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Overview
of Age Management Medicine
The Symptoms of Aging
Catch Us Off-Guard
At 20, we’re invincible. At 30, awareness of
our mortality begins to become more evident, along with awareness of
beginning diminution: vigor and vitality, focus and sharpness, and the
body’s seeming refusal to keep pace with the spirit. As the years go by,
signs and symptoms of aging insidiously make themselves more of an
issue. Fat seems to be accumulating, and it’s no longer so easy to get
rid of it. Workouts at the gym require increasing effort to achieve
results that no longer match those of our earlier years. Increasing
forgetfulness, lack of focus, loss of skin tone and elasticity, thinning
hair and a myriad of other all-too-common woes are not restricted to the
minority. Most of us experience many of the signs of aging, beginning in
our mid-thirties. Until recently, we had limited options to fight them.
What is Age Management Medicine?
Age management medicine is based on the
concept that sufficient medical evidence reveals we can improve the
quality of life by delaying the onset of signs and symptoms,
associated with aging. A large body of literature not only supports
this concept, but it also confirms its safety—sans side effects and
complications.
Age management medicine is defined as
preventive medicine, focused on regaining and maintaining optimal health
and vigor. Issues associated with aging—from body composition and energy
to brain and sexual function—are largely related to hormonal
deficiencies. The truth is, we start to lose one to three percent of
our hormones at age 30. By the time we turn 40, we clearly are aware of
the difference.
Age management medicine incorporates
well-known and accepted markers of disease risk into proactive patient
management and uses hormone modulation for the endocrinologically
“normal” by identifying hormone levels, which yield superior health
outcomes. For most hormones, this is simply the upper 33% of the normal
range for a patient’s age. The exceptions are insulin and cortisol
(which should be modulated to the lower 33% of the normal range) and
human growth hormone, which is only prescribed to deficient adults.
Age management medicine recognizes that
successful therapies necessitate a healthy lifestyle, including optimal
low-glycemic index nutrition, appropriate nutrient supplementation and
the absolute need for physical exercise. This unique field of medicine
focuses on the synergy of these elements, which enhances vitality and
extends our health span. While we may or may not be able to increase
longevity, we are able to prevent premature disability and death while
enjoying a better quality of life.
We have the knowledge, technology and
expertise to prevent or delay degenerative disease as well as the signs
and symptoms associated with aging. The starting place, of course, is a
comprehensive evaluation to understand each patient’s unique needs.
Today, each of us has the power to improve the quality of our lives by
focusing on improving our health.
The American medical care system is based on
the treatment of disease—waiting for something negative to happen, then
trying to fix it after the fact.
Age management medicine takes a positive
turn in medical science, using a preventive, proactive approach to
lengthen health span and enjoy a more youthful aging process.
Slide01
What Causes Aging
Symptoms?
Much of aging can be
seen as deficiencies in many substances our body once produced in
abundance. Improper nutrition can exacerbate problems consistent with
aging. Two key factors make it extremely difficult for anyone to obtain
all the micro and macronutrients, vitamins and minerals essential for
good health—despite American awareness about the need to improve
nutrition: (A) the soil where our food grows and animals graze is
depleted severely, lacking essential nutrients; (B) the foods we
actually eat are generally highly processed. Finally, increased risk of
injury and day-to-day aches and pains are more prevalent in the many
middle-aged and senior individuals who don’t participate in effective,
regular physical activity.
Until relatively
recently, the best offered for living a healthy life were good nutrition
and exercise—both well-accepted measures for good health. For over 60
years mothers have supplemented their children’s diets with vitamins and
minerals…whatever the doctor ordered. The plethora of health food
stores, nutraceutical houses, fitness studios and gyms is evidence the
public is aware that nutrition and exercise are beneficial. But it
hasn’t been enough. (1)
Slide02
Most medical researchers
agree there is a 2% to 3% decline in many hormones, beginning at age 30.
These deficiencies contribute to a decline in energy levels as well as
muscle and bone strength. Additional age markers include diminution of
sensory, cognitive, motor and pulmonary functions; loss of skin
elasticity; increased fat-to-muscle ratio; onset of osteoporosis;
diminished libido; and erratic male erectile function. The entire
endocrine system participates in the aging process. The master hormone
(pituitary growth hormone) plays a pivotal role—but diminishes with age.
(There are criteria for adult onset growth hormone deficiency, which
must be met before therapy is instituted.) Thyroid hormone plays a
powerful role in metabolic regulation; low levels contribute to weight
gain, depression and fatigue. Testosterone, estrogen, progesterone, etc.
also play significant roles. Less than optimal levels of important
nutrients play a large role as well. While genetic programming does many
wonderful things, nature’s plan brings us to the age of reproduction and
nurturing . . . and then seems to have little use for us. At that point,
we begin to fail.
Slide03
We really don’t die of
old age: We die of degenerative diseases.
