delivery forms • Common products related to hormone treatments, erectile dysfunction, pain gels/creams, hair growth gels, side effect management products, and quality of life related formulations. • Most do not take insurance but provide info for your own filling • I have been using APSMeds.com for the past 4 years since they have the best pricing and a specialized patient support person for HIV+ and HIV- patients.
  • 39. Causes of ED Risk Factors Massachusetts Male Aging Study¹  Treated heart disease 39%  Treated diabetes 28%  Treated hypertension 15% ¹Feldman Ha, J Urol 1994; 151:54-61
  • 40. Causes of ED Medications (cont.)  Anti-hypertensive drugs – All capable – Common: thiazides and beta blockers – Uncommon: calcium channel blockers, alpha-adrenergic blockers, and ACE inhibitors
  • 41. Causes of ED Medications (cont.)  CNS drugs: – Antidepressants, tricyclics, SSRIs – Tranquilizers – Sedatives – Analgesics  H1 and H2 receptor blockers
  • 42. Causes of ED  Organic Causes – Cardiovascular disease – Diabetes mellitus – Surgery on colon, bladder, prostate – Neurologic causes (lumbar disc, MS, CVA) – Hormonal deficiency
  • 43. Cause of ED  Psychogenic Causes: – Anxiety – Depression – Fatigue – Guilt – Stress – Marital Discord – Excessive alcohol consumption – Street drugs
  • 44. How to Treat Sexual Dysfunction • Avoid excessive alcohol and smoking • Balance your testosterone- injection/cream /gel/patch • Viagra, Levitra, Cialis • DHEA - men 50 - 500 mg, women 25 - 100 mg • Trimix (prescription)- Injection of 0.1-0.2 cc in the penis. Less expensive than Caverject. See an Urologist. Visit apsmeds.com, gotocompoundingshop.com, etc • Yohimbe - stimulant, concerns about hypertension (Prescription: Yocon) • Counseling may help those with psychologically induced sexual dysfunction • Talk to an Urologist for other tests!
  • 45. Sexual Dysfunction Oral Drugs Drug Onset of Duration Action of Activity Viagra 60 minutes 4-5 hours Levitra 30 minutes 4-5 hours Cialis* 15 minutes 36 hours * No food effect
  • 46. Medication Side Effects (PDE Inhibitors) Side effects:  Headache  Flushing  Dyspepsia  Nasal congestion  Visual disturbances  Back ache (Cialis)
  • 47. Penile Injection Therapy Caverject, Edex, Tri/Bi-Mix  Mechanism of action: smooth muscle vasodilator  Monotherapy (protaglandin E1) or combination of 2 or 3 agents (Papaverine+ Phentolamine + Alprostadil )  Administration: 10, 20, 40ug  Inject directly into corporeal bodies of the penis  Results: 70%-90%  Dropout rates: 25%-60%  Side effects: pain (36%), priapism (4%), fibrosis
  • 48. Trimix (Papavarine+ Phentolamine + alprostadil) Available by prescription from compounding pharmacies
  • 50. Stages of Change © 2010 Pro-Change Behavior Systems, Inc.
  • 51. COMPREHENSIVE APPROACH TO WELLNESS Stress Reduction Medications Nutrition Exercise
  • 54. How To Minimize Heart Disease  Do not smoke!  Exercise and low animal fat/sugar diet  Lose weight if you are overweight  Manage stress and keep blood pressure in check  Decrease triglycerides with Omega 3 fatty acids (cold water fish oils), low sugar intake, exercise.  Improve HDL with Niacin 300-500 mg 3 x day. Start with lower dose to minimize “flushing” and take an aspirin 20 min before (Niaspan is the prescription grade)  Soluble Fiber (oats, fiber supplemengts, etc)  If everything else fails, use prescription lipid lowering agents (statins, fibrates, etc)  A baby aspirin a day (81 mg)  Keep healthy blood levels of testosterone and thyroid hormones.
