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 a few. 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 that 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.  Researchers in Turku, Finland studied 15,500 men aged 40 to 69 years.  Moderate or severe sexual symptoms (decreased frequency of erections, libido, and potency) were observed in 20% of men of the youngest age group of 40 to 44 years. The proportion of men with significant symptoms increased linearly with age up to 67% in the oldest age group (65 to 69 years). Other symptoms did not show a similar age trend. On multifactor analysis, sexual symptoms were independently associated with decreased life satisfaction and increased visits to the physician after adjustment for coexisting morbidities. Visits to the physician were up to three times more frequent among men with moderate to severe sexual symptoms than among those with mild or no symptoms.  The researchers concluded that these symptoms deserve more attention in the workup of aging male patients, because they offer a simple screening tool to detect impaired well-being associated with increased consumption of health services.³²

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, and 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 that was 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 that thethe 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.  A meta-analysis conducted in 2008 and published in 2009 looked at the mortality effects of 12 modifiable dietary, lifestyle, and metabolic risk factors in the United States (US) using consistent and comparable methods: high blood glucose, low-density lipoprotein (LDL) cholesterol, and blood pressure; overweight–obesity; high dietary trans fatty acids and salt; low dietary polyunsaturated fatty acids, omega-3 fatty acids (seafood), and fruits and vegetables; physical inactivity; alcohol use; and tobacco smoking.

Danaei, et al (2009) conducted a metaanalysis on risk factor exposures in the US population.  They derived their data from nationally representative health surveys and disease-specific mortality statistics from the National Center for Health Statistics. They obtained the etiological effects of risk factors on disease-specific mortality, by age, from systematic reviews and meta-analyses of epidemiological studies that had adjusted (i) for major potential confounders, and (ii) where possible for regression dilution bias.  They estimated the number of disease-specific deaths attributable to all non-optimal levels of each risk factor exposure, by age and sex. In 2005, tobacco smoking and high blood pressure were responsible for an estimated 467,000 and 395,000 deaths, accounting for about one in five or six deaths in US adults. Overweight–obesity (216,000) and physical inactivity (191,000) were each responsible for nearly 1 in 10 deaths. High dietary salt (102,000), low dietary omega-3 fatty acids (84,000), and high dietary trans fatty acids (82,000) were the dietary risks with the largest mortality effects. Although 26,000 deaths from ischemic heart disease, ischemic stroke, and diabetes were averted by current alcohol use, they were outweighed by 90,000 deaths from other cardiovascular diseases, cancers, liver cirrhosis, pancreatitis, alcohol use disorders, road traffic and other injuries, and violence.  Slide05  

The authors concluded that smoking and high blood pressure, which both have effective interventions, are responsible for the largest number of deaths in the US. Other dietary, lifestyle, and metabolic risk factors for chronic diseases also cause a substantial number of deaths in the US.⁴⁵

In age management medicine, the goals are to enhance vitality, vigor and health through nutrition, supplementation, exercise and hormone optimization. The Canadian Study of Health and Aging (CSHA), in 2008, investigated how exercise is associated with cognitive change and mortality in older people and, particularly, whether exercise might paradoxically increase the risk of dementia by allowing people to live longer.  They found that exercise is strongly associated with improving cognition. As the majority of mortality benefit of exercise is at the highest level of cognition, and declines as cognition declines, the net effect of exercise should be to improve cognition at the population level, even with more people living longer.³¹

Depression is highly prevalent among elderly individuals, with a reported prevalence in the community of 1.8% for major depression, 9.8% for minor depression, and 13.5% for clinically relevant depressive symptoms (CRDSs).  Although cross-sectional studies have shown depression to be associated with poor health, functional impairment, decreased quality of life, and greater use of health services, prospective studies have shown depression and depressive symptoms to be independent determinants of mortality. (41)

Slide06  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 lives. 

Slide07

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 21^st-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

One of the major issues often brought up by critics of hormone optimization is that while it might work in patients who are truly hypogonadal and/or AGHD by traditional definitions, it does not apply to those who are eugonadal or have low but normal IGF-1.  So it's interesting that some researchers recently (2009) looked at 120 community dwelling men, average age 71yo w/BMI 27+. 