Slide04
Of
these, heart disease, cancer, stroke and diabetes all have to do with
obesity and lifestyle. In age management medicine, the goals are to
enhance vitality, vigor and health through nutrition, supplementation,
exercise and hormone optimization. Note that
Slide05
depicts
a curve of the average American with age on the X-axis; quality of life
and health are on the Y-axis. At about age 40-45, our quality of life
and health peak out. From that point out, they slowly decline until we
die. Age management medicine is all about “squaring” that curve, so our
quality of life and health remain optimal—until just before we die.
There are obvious
benefits to this, but there also is a hidden one. Medical breakthroughs
will continue, potentially resulting in increased longevity. The
question is, will we able to take advantage of them? That depends on
where we are on the curve. If we’re on the extreme, declining line of
the curve prior to entering a nursing home, we won’t be physically able
to take advantage of these breakthroughs, nor would we want to. However,
if we remain on the stable part of the curve, enjoying great health and
better quality of life, then we would be physically able to take
advantage of the medical breakthroughs . . . and would welcome the
opportunity to add another 10 or 15 years to our life.
Slide06
Traditional medicine continues to be excellent at serving the needs of
the very sick, injured and dying—what is generally referred to as
“acute” illness. Far too often, a large percentage of a patient’s
medical costs are spent during the last few years of life. The money is
spent with the frequent recognition that it is futile, since
extraordinary measures may not increase the life span with any
significant quality. It would make more sense to invest in preventing
illness early on, so middle and older years can be vigorous and
productive. That is the mindset of those investing in the programs,
products and protocols of age management medicine.
Using the narrowest of meanings, health has
traditionally been defined as “the absence of disease.” Yet,
historically, Western medicine has conditioned people to wait until the
onset of “symptoms” before taking concrete steps to correct what may
have been wearing down silently for years. Age management
practitioners—pioneers in 21st-century medicine—view health
as a lot more than simply “not being sick.” Health is a positive state .
. . an optimal state . . . a state where all faculties and senses are
fully alive, functioning at their peak in top running order. By this new
and better definition, health means much more than just the absence of
symptoms. It means the mind is sharp and focused; energy and enthusiasm
is boundless; the body is in peak condition. Individuals can experience
life fully and gloriously with passion and enthusiasm. (8)
The Emerging Field of “Anti-Aging” Medicine
Until slightly over a
decade ago, there was no medical specialty to deal with slowing down and
reversing many of the signs of aging—from the inside out. While human
Growth Hormone (hGH) had been used for over 50 years in the treatment of
hormone deficient children, the New England Journal of Medicine
published a groundbreaking clinical study on July 5, 1990, by Daniel
Rudman, MD. The study involving 12 sedentary men (ages 61 to 81)
demonstrated that human Growth Hormone (hGH) supplementation for mature,
sedentary adults—even without lifestyle changes—could result in improved
health and potentially reverse the signs and symptoms of aging . . .
but, of course, not aging itself. (2) Follow-up studies led Rudman and
other pioneers in the field to conclude that physical deterioration
associated with aging is not inevitable and that “some aspects of [the
aging process] can be prevented or reversed.” (3) We are in the early
stages of understanding the benefits of endocrine balance and the
possible role of growth hormone supplementation in adult onset
deficiency. Although we cannot yet affect aging at the cellular level,
the possibility of a higher-quality life—available through our improving
the signs and symptoms of aging—is now upon us. (4)
Slide07
Age management medicine
is defined as preventive medicine focused on regaining and maintaining
optimal health and vigor. This medical specialty incorporates well-known
and accepted markers of disease-risk into proactive patient management
and uses hormone modulation for the endocrinologically normal by
identifying hormone levels, yielding superior health outcomes. For most
hormones, this is simply the upper 33% of the normal range for a
patient’s age. The exceptions are insulin and cortisol, which should be
modulated to the lower 33% of the normal range.
Age management medicine
recognizes that successful therapies necessitate healthy lifestyle,
including optimal low-glycemic index nutrition, appropriate nutrient
supplementation and the absolute need for physical exercise. Age
management medicine focuses on the synergy of all of these elements in
order to enhance vitality and extend our health span. While we may or
may not be able to increase longevity, we are able to prevent premature
disability and death as well as enhance quality of life.
The most important
element necessary for the success of any medical therapy is the
expertise and experience of the physicians, entrusted with patients’
healthcare. Physicians can now be certified in age management medicine
after completing a rigorous program in hormone modulation therapies,
nutritional strategies and exercise science.
Hormone modulation is
the science of optimizing hormones, which are no longer adequately
produced by the body. The objectives of hormone modulation are to bring
the patient’s hormone levels back to those of their mid-30s, when the
immune system was the strongest, metabolism was the most efficient and
ability to build muscle rather than fat was the greatest. Achieving and
maintaining the newly re-optimized state of health is accomplished
through highly individualized programs, taking into account the
patient’s lifestyle, medical history, emotional stresses and personal
goals.
Traditional medical
practices follow a fix-it-when-it-breaks or diagnose-and-treat approach.
Age management medicine emphasizes the enhancement of health over the
treatment of illness. It is focused on prevention and wellness,
resulting in a more dynamic life throughout middle age and beyond. This
can be accomplished through the synergy of hormone modulation, nutrition
with appropriate supplementation and physical activity. Once understood
by both physician and patient, this synergistic approach must be
implemented with the patient in a partnering way to assure compliance.