  • 55. Insulin Resistance: A Silent Health Threat Pre diabetes Keeping a healthy weight, exercising, low glycemic load diet, certain supplements and medications can decrease Insulin resistance and glucose intolerance
  • 57. Potential Interventions for Decreasing Abdominal Fat (visceral adipose tissue-VAT)  Diet- Lower carbohydrate diets, Mediterranean diet  Exercise- cardiovascular and resistance training- Some pilot data with good results  Anti-diabetic drugs: Metformin (Glucophage)- conflicting and inconclusive data  Testosterone gel- subcutaneous fat loss only  Anabolic steroids- Oxandrin, nandrolone?- limited VAT data  Human Growth Hormone  Human Growth Hormone Releasing Hormone- Sermorelin and Tesamorelin- Approved for the treatment of HIV related visceral fat accumulation  Surgery- Liposuction of visceral fat very difficult and risky
  • 58. How to Increase Lean Body Mass  Higher protein intake (whey, egg white protein supplements, lean meats, nuts, fish, eggs, etc) and more frequent snacking with right balance. More in nutrition section  Resistance exercise. More in exercise section  Testosterone Replacement if needed  Growth Hormone replacement  Medical use of oxandrolone and nandrolone  Creatine Supplementation  Healthy sleep habits
  • 60. Supplements- What Works?  Niacin 1000-3000 mg/day – Increases good cholesterol (HDL). Caution with “flushing”. Take a baby aspirin 20 min before taking niacin  Selenium – Glutathione production (anti-oxidant.) A study showed people who took 200 mcg/day had better immune function  Calcium Carbonate- 500-2000 mg/d – Bone protection, diarrhea control  Vitamin D- Bone protection and other emerging benefits (2000-4000 IU/d)  SAMe (S-Adenosyl-L-Methionine) – energy, depression, liver detox
  • 61. Supplements -Any data?  Whey Protein 20-100 grams/day – Popular with bodybuilders. HIV study found compensatory response. People ate less food and no increased LBM was found  Creatine 5-15 grams/day – Muscle voluminizer, strength enhancer. Caution with diarrhea and kidney overload.  Omega 3 oils (fish oils) 3000- 6000 mg/day – Decreases cholesterol/triglycerides, anti-inflammatory, mood stabilizer?  L-Carnitine 1000-3000 mg/day – Helps use fat for energy, cell protection, lowers lipids, anti- catabolic, heart muscle protection, N-Acetyl Carnitine may restore nerve damage in neuropathy  B Vitamins (100 mg each/day)- whole body processes, possible prevention of mitochondrial toxicity
  • 62. Great Web Site to Find Out What Supplements to Trust ConsumerLabs.com
  • 64. What Your Plate Should Look Like….
  • 66. The ZONE & Modified Atkins South Beach Diets
  • 67. Low- Fat vs Mediterranean vs Low-Carbohydrate Diets- Effect on Weight Loss
  • 68. More Nutritional Tips • Shop the perimeter of the store • Do not skip breakfast (keep an eye on sugar and refined flower products!) • Try to eat several smaller meals or snacks instead of 2-3 large ones • Eat more almonds, walnuts, pecans and pistachios (good cholesterol lowering fats) • Eat fruits and vegetables of all colors • Avoid sweet drinks and fruits juices. Eat the fruit! • Eat a high protein, complex carbohydrate- rich meal after work outs • Get a slow cooker • Cook for the week and freeze
  • 69. Nutritional Considerations • Reduce saturated (animal) fats, fried foods and hydrogenated oils • Eat omega-3 fish oil-rich foods- salmon, tuna, sardines or flax seed oil (alternative) • Use good fats: olive oil, nuts, avocados, flaxseed • Minimize sugar, fructose (sweets, sodas, foods with high fructose corn syrup ) • Eat adequate amounts (0.7-1 gm/lb/day) of protein (fish, eggs, cottage cheese, lean meats, chicken, whey, yogurt, nuts, etc)
  • 70. Best Protein Sources  Building block of muscle mass and food for the immune system  Dairy proteins - best is cottage cheese (casein), whey, yogurt… made to make mammals grow bigger . Be careful with milk allergies/lactose intolerance  Whole eggs are better than egg white  Fish - cold water fish like salmon and tuna  Lean beef  Chicken (no skin)  Natural almond butter (no added hydrogenated oils and fillers)  Beans, rice - vegetarian diet requires good knowledge of protein sources
  • 71. Good Carbohydrates Bad Carbohydrates  Provide energy and nutrients  Bad carbs can worsen insulin resistance and triglycerides  Bad: Avoid/reduce high glycemic, high calorie carbs – refined flour, especially milled grains, sugar, high fructose corn syrup  Good: Eat more fiber, nutrient, and fluid-rich, low calorie, low glycemic carbs like: oatmeal, multi-grain breads, vegetables, fruits, roots, greens, wild rice and beans
