The Age Management Medicine Conference is an opportunity for practitioners to learn about options available to help their patients age gracefully. Many of the presentations deal with hormone supplementation, functional medicine and endocrine balance. Following is a summary of a number of speakers to give an idea of content.

Dr. Henry Hess

The Perfect Menopause 7 Steps www.theperfectmenopause.com

1. Know your menopause: the time from the last period and the rest of the person's life. At this point estrogen is down, progesterone down, FSH and LH are up and testosterone remains even. Perimenopause is the stage of irregularity and consists of the few years leading up to menopause. There are three stages of menopause: early, intermediate and late.
2. Determine treatment goals: natural, bioidentical hormones, herbs, medicines
3. Manage the symptoms: begin with a symptom chart and discussion of life style changes and nutrition. Learn deep breathing and exercise. Supplements that support menopause could be Maca, Siberian ginseng, gingko biloba, St. John's Wort, red clover leaf, black cohosh, fish oils and vitamin E. Techniques to investigate include massage, acupuncture, meditation and hypnosis. Hormone therapy with bioidentical* hormones must be individualized.
4. Weight gain: address with commitment and action.
5. Reverse aging and manage your dryness inside and out: address hydration and collagen depletion. Consider that the inner organs dry out as well.
6. Dramatically improve your sexual desire: this is a very complex issue. Therapies include natural, herbal, hormonal and medicinal options.
7. Have a better night's sleep: Investigate therapies available for this to empower the patient.
8. Choose the right doctor.
9. Put your plan into action.

*Bioidentical: Those products with a chemical structure identical to what the body produces.

J.J. Virgin, PhD, CNS

Toxicity: the Hidden Epidemic in Weight Loss Resistance

The person with weight loss resistance eats correctly but fails to lose weight despite rigorous exercise and a healthy diet. Factors that contribute to this include chronic stress, poor sleep, GI issues and sex hormone imbalances, insulin and leptin resistance, thyroid fatigue and toxic burden.

1. Toxins are everywhere. Our detoxification organs are overloaded. Worldwide 80 billion pounds of toxins are released annually. Go to www.ewg.org for additional information. It starts in the womb and then new burdens are added daily with exposure. It is accentuated due to deficiencies in B6, magnesium and selenium as well as deficient HCl in the gut. Other physiological issues play a part like poor elimination through the kidneys, colon, skin, lungs and liver.
2. Toxicity causes Weight Loss Resistance: too many fat cells and thyroid issues cause leptin resistance. Toxins are stored in the fat so the body retains these.
3. Fungicide increases fat cell numbers causing permanent endocrine disruptions. Diethylstilbestrol (DDS) and Bisphenol A(BPA) promotes fat cell activity. BPA is what is out gassed from plastic bottles. MSG and lead have the same effects.
4. Symptoms: moody, ears ringing, itchy skin, allergies, palpitations, swollen hands and feet, difficulty breathing, eyelid swelling, unsteady gait, burning hands, blurred vision, PMS, hypoglycemia, energy , dark circles under eyes, headaches, constipation, food craving and sore throat.
5. Test for: Amino acids, vitamin status and determine if the detoxification system in a state of alarm or not.
6. Approach: look at genetic markers, eliminate toxins, ensure good gastrointestinal (GI) health, achieve a healthy diet and lifestyle, possibly use chelating agents and intensive detoxification as needed. Far infrared saunas are good for sweating. Supplemental fiber is helpful. Baking soda and Epsom salt baths (as a soak) pull out toxins. Supplements include amino acids and antioxidants.

Neal Rouzier, MD

Human Growth Hormone

There is a lot of mis-information regarding human growth hormone (HGH) in the literature. The key is to use a low dosage. There are contraindications with malignancy, retinopathy and lung issues. Using human growth hormone is not a panacea.

There are over 1,000 studies in the literature on beneficial effects of HGH. Decreased HGH levels exhibit all of the typical signs of aging. With the treatment, body composition changes, cardiovascular function improves along with lipids levels, insulin sensitivity improves, blood pressure decreases, visceral fat decreases, muscle mass increases, bone strength and formation increases, atherosclerotic reverses, quality of life improves, cognitive function improves and bone mineral density increases. The lower the level of growth hormone, emotional stability is decreased, cardiovascular disease is