The result is optimal health and longevity.
The healthy 30-year-old
individual is the model to emulate physiologically and biochemically
since this is the age (on average) where “all systems are go.”
Oxidative Stress & Aging
Here in the 21st
century, more advanced medical studies are bearing out the validity of a
50-year-old idea, regarding the important relationship between aging and
“oxidative stress.” The first cellular theories of aging and oxidative
stress were developed in the early 1950s, with the discovery of oxygen
free radicals and their association with the age-related accumulation of
oxidative damage to cells. It was found that as a normal part of human
physiology, our bodies routinely split oxygen molecules in order to
carry out metabolic tasks: You may recall that we call everyday oxygen
“O2” –signifying two oxygen atoms bound together, sharing a
common electron. When these two atoms go their separate ways, one of the
oxygen atoms gets sole custody of the formerly shared electron; the
other gets none. The atom without the electron is chemically unstable
and called “oxygen free-radical.” This free radical has a potent
attractive force for pulling a replacement electron away from
surrounding tissue. When this tissue is forced to give up an electron to
the free radical, it becomes oxidized. Oxidation damages tissue, so the
tissue must either be repaired, continue to soldier on damaged with
diminished functional capabilities or die. The initial research studies
revealed evidence of oxidative damage invariably accumulates with age,
with the body’s repair rate never quite keeping pace with the damage
rate. These results heralded the beginnings of current scientific
reasoning, regarding the importance of preventing oxidative damage and
the crucial role, played by antioxidant compounds.
The body’s antioxidants act to prevent oxidative damage to cells. They
are preferential oxidants, meaning they “take the bullet” on our behalf
and donate electrons to free radicals so our tissues don’t have to. They
become oxidized, rather than our tissues. Studies looking at the
healthiest members of older age groups reliably demonstrate that these
healthy subjects have higher levels of antioxidant compounds than their
less healthy counterparts. People who have “aged successfully” have been
found to have higher levels of antioxidants in their circulation and
cells. Their antioxidant levels actually are comparable with the
average levels of much younger subjects.
Other studies have shown that while antioxidants can mitigate the
progression of a given disease, their greatest power is in disease
prevention. People who have measurably higher antioxidant levels are at
reduced risk for Parkinson’s Disease; but if therapy is not undertaken
before the onset of this disease, later use of antioxidants has minimal
or no benefit. (9) Adequate antioxidant levels have been consistently
shown to prevent or lessen cognitive function declines. In fact, vitamin
E supplementation is now regarded as part of standard care for
Alzheimer’s. (10)
Most of the antioxidant vitamins have been shown to decrease
well-described and universally accepted markers of oxidative damage.
Medical literature has begun to suggest that different antioxidants have
specific organs, which they benefit most. The cardiac and coronary
artery disease literature has shown the value of coenzyme Q-10. The
neurology literature has established vitamin E as a valuable contributor
in the care of Alzheimer’s patients. (11) Also, vitamin E has been shown
to improve immune function, decrease oxidized LDL cholesterol (the first
step in coronary artery blockage), decrease markers of oxidative damage
to DNA (reducing cancer risk), improve glucose transport and increase
insulin sensitivity. Lycopene has shown to be useful for optimum
prostate health and may decrease prostate cancer risk. (12)
Antioxidants can work
together to maximize each other’s effect. Coenzyme Q-10 can act as an
“electron tanker” and recharge other antioxidants. N-Acetyl-Cysteine is
nature’s most potent vehicle for generating the production of
glutathione, perhaps the most important antioxidant of all.
In the past, there was
no readily available method to accurately measure markers of oxidative
damage or antioxidant levels. Now, some specialized laboratories cannot
only measure these factors, but also can give us objective measures to
use, specifically guiding an individual’s supplementation regimen.
As these studies become
more widely available, they can be used to make recommendations, which
are patient specific. Also, we will be able to follow results over time
to verify the effectiveness of a patient’s program.
Markers of Oxidative Stress & Disease Risk
The following markers
are useful for measuring the impact of therapy and disease-risk
alteration:
-
8-(F-2 alpha)
Isoprostane: This molecule is a product of lipid oxidation-and, most
importantly, as the result of oxidizing arachidonic acid.
Isoprostane is able to adversely alter the function of platelets and
smooth muscle cells, lining arteries—and has been established as a
valid marker of oxidative stress. It is found in higher levels in
patients with diabetes, coronary artery disease, Alzheimer’s and
cirrhosis of the liver. Isoprostane levels correlate with the degree
of severity of these diseases as well.
-
8-OH-deoxyguanosine
(8-OH-dg): When DNA undergoes oxidative damage, it can repair itself
to a great degree. Once repaired, pieces of damaged DNA are snipped
out (8-OH-dg) and replaced by new pieces. By measuring how many
snipped pieces are present, we can assess the degree to which this
oxidative DNA damage has occurred. The amount of oxidative damage to
DNA also correlates with a subject’s total oxidative stress.