The inclusion criteria were interesting in that rather than exclude those with TT in the "normal" reference range, they actively sought out those with morning TT in the lower half, eg 150-550ng/dL (their definition).  Average TT ended up between 311-377ng/dL.  Really intriguing was that they also sought out those with IGF-1 in the lower tertile for adults, eg <167ng/mL, rather than limit the study to those w/AGHD who failed stimulation tests.  Average IGF-1 ranged 105-127ng/mL This is our patient population.

The authors used 1% transdermal testosterone, offering 5g or 10g QAM x 16wks in order to achieve either the low normal range typical of older men or mid-to-high normal range typical of younger men.  Placebo injections or hGH was given as either 3ug/kg nightly or 5ug/kg nightly.  The lower was picked because 2ug/kg had NOT been shown to increase whole-body protein synthesis in AGHD but 3.3ug/kg had.  5ug/kg dose was chosen to offer even greater anabolic stimulus with minimal risk of side effects from even higher doses.

As a result of the above interventions, TT increased by 143+/-379ng/dl in those receiving 5g/d while it increased by 510+/-503ng/dL in those receiving 10g/d.  Those who received 3ug/kg/d saw their IGF-1 increase by 64+/-44ng/dL while those who received 5ug/kg/d increased by 108+/-51ng/dl. Those who received testosterone cream plus placebo saw a statistically significant increase in IGF-1 of 14+/-28ng/dL. 

Most importantly, at the end of just four months, the authors noted significant increases in whole-body and limb skeletal muscle mass, reduction in whole-body and trunk fat, and overall improvement in strength and even physical performance as measured by VO2max.  Better results were found in those who received hGH on top of testosterone cream and in those who received 10g/d compared to those who only received 5g/d.

HDL did increase by 3.5md/dL but so did TC & LDL while TG dropped by 18mg/dL.  Fasting glucose increased by 3mg/dL.  Average PSA increased from 1.5ng/mL to 1.7ng/mL over the course of four weeks so this would bear watching closely.  Hct also increased from 43.2% to 45.2%.  While most of these changes were statistically significant, one would not consider them clinically significant.  However, most concerning was an increase in BP by 12/8mm Hg, bringing the subjects from truly optimal to pre-hypertensive.  So BP needs to be monitored closely.⁴³

Slide08

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 that 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 21^st 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.

Aging and related diseases are accompanied by increased Oxidative Stress (OS) and accumulation of Advanced Glycation End products (AGEs). One important component of AGEs accumulation with aging appears to be the sustained exposure to dietary AGE (dAGEs), which contributes to overloading of anti-AGE receptors and depletion of antioxidant reserves. support this postulation. Lowering the content of AGEs in the normal diet significantly prevents AGEs accumulation and the increased OS caused by aging and also extends lifespan in mice. In humans, short-term trials indicate that a Low AGEs diet reduces oxidant burden and inflammatory markers.³⁸

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

Oxidative stress has been implicated in sarcopenia and the loss of muscle strength with aging, but the relationship between oxidative stress and decrease in muscle strength and physical performance has not been well characterized. Serum protein carbonyls are markers of oxidative damage to proteins and are caused by oxidative stress.  High oxidative stress, as indicated by oxidative damage to proteins, is an independent predictor of decrease in walking speed and progression to severe walking disability among older women living in the community.³⁹ Slide09

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 that 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  Slide10  

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 (CRP)

CRP 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 five ounces of wine, 1½ ounces of liquor or one 12-ounce beer. 

• Exercise and physical activity

• Weight loss

• Medications, including statins, niacin and fibrates

• Omega-3 fatty acids

• Dietary fiber

• Right diet 

Aging Skin

Skin represents a valuable model to study aging in humans, since it is widely affected by this process and is easily accessible. Modifications related to aging are particularly visible in human skin, which becomes wrinkled, lax, dry, and irregularly pigmented over time⁵. Aged skin is characterized by a flattening of the dermal-epidermal junction, a marked atrophy and a loss of elasticity of the dermal connective tissue⁶,  associated with a reduction and disorganization of its major extracellular matrix components, such as collagen and other elastic fibers⁷, proteoglycans and glycosaminoglycans^8. A histological characteristic of chronological aging in the epidermis is a decrease of tissue thickness⁷. Solar radiations are particularly studied as environmental factors promoting skin aging⁹ and carcinogenesis¹⁰. UV lights have been shown to affect both epidermal keratinocytes¹¹ and dermal fibroblasts¹². However, at present, age-related modifications of the different dermal fibroblast populations and the consequent effects on skin aging remain poorly understood.  