  • 72. Fat is not a Four Letter Word  Fats are needed for energy, immune function, vitamin absorption, and hormones  Good Fats- monounsaturated- Olive Oil Essential Fatty Acids- polyunsaturated Omega 3’s- cold water fish (salmon) Omega 6’s- high oleic sunflower oil, walnuts, almonds, pecans, avocado Omega 3’s and 6’s- Flaxseed meal  Bad Fats-processed/hydrogenated oils,margarine, artificial creamers, any man- made oil, burned oils, rancid oils, lard
  • 73. Grocery Shopping List  Almonds and other nuts  Beans and other legumes  Spinach and other green leafy vegetables  Low fat dairy, yogurt  Hummus  Whey protein  Oatmeal  Eggs  Lean meats  Whole grain breads and pasta  Peanut, almond , cashew butters  Olive oil and avocados  Raspberries and all berries. Fruits (avoid fruit juices)  One or two glasses of red wine per day (optional)  Flaxseed , pumpkin and sunflower seeds  Sweet potatoes and wild rice  Green tea (optional)
  • 74. Exercise, the Best Therapy for Most Health Problems
  • 75. Exercise: The Best Medicine Benefits:  total and abdominal fat improves insulin sensitivity improves glucose tolerance increases HDL cholesterol  triglycerides and LDL increases muscle mass improves endurance improves strength improves bone density improves mood
  • 76. EXERCISE FOR BEST RESULTS
  • 77. Aerobic (Cardiovascular) Exercise  Start with a brisk walk every day if tired  Concentrate in low impact or no impact exercises (e.g. Elliptical Trainers)  Do what you enjoy (bicycling, roller skating, etc)  Good for burning fat, triglycerides, blood sugar, but it may decrease muscle mass  20 - 30 minutes 3-4 times a week is enough for many people
  • 78. Resistance Exercise  Exercise using weighs, machines, your own body  Warm up by doing a light set  Lift maximum weight for muscular failure (exhaustion) at 8-12 repetitions  One body part per week  One hour sessions 3-4 times a week  Three sets per body part  If no access to a gym, start with crunches, push ups, and squats at home
  • 79. Resistance Exercise Principles  Safety First - Stop if if hurts!  High Intensity - Momentary muscular failure to stimulate growth  Recovery = Rest, nutrition, and time  2 - 3 warmup, 2- 3 heavy sets per exercise  45 to 60 minutes per session, 3 - 4 sessions per week. DO NOT OVERTRAIN!
  • 80. Resistance Exercise Principles (continued)  Major muscle group first when energy is highest  Do compound exercises first while energy is up. They affect the most tissue/mass for quickest growth (squats, bench press)  Secondary/ancillary muscles follow  Important: Full range of motion - recruits/builds the most muscle mass
  • 81. Resistance Exercise Principles (continued)  Warm up sets: 50 - 60 % of the heavy weight you can lift 6-12 times  Heavier sets: Weight you are capable of lifting 6 - 12 times to momentary muscular failure  When strength increases so you can do 12 reps, increase weight 5 – 10 lbs so you can only lift about 6-8 reps to momentary muscular failure
  • 82. Best Exercise Sites with videos, etc www.exrx.net www.MyFit.ca Ipod exercise routine downloads: http://www.menshealth.com/download/
  • 83. Final Words  There are several life style modifications in your control to stay healthy and in shape as you age to prevent lean body mass and bone loss, sexual dysfunction, and heart disease.  You do not have to accept sexual dysfunction as a reality of aging. There are several treatment options!  Find out your free testosterone and thyroid function if you have fatigue, sexual dysfunction, etc. Supplement if needed. Readjust the dose if you do not achieve optimum levels.
  • 84. Final Words  Do not waste your money and risk liver or medication interaction problems with unproven supplements. Support the New York buyers’ club.  Combat loss of lean mass and increased fat with resistance and cardiovascular exercise 3 to 4 times a week for an hour  Diet: Avoid sweets, hydrogenated oils, high fructose corn syrup, animal fats and consume more fruits, vegetables, fish, lean meats, yogurt and nuts.  An informed man helps his doctor to give him the best care
  • 85. For More Information More details in ”Testosterone- A Man’s Guide” on www.amazon.com Nelson Vergel – nelsonvergel@yahoo.com TestosteroneWisdom.com Mesomorphosis.com The New York Buyers Club (supplements) newyorkbuyersclub.org