-
Myeloperoxidase
-
Nitrotyrosine
Inflammation
The role of inflammation
and chronic disease is familiar. Inflammation is also a cause of
aging. Let’s talk about the role of inflammation in cardiovascular
disease and other degenerative diseases. The inflammatory response is
part of our innate immunity. It occurs when tissues are injured by
bacteria, viruses, trauma, toxins, heat and many other causes. In
recent years, medical science has learned there are low levels of
chronic inflammation, occurring at the cellular level. It is this kind
of inflammation that is now linked to all of the degenerative
diseases. In fact, it is thought by many authorities that low levels of
chronic inflammation cause degenerative diseases. These diseases would
include Alzheimer’s, type 2 diabetes, hypertension, cancer, stroke,
heart disease, osteoporosis, accelerated aging, insulin resistance,
altered immune function, rheumatoid arthritis and sarcopenia.
Sarcopenia is the loss
of muscle tissue and strength associated with aging. It’s what causes
frailty. Between the ages of 24 to 80, we can experience as much as a
40% loss in muscle size and strength—occurring at 1.4% per year and
targeting mostly the fast-twitch muscle fibers, although slow-twitch
muscle fibers are targeted as well. New research findings suggest
inflammation may be an important cause of sarcopenia, which results in
significant disability as we age. There are also higher rates of
osteoporosis, insulin resistance, obesity, and arthritis among those
with sarcopenia.
How do we detect
inflammation? There are several markers that can be used for predicting
inflammation, which would ultimately lead to cardiovascular
events—including Interleukin-6, aerum amyloid A, tumor necrosis factor
alpha, soluble intracellular adhesion molecules-1, macrophage inhibitory
cytokine-1, sP-Selectin, CD40 Ligand and hs-C-reactive protein.
Definitions of Terms
Inflammation
- local
response to cellular injury is marked by capillary dilatation,
leukocytic infiltration, redness, heat, pain, swelling and, often, loss
of function. It serves as a mechanism initiating the elimination of
noxious agents and of damaged tissue.
Cytokine
- any of a class of immunoregulatory proteins such as interleukins,
tumor necrosis factor, and interferon, secreted by cells, especially of
the immune system.
Chemokine
- any group
of chemotactic cytokines, produced by various cells. Inflammation sites
are thought to provide directional cues for white blood cell movement,
such as T-cells, monocytes and neutrophils.
Endothelium
- an
epithelium of mesoblastic origin composed of a single layer of thin,
flattened cells, which line internal body cavities and blood vessels.
Blood Cell Definitions
Leukocyte
– white blood
cells.
Monocyte
– a large white blood cell with finely granulated chromatin disbursed
throughout the nucleus. It is formed in the bone marrow, enters the
blood and migrates into the connective tissue, where it differentiates
into a macrophage.
Macrophage
– a phagocytic tissue cell, derived from a monocyte; protect the body
against infection and noxious substances.
Interleukin
– any of various compounds with low molecular weight, produced by
lymphocytes, macrophages and monocytes; regulates the immune system and
cell-mediated immunity.
Cytokines
- messengers of inflammation. A class of immunoregulatory proteins, such
as interleukins, tumor necrosis factor and interferon, secreted by cells
(especially immune system) that activate other nearby cells; promulgates
the inflammatory cascade. Interleukin-6 is a powerful pro-inflammatory
cytokine; it is the most important factor in controlling hepatic
acute–phase response. Total body adiposity is the single most important
determinant of serum interleukin-6 concentrations. (4) (5)
C-reactive protein is
the ideal biomarker for inflammation. It is the one most clinically
useful, especially in detecting cardiovascular inflammation. CRP screen
now is recommended for patients at intermediate cardiovascular disease
risk—a 10%-20% risk over the next 10 years. It is highly correlated
with future risk of a cardiovascular event. The highly sensitive
C-reactive protein must be measured with levels less than 1.0
desired. Levels between 1.0 and 3.0 are average risk; levels greater
than 3.0mg/L are high risk. It is important for patients to know what
their CRP levels are.
Patient factors
associated with elevated CRP levels include . . .
-
Hypertension
-
Body mass index
greater than 25
-
Metabolic syndrome
-
Hyperglycemia
-
Poor nutrition
-
Sedentary lifestyle
-
Dyslipidemia, which
would include high triglycerides, low HDL and high LDL
-
Chronic infection
-
Cigarette smoking,
both active and passive
-
Excess alcohol
intake
-
Poor dental hygiene
-
Rheumatoid arthritis
Patient factors
decreasing CRP levels include . . .
Alcohol consumption in
moderation: no more than one drink per day for a woman or two per day
for a man. A drink is defined as 5 ounces of wine, 1½ ounces of liquor
or one 12-ounce beer.
Exercise and physical
activity
Cardiovascular Disease
Approximately 61.8
million Americans have cardiovascular disease. Of these, 13 million have
coronary artery disease, resulting in 2,000 deaths in the nation daily.