Characteristics of matched pairs of dermal papillary and reticular fibroblasts (Fp and Fr) were investigated throughout aging, comparing morphology, secretion of cytokines, MMPs/TIMPs, growth potential, and interaction with epidermal keratinocytes. We observed that Fp populations were characterized by a higher proportion of small cells with low granularity and a higher growth potential than Fr populations. However, these differences became less marked with increasing age of donors. Aging was also associated with changes in the secretion activity of both Fp and Fr. Using a reconstructed skin model, we evidenced that Fp and Fr cells do not possess equivalent capacities to sustain keratinopoiesis. Comparing Fp and Fr from young donors, we noticed that dermal equivalents containing Fp were more potent to promote epidermal morphogenesis than those containing Fr. These data emphasize the complexity of dermal fibroblast biology and document the specific functional properties of Fp and Fr. Our results suggest a new model of skin aging in which marked alterations of Fp may affect the histological characteristics of skin.

Memory 

Stevens, et al (Nov. 2008) published a meta-analysis of memory failure in older adults.  Their results provide new insight into the nature of age-related memory decline, suggesting that at least two distinct neurocognitive mechanisms play a role in encoding failures in older adults: 

1.  a general failure to engage brain regions crucial to encoding new information, such as MTL structures, can contribute to failed encoding regardless of age.

2.  Older, but not younger, adults are vulnerable to distraction due to an inability to suppress processing of irrelevant environmental stimuli. This distraction is reflected in age differences in those brain areas that process the irrelevant stimuli, such as auditory stimuli during a visual task (i.e., auditory cortices), as well as in DMRs (e.g., medial parietal cortex) that may be involved in environmental monitoring.  

In addition, these results support previous research showing that while both younger and older adults’ performance was decreased on a long-term recognition task following encoding inside, relative to outside, the fMRI scanner, the deleterious effects of fMRI on performance were greater for older adults (Gutchess and Park, 2006). This raises the possibility that the distracting properties of fMRI scanning per se may be disproportionately detrimental to older adults, relative to younger adults, a potential confound that may have implications for fMRI investigations of neurocognitive aging.³⁵

Brain Aging

Normal brain aging can be defined as a normal biologic process of the elderly characterized by

relative cerebral atrophy without severe compromising of normal cognitive and motor performances.  The aging brain shows volumetric decrease, usually associated with diffuse or focal white-matter signal abnormalities. A clear clinical or pathologic cut-off between physiologic and abnormal aging in the brain does not exist, however. ³⁶

Brain weight declines on average by about 2 to 3% per decade after age 50, accelerating in later years, so that beyond age 80, it is typically decreased by 10% compared with the brains of young adults at postmortem.  In a cross-sectional study, the rate of shrinkage of total brain volume was calculated to be about 0.32% per year over adult life span, whereas temporal lobe atrophy averaged 0.68% and hippocampal atrophy 0.82% annually.  Other intrinsic (programmed) changes are the Hayflick phenomenon (decreasing ability of the cells to divide), telomere shortening, decreased neurogenesis (exhaustion of neural stem cells), decline of growth factors (brain-derived neurotrophic factor, nerve growth factor, TrkA receptor), and apoptosis.³⁷

Sleep

Sleep propensity and skin temperature are func­tionally related. In young adults, changes of skin temperature within the comfortable thermoneutral zone affect sleep-onset latency and vigilance performance. Aging is associated with both decreased ther­mosensitivity and poorer sleep. A study of sleep patterns and the elderly was conducted in the Netherlands.  The goal was to test whether subtle manipulations of core body and skin temperature affect sleep onset in elderly people without sleep complaints and in elderly insomniacs and whether the subjective perception of these mild body temperature ma­nipulations is preserved with aging and insomnia. They found that warming the proximal skin by 0.4˚C fa­cilitates sleep onset equally effective in healthy elderly (by 18% ie, by 1.84 minutes and elderly in­somniacs (28%, 2.85 minutes). These effects were com­parable to the results in healthy young subjects, in spite of a marked decrease in the subjective perception of temperature changes in eld­erly subjects, especially in insomniacs. The researchers concluded that the findings show that mild changes in skin temperature have an effect on sleep propensity in elderly and indicate that elderly insomniacs may have a diminished capability to recognize that a slight increase in bed temperature facilitates the initiation or re-initiation of sleep.⁴⁰

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:

1.      Heart Protection Trial from Great Britain published in Lancet in 2002.¹⁶

2.      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

3.      “A to Z” Trial.  Published in JAMA in 2004.¹⁸

4.      “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.” ¹⁸  Ultra-low LDL should also be a goal for all diabetic and metabolic syndrome patients.

