Nelson Vergel, author of Testosterone: A Man's Guide (amazon.com) provides an overview of the latest developments on men's health including testosterone replacement, exercise, nutrition and other health issues
Objectivesn 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 tipsn Questions and answers
This information (and any accompanying printedmaterial) is not intended to replace the attention oradvice of a physician or other health care professional.Anyone who wishes to embark on any dietary, drug,exercise, or other lifestyle change intended to preventor treat a specific disease or condition should firstconsult with and seek clearance from a qualified healthcare professional.
Copies of these slides are available free online atTestosteroneWisdom.com on the “Lectures” page
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 countTenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987Petak 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
TestosteroneReplacement Benefits Mental focus Stamina and Bone Strength Sexual function Lean Body Mass
Effects of Physiologic TestosteroneSupplementation on Fat Mass andDistribution in HIV-Infected Menwith Abdominal ObesityCM Shikuma1, RA Parker2, F Sattler3, B Alston4, RHaubrich5, T Umbleja2, S Bhasin6, for the AIDSClinical Trials Group Protocol A5079 Study Team1 University of Hawaii, Honolulu, HI; 2 Harvard School ofPublic Health, Boston, MA; 3 University of SouthernCalifornia, Los Angeles, CA 4 Division of AIDS, NIAID,Bethesda MD; 5 University of California, San Diego, SanDiego, 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 FatEntries 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 TissueEntries 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 Alcoholn Amphetaminesn Marijuanan Heroinn Soy and flaxseed- There are conflicting studies but it is something to keep in mindn 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 bloodor therapeutic phlebotomy (4-5 units every 3-4 months)
Side Effect: Testicular Shrinkage (atrophy) Dosing protocols varyTreatment:Human Chorionic Gonadotropin(hCG) – It mimics LH to jumpstart testicles
Side Effect : Increased prostate size (benign prostatic hypertrophy) Potential treatments: Finasteride,etc Or alpha blockers to increase urinary flowPrevention:Digital Rectal Exam (DRE)Prostatic Specific Antigen (PSA) blood test
Side Effect: AcneTreatment: Bezoyl Peroxide, salicilic acid lotions, soaps,showering after exercising, 20 min of sun a day, Zinc supplements
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
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 PropertiesNandrolone 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 virilizationOxandrolone 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 inCypionate 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.
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
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 diabetesKeeping a healthy weight, exercising, low glycemic load diet, certain supplementsand medications can decrease Insulin resistance and glucose intolerance
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- 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 OutWhat Supplements to Trust ConsumerLabs.com
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 MedicineBenefits: 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
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.caIpod 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 InformationMore details in ”Testosterone- A Man’s Guide” on www.amazon.comNelson Vergel – email@example.comTestosteroneWisdom.comMesomorphosis.comThe New York Buyers Club (supplements) newyorkbuyersclub.org