Cardiovascular disease claims more lives each year than the next five
leading causes of death combined. Reports show 1 in 2.4 women die from
cardiovascular disease, compared to 1 in 29 from breast cancer. If we
could eliminate all major forms of cardiovascular disease, we could add
7 years to everyone’s life expectancy. The cost of cardiovascular
disease and stroke in the U.S. during 2003 was $351.8
billion. Approximately 105 million American adults have a blood
cholesterol level equal to or greater than 200mg/dl. (32) Clearly, as
Galen said, “Prevention is better than cure.”
Lipids & Cardiovascular Disease
LDL cholesterol—the
first category of lipids, which also is a major cholesterol carrier in
blood. LDL promotes atherosclerosis and is influenced by genetics,
high-saturated fatty acid diets and inactivity. Secondary causes
include diabetes, hypothyroidism, obstructive liver disease, chronic
renal failure and certain drugs.
HDL cholesterol—a
lipid carrying cholesterol away from the arteries. It may remove excess
cholesterol from atherosclerotic plaque. HDL has antioxidant and
anti-inflammatory properties. It is influenced by genetics, insulin
resistance, high triglyceride levels, overweight and obesity,
inactivity, cigarette smoking, high carbohydrate diets and certain
drugs, like beta-blockers, anabolic steroids and progestational agents.
Triglycerides—the
next category of lipids, obtained from the blood and also made by
the liver. It’s transported through the blood on either chylomicrons or
VLDL. Triglycerides are influenced by obesity, insulin resistance,
inactivity, smoking, high carbohydrate diets, diseases (such as Type 2
diabetes), chronic renal failure and nephrotic syndrome, excess alcohol,
drugs (including corticosteroids, oral estrogen, retinoids) and
genetics.
LDL is the primary
atherogenic factor. Trial after trial has shown that lowering LDL
reduces cardiac events. Low HDL remains an important independent risk
factor for cardiac events. The Air Force/Texas Coronary Atherosclerosis
Prevention Study showed that aggressive statin therapy is an appropriate
treatment for low HDL syndrome. Triglycerides are probably a secondary
risk factor in coronary artery disease. (15)
The “Big Four” low-LDL
trials:
-
Heart Protection
Trial from Great Britain published in Lancet in 2002 (16)
-
Pravastatin or
Atorvastatin Evaluation and Infection Therapy-Thrombolysis in MI 22
(PROVE IT) Trial, published in the New England Journal of
Medicine in 2004. (17)
-
“A to Z” Trial.
Published in JAMA in 2004. (18)
-
“Treating to New
Targets,” published in the New England Journal of Medicine in
2005. (19)
The bottom line to all
these trials is that LDL should be lowered to less than 70 in all
patients with recent or remote coronary artery disease. Dr. Robert
Guthrie, an authority in the matter, states, “If these guidelines are
ignored, a physician is very vulnerable to legal action.” (20) Ultra-low
LDL should also be a goal for all diabetic and metabolic syndrome
patients.
Hyperhomocysteinemia
Homocysteine is a
substance produced, when the body breaks down the amino acid methionine.
High levels of homocysteine are inflammatory and injure arterial
endothelial cells, which promote proliferation of arterial smooth muscle
cells, vascular inflammation, atherogenesis and destabilization of
established plaque. (21) Deficiencies of folic acid, vitamin B-6 and
B-12 are associated with hyperhomocysteinemia. An investigation is
underway, determining whether vitamins correct elevated homocysteine
levels and reduce vascular events. In 1999, the American Heart
Association recommended that all patients with a family history of
cardiovascular disease should exceed the recommended dietary allowance
values for folic acid, vitamin B-6 and vitamin B-12. (22)
A few comments need to
be made about homocysteine levels and sample handling. Homocysteine is
released from cells in whole blood, left at room temperature. A rapid
separation of plasma homocysteine is required for testing
reliability. The plasma should be immediately cooled on ice, then frozen
below -20°C until time of analysis. (23) At this point in time, there is
no consensus on homocysteine management with regard to B vitamin
supplementation for treating hyperhomocysteinemia. Baseline serum levels
of B-12 should be checked prior to supplementation to avoid masking a
B-12 deficiency. Dosages of B-6 greater than 500mg/day are not
recommended and may cause irreversible nerve damage. (24)
Patient Evaluation
Every patient must begin
with an appropriate, thorough and uncompromising evaluation—including
the following laboratory analysis—before any hormonal intervention is
contemplated.
Slide09
To provide sufficient
time for processing, it is suggested that labs be performed prior to the
patient’s visit. The patient’s in-office visit should be scheduled no
sooner than two weeks out, allowing adequate time for the results.
Immediately upon scheduling the appointment, a medical history and
lifestyle questionnaire is expedited (overnight to the patient),
allowing adequate time to thoughtfully complete the form and return it
back to the physician. This allows the physician to correlate the
laboratory finding with the history prior to the patient’s visit,
maximizing the quality of time spent with the doctor. Ideally, the
actual patient appointment at a state-of-the art age management center
should be a full-day visit, which includes additional biological
testing, a complete physical examination, nutritional consultation,
exercise program discussion and design as well as the consultation with
the doctor, which may last for two hours or more.