Metabolic Syndrome

A growing but conflicting body of literature suggests that the metabolic syndrome may be associated with cognitive impairment.  A study, published in March, 2009, was conducted at 180 clinical centers in 25 countries.  A total of 497 women (10.2%) had the metabolic syndrome, and of these, 36 (7.2%) developed cognitive impairment compared with 181 women (of 4398, 4.1%) without the syndrome. The mean (SD) number of metabolic syndrome components for all women was 1.0; 518 women (10.6%) were obese, 895 (18.3%) had hypertriglyceridemia, 1200 (24.5%) had low high-density lipoprotein cholesterol levels, 1944 (39.7%) had high blood pressure, and 381 (7.8%) had high fasting blood glucose levels. There was a 23.0% age-adjusted increase in the risk of developing cognitive impairment per unit increase in the number of components. Further multivariable adjustment somewhat reduced the effect.  The researchers concluded that there was an association between the metabolic syndrome and the number of components and risk of developing cognitive impairment in older women. Additional studies are needed to determine if screening and close management of these at-risk elderly women would diminish the incidence of cognitive impairment.³³  Slide11

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. Slide12  

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).²⁴ 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. ²⁴ 

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. ²⁴ Slide13

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

 During the last 50 years there has been a marked increase in the number of persons in the United States who have diabetes. In 1958 fewer than two million in the United States were diabetic, whereas today the number approaches 16 million. There has been a similar increase in diabetes throughout the world, with alarming recent increases in diabetes in developing nations as well as in the developed.  

Diabetes mellitus is a disease of older persons: more than half of all diabetics in the United States are over 60 years of age. The prevalence of diabetes mellitus peaks in persons between 65 to 74 years of age. Twenty percent of men and more than 15% of women 65 to 74 years of age have diabetes. There is a decrease in prevalence rates in persons 75 years and older. It is important to recognize that in 25% to 41% of persons who have diabetes the diagnosis has not been made. Diabetes mellitus is more common in Hispanics (especially those from Mexico).   

At a basic level, diabetes mellitus accelerates the aging process. Diabetes is associated with a decrease in DNA unwinding rate, increased collagen cross-linking, increased capillary basement membrane thickening, increased oxidative damage, and decreased NaþKþATPase activity. These basic changes result in increased clinical signs of aging. Cataracts

occur 2.5 times more commonly in diabetics than in nondiabetics. Diabetics have accelerated atherosclerosis with increased propensity to have a myocardial infarction, stroke, and peripheral vascular disease.⁴²  Slide14

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.²⁶ Slide15

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.

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.” ²⁷ Slide16

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.” ²⁸ Slide17

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 10.²⁸  

For optimal ranges for women, see Slide18 Slide19

For optimal ranges for men, see Slide20 Slide21

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:

1.      Natural foods only—if God didn’t make it, don't eat it.

2.      Moderate protein

3.      Healthy natural fats, preferentially mono-unsaturated, like virgin olive oil. No artificial or hydrogenated fats.

4.      The only carbohydrates should be fruits and vegetables, no bread, pasta, rice, wheat of any kind.

5.      “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.²⁹     

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 prevalence of overweight and obesity is higher in the US than in Japan, as is the prevalence of heart disease, diabetes, arthritis, and functioning problems. Researchers looked at the data from many studies conducted in the US and Japan to try to determine if the differences in health status are due to differences in rates of obesity.  They found that education level and marital status are predictors of overweight for older Americans but not for older Japanese people. Health behaviors affect weight in all groups. The prevalence of functioning problems and disease are more likely to be associated with being overweight in US men and women than in Japanese women, and are not associated with being overweight in Japanese men.(34)  

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.  

For a normal-weight woman, if the goal is to maintain this weight over time, normal-weight women need 60 minutes a day of moderate exercise in order to maintain a healthy weight, researchers have found in a recent study. Those who exercised fewer than 420 minutes a week gained significantly more weight than those who met this target, I-Min Lee of Brigham & Women's Hospital in Boston, and colleagues reported in the March 24/31, 2010 issue of the Journal of the American Medical Association. ³⁰   

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.  Slide24

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  

Post Test