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
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
1. Latest Advances in Men’s Health Nelson Vergel PoWeRUSA.org TestosteroneWisdom.com Copyright © 2011 by Nelson Vergel
2. 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
3. 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.
4. Copies of these slides are available free online atTestosteroneWisdom.com on the “Lectures” page
5. Testosterone and Aging
6. 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
7. 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
8. TestosteroneReplacement Benefits Mental focus Stamina and Bone Strength Sexual function Lean Body Mass
9. Testosterone and The Body
10. The HPT Axis
11. Testosterone Fractions in the Blood Bioavailable T Free T 2% Albumin-bound T 38%T = testosteroneOnly 2% is free Sex Hormone Binding Globulintestosterone SHBG-bound Tand 98% is bound 60%
13. (binds testosterone)
14. Conditions associated with alterations in SHBG concentrationsConditions associated with decreased SHBG concentrations – Moderate-severe obesity – Hypothyroidism – Type 2 Diabetes mellitus – Nephrotic syndromeConditions 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
15. Potentially Approved in the Next 12-24 Months
16. 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
17. 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
18. 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
19. Side Effect: Gynecomastia (breast enlargement in men)Treatment: Estrogen Blocker Medications or surgery (in worst cases)
20. 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
21. 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.
22. 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)
23. Side Effect: Testicular Shrinkage (atrophy) Dosing protocols varyTreatment:Human Chorionic Gonadotropin(hCG) – It mimics LH to jumpstart testicles
24. 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
25. Side Effect: AcneTreatment: Bezoyl Peroxide, salicilic acid lotions, soaps,showering after exercising, 20 min of sun a day, Zinc supplements
26. 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
27. Exercise Oxandrolone in Patientson HAART
28. 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
29. 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
30. 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.
31. For More Information:TestosteroneWisdom.com
32. Protecting Your Sexual Function
33. 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
34. Causes of EDMedications (cont.) Anti-hypertensive drugs – All capable – Common: thiazides and beta blockers – Uncommon: calcium channel blockers, alpha-adrenergic blockers, and ACE inhibitors
36. Causes of ED Organic Causes – Cardiovascular disease – Diabetes mellitus – Surgery on colon, bladder, prostate – Neurologic causes (lumbar disc, MS, CVA) – Hormonal deficiency
37. Cause of ED Psychogenic Causes: – Anxiety – Depression – Fatigue – Guilt – Stress – Marital Discord – Excessive alcohol consumption – Street drugs
38. 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!
39. 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
40. Medication Side Effects (PDE Inhibitors)Side effects: Headache Flushing Dyspepsia Nasal congestion Visual disturbances Back ache (Cialis)
41. 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
42. Trimix (Papavarine+ Phentolamine + alprostadil)Available by prescription from compounding pharmacies
43. Stages of Change© 2010 Pro-Change Behavior Systems, Inc.
44. COMPREHENSIVE APPROACH TO WELLNESS Stress ReductionMedications Nutrition Exercise
45. Protecting Your Heart
46. 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.
47. 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
48. Visceral Fat and Health
49. 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
50. 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
51. Supplements- Snake Oil?
52. 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
53. 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
54. Great Web Site to Find OutWhat Supplements to Trust ConsumerLabs.com
55. What Your Plate Should Look Like….
56. The ZONE &Modified Atkins South Beach Diets
57. Low- Fat vs Mediterranean vs Low-Carbohydrate Diets- Effect on Weight Loss
58. 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
59. 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)
60. 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
61. 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
62. 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
63. 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)
64. Exercise, the Best Therapy for Most Health Problems
65. 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
66. EXERCISE FOR BEST RESULTS
67. 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
68. 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
69. 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!
70. 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
71. 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
72. Best Exercise Sites with videos, etc www.exrx.net www.MyFit.caIpod exercise routine downloads: http://www.menshealth.com/download/
73. 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.
74. 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
75. For More InformationMore details in ”Testosterone- A Man’s Guide” on www.amazon.comNelson Vergel – firstname.lastname@example.orgTestosteroneWisdom.comMesomorphosis.comThe New York Buyers Club (supplements) newyorkbuyersclub.org