This full day of
diagnostics and consultations, combined with the information analyzed
from the lab results and the medical history, allows the age management
healthcare team (physician, nutritionist and exercise physiologist) to
thoroughly assess the general health, as well as the hormonal and
nutritional needs of the patient. The team is then able to recommend
suitable program options for the patient’s consideration.
It is interesting to
note (and, perhaps, reflective of our current medical scene) that 10% of
the patients experiencing the comprehensive diagnostic evaluation
described above were found to have a significant medical problem, which
had been missed by their regular physician.
When such patients are
seen, the responsible age management physician generally sends them back
to their primary physicians for work-up and care. Many of those patients
return to the age management physician later for appropriate program
implementation. It is important to note that qualified age management
physicians are not interested in taking over as the patient’s primary
physician. On the contrary, and with the patient’s consent, the age
management healthcare team wishes to keep the patient’s primary
physician fully informed of diagnoses and instituted protocols. Such
cooperation is for the patient’s welfare, but often becomes an
educational process for the primary physician, who observes how the
patient’s general health improves.
Some general indicators
of physical condition also serve as possibly significant indicators for
additional therapy, including greater emphasis on dietary and specific
nutraceutical supplementation: strength, flexibility, agility and other
biomarkers of aging, such as bone density, percentage of lean body mass
and percentage of body fat (measured by body region and total body).
Additional biomarkers are assessed for mental function (cognition and
memory). Included are cognitive testing for the earliest possible
detection of any form of dementia and high-performance cardiac stress
testing with pulmonary function.
Many physicians are
incorporating age management medicine into their current specialty. By
affiliating and working with a qualified age management center, the
individual physician is developing a quality age management component in
his/her practice. Such physician partnering is an excellent way for a
physician to build up the age management component—without major
investments in diagnostic equipment and with the full support of
experienced age management medicine practitioners.
Risk Modeling
Over the last two
decades, the medical community has embraced medical risk statistics and
the imperative for early interventions. Classically, physicians have
been taught only to consider markers of disease states, which correlate
with the presence of significant preexisting clinical pathology -
diagnosis. The concept of disease risk markers in patients who do not
yet manifest a given disease is relatively new in medical history,
approaching only 40 years of clinical use.
Although the treatment
of hypertension is now widely understood as an important intervention
based on hypertensive outcomes, rather than hypertensive symptoms, the
clinical utility of managing blood pressure was not widely accepted
until the 1960s. Outcome studies uniformly acknowledge the validity of
intervention in this regard—but it was a point of dispute in most of our
patients’ lifetimes, rather than the self-evident truth it has become.
Modern medicine has
become comfortable with risk modeling. We accept the fact that 90% of
American subjects who are normotensive at age 55 will eventually become
hypertensive, according to the Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation and Treatment of High
Blood Pressure (JNC7). (26) The blood pressure diagnosis and treatment
values set forth by the JNC7 are the current standard of care.
Hypertension is defined as systolic blood pressure (BP) equal to or
greater than 140mm Hg or diastolic BP equal to or greater than 90mm Hg.
Strong data correlate blood pressure in this range with risk for
cardiovascular disease (CVD); intervention is associated with improved
outcomes. Prehypertension is a pathological state associated with future
CVD risk, requiring intervention as well. Prehypertension is defined as
a systolic BP between 120 and 139mm HG or diastolic BP between 80 and
89mm HG. (27)
This standard of care
demonstrates an important point, beyond its use as an interventional
guideline:
According to the WHO
MONICA Project, published in 1998, the average systolic BP for Americans
is 124mm Hg, with a standard deviation value of 16mm Hg. According to
population data, people with a systolic BPs who are actually below the
mean are considered prehypertensive by the JNC7 protocol. BP values from
96% of the mean to 1 standard deviation above the mean qualify as having
higher than acceptable risk. Hypertension is defined as starting 1 SD
above the mean. To satisfy the classic medical approach for identifying
pathology, systolic BP must be 156mm Hg and above before that value is
considered abnormal. (25)
For diastolic blood
pressure, similar data hold true. Campbell, in the British Medical
Journal (1997), evaluated diastolic BP (DBP) statistics and found
the mean for DBP values was 82.5mm Hg with an SD of 10mm Hg. According
to JNC7 criteria, average DBP is prehypertensive; less than one SD
separates low-risk values from hypertension. Again, the standard 2 SD
model would require a DBP of 102.5mm Hg or above to satisfy diagnostic
criteria. (27) Slide10
Risk assessment and
intervention have morphed with relative risk now being as routine and
accepted a consideration as any other diagnostic modality in the medical
setting.
Like blood pressure
measurement, the same trend has held true for interpretation of lipid
levels and other asymptomatic markers of future risk. Progress in
identifying and altering markers of disease risk as they relate to
patient outcomes has been steady and rewarding.
This transformation from
diagnosing disease to assessing risk has had a profound effect on the
statistics of what is defined as a healthy vs. potentially unhealthy
laboratory value and has shaped the way we decide when intervention
should take place.
Glucose & Insulin Metabolism Measurements
In this age of
epidemic diabetes, the use of glucose measurement as a marker of disease
risk is well established in the medical literature, but there is utility
in this measure beyond the standard categorization of a value as
“normal” or “abnormal.”
An aside: Clinicians
often exhibit traits that are all too human in our interpretation of
these values. We were taught implicitly in medical school to peruse a
laboratory report and quickly scan past any values not conveniently
marked with an “H” or an “L”—hopefully in a contrasting color that
stands out nicely on a printed page or cathode ray tube. This made for
fast and directed medical decision making, which may have been useful in
the emergency at 3 am, but do not fully serve our patients’ interest in
a longitudinal care setting.
With regard to “normal”
glucose and health risk, even values within the “normal” range
associated with risk stratification in the same way cholesterol values
are.
Hoogwerf, in the 2002
American Journal of Cardiology, reported on the coronary artery
disease risk (CAD), associated with glucose values of 125mg/dl and
below. (28)
The study followed 2,440
non-diabetic subjects for a five-year period. People with fasting
glucose levels of greater than 100, but less than 125mg/dl were found to
have nearly triple the risk for CAD as those subjects with fasting
glucose levels of less than 86mg/dl. For each quintile within the normal
range that glucose was reduced, there was a demonstrable and significant
reduction in disease risk. These findings remained significant down to
glucose levels below 86mg/dl before the risk curve flattened out and no
further advantage was demonstrated.
The findings were
consistent through all accompanying adjustments for other cardiac risk
factors. The table demonstrates the odds ratios for CAD for unadjusted
glucose values and after adjustment for Framingham risk score, body mass
index, homocysteine and ferritin. Glucose values are independent
variables of CAD risk.Slide11
Interestingly, in the
short time since publication, laboratory reference ranges (based partly
on these findings) have been established placing the upper limit of
normal at 100mg/dl. This study readily demonstrates the “trouble with
normal” when trying to place our patients in categories of lowest
disease risk.
Similar risk
associations have been demonstrated with hemoglobinA1C (HBA1C). Adler,
in the 2000 British Medical Journal, discussed an 8.5-year study
on 3,642 subjects with a history of NIDDM Type II. The study
demonstrated CAD risk in association with HBA1C values, with the lowest
risk category being HBA1C values of 5.1% or below, even though standard
lab references identify HBA1C values of 6.0% or below as being “normal.”
(29)
Slide12
Lastly, fasting insulin
levels have been correlated with CAD risk, as well. Haffner, in the 2002
American Journal of Cardiology, reviewed findings from the
Helsinki Heart Study, showing the association between fasting insulin
levels and CAD risk in non-diabetic men. Over a 25-year follow-up
period, subjects in the lowest quintile for fasting insulin levels
demonstrated one-third the CAD risk as those in the highest quintile.
The target level for fasting insulin in patients correlates with the
lowest risk group in this large population based study. The graph below
demonstrates insulin quintile risk within “normal range.” (30)
Slide13
Lipid Markers
As mentioned in the
introduction, lipid metabolism markers are well-established in the
disease risk literature. The age management goals for lipid modulation
are the achievement of lipid values, which place each measurement in the
lowest category of risk for each marker. For LDL, this value is less
than 100mg/dl; for coronary risk ratio, this value is less than 4.0 for
men and less than 3.5 for women; for triglycerides, the value is less
than double HDL or less than 100, whichever is lower; for Lp (a), the
value is less than 10. (30)
For optimal and “normal” ranges for women, see
Slide14
Slide15
Slide16
For optimal and “normal” ranges for men, see
Slide17
Slide18
Slide19
The Age Management Medicine Patient Program
Naturally, the patient
programs are dependent upon individual needs and goals. The following is
a brief overview of the treatment program.
The most comprehensive
program should be a combination of optimal diet (including
supplementation), ongoing exercise (both aerobic and weight bearing) and
hormone modulation, when indicated. Each of these components offers
something positive to the patient, yet the combination of the three is
greater than each part. Each synergizes the others to become more
effective than if it was the sole program for the patient.
Nutrition
While this may be overly
simplifying the issue, sound nutritional advice can be generally
condensed as this:
-
Natural foods
only—if God didn’t make it, don't eat it.
-
Moderate protein
-
Healthy natural
fats, preferentially mono-unsaturated, like virgin olive oil. No
artificial or hydrogenated fats.
-
The only
carbohydrates should be fruits and vegetables, no bread, pasta,
rice, wheat of any kind.
-
“Cheat” only if you
must, but keep it to less than 10% of your dietary intake.
This is a low-glycemic
philosophy. It is extremely healthy and reduces the need for insulin,
reaping all the resulting benefits.
Suffice to say, our
American diet is terrible. Since the introduction of “diet” foods, our
nation has become a society where obesity has risen steadily. Author
Deborah Shelton quotes the following statistics in an abstract of the
November 8, 1999 issue of the American Medical News, "Most
Patients Don't See Excess Weight as Health Danger":
¨
85% of overweight adults who
tried to lose weight, attempted it without consulting a doctor
¨
55% of overweight and obese
adults had not discussed weight loss with a primary care provider
¨
63% of those who talked to a
doctor about weight loss said they initiated the discussion. (31)
The statistics were a
result of a survey, commissioned by Shape Up America!—a nonprofit
organization founded by former U.S. Surgeon General C. Everett Koop, MD.
The survey concluded most overweight Americans are in a state of denial,
and the medical community has been lax in communicating the health
dangers of obesity to society in general. The American Obesity
Association has placed obesity as the second leading cause of
preventable death; U.S. government estimates that 25% of children, 35%
of women and 31% of men in this country have a body mass index
approaching obesity. Nonetheless, most people are oblivious to the
severe health consequences of being overweight.
More surprising is the
survey’s conclusion that the medical community not only neglects to
bring up the subject of a patient’s weight, but often fails to educate
the patient about treatment, such as behavior modification, exercise,
diet and effective medication. Weight control is imperative in an
effective program, focused on optimal health and longevity.
The topic of nutritional
supplementation is much more complex and lengthy and, perhaps, the
subject of another course. But with a food supply now depleted of
sufficient nutrients, a plethora of processed food and faulty
governmental nutritional guidelines, it is easy to see the need for
nutraceuticals. The multimillion-dollar nutraceutical industry evidences
the public’s awareness of their need to supplement dietary intake with
vitamins and minerals. Here again, however, the public is uneducated as
to what nutritional supplements are needed, what the difference is
between food grade and pharmacy grade, how bioavailable their
nutritional supplements are and if their current nutritional supplements
are actually being absorbed. Most people on a comprehensive formulation
do not need additional supplementation; however, if lab results indicate
supplementation is required, then individual needs should be pinpointed
and additional nutrients made available. Nutritional supplementation can
also address unique needs, such as joint pain relief, desire for brain
enhancement, help to reverse adult onset diabetes, etc. Qualified age
management practices provide patients with the specific nutraceuticals
those needs demand.
Hormone Modulation
The preferable term is
now hormone “modulation,” rather than hormone “replacement,” because we
never want to shut down a patient’s own output. Therefore, we supplement
when needed per a comprehensive evaluation process. We monitor the
stimulating hormones whenever possible to be certain we don't shut off
the body's own biofeedback mechanisms. (Shutting off the body’s own
biofeedback mechanism is our definition of abuse and is to be avoided at
all costs.) Not all hormones need to be supplemented. Sometimes we need
to reduce the body’s own output of hormones, such as insulin or cortisol.
Like a fine-tuned
symphony orchestra, where the music sounds best when the instruments
play together at the appropriate sound level and timing, modulating the
body’s hormones “fine-tunes” the human body.
Exercise
To be maximally
effective for therapy or health enhancement, an exercise prescription
must fulfill certain basic requirements: It must be a daily activity (7
days a week); it must be fun, not painful or excessively fatiguing; and
it must fit an individual’s preferences. The selected activities must be
readily available, not distant or difficult to reach—and preferably be
close to the home or workplace. The clothes, equipment and/or club
membership associated with the activity must be inexpensive. Ideally,
the activity should not depend on other people (team, class or
partners), but should permit group participation if desired. And
finally, the activity must be suitable for lifelong participation.
The major form of
aerobic exercise should be (walking, running, cycling, swimming or
cross-country skiing). Variety is an important part of the prescription:
At least two or preferably three different activities are recommended,
such as walking-running-tennis or walking-cycling-swimming.
The choice of exercise
should be guided by individual preference and previous experience.
Walking and running are most often recommended because they don’t
require special training or skills. They are inexpensive, readily
available, safe and suitable for doing alone or with others. The
acronym DFALIVE is helpful to guide a patient’s exercise prescription:
Daily, Fun, Available, Lifelong, Independent, Variety, Endurance.
Slide20
Continuity of Care
As qualified age
management practitioners, we closely monitor our patients through
regularly scheduled blood tests, diagnostic evaluations and ongoing
communication. We also encourage our patients to continue with their
primary physicians; we must frequently keep their primary physicians
well-informed of a patient’s progress.
Patients may remain on
their programs for as long as they desire to maintain their vigor and
experience the other benefits. Should they wish to stop the program,
patients shouldn’t be concerned about sudden rapid aging; they will
simply continue to age at the rate they experienced prior to going on
age-management protocols.
While some patients
undergoing hormone modulation feel results within days, it generally
takes three to six months to titrate an individual’s hormone levels. The
placebo effect shouldn’t be discounted, but careful monitoring through
blood tests objectively shows the practitioner how the therapy is
working. Frequently, patients will begin to notice progress by what they
don’t feel (sick, tired, moody, etc.).
Much of the
supplementation or modulation can be accomplished through pills,
capsules and gels. It is important to note that human Growth
Hormone—only prescribed for individuals with proven adult
deficiencies—breaks down if taken orally. The only truly effective way
to obtain its benefits, at this time, is by subcutaneous injection. This
procedure is easily learned by the adult growth hormone deficient
patient and becomes routine.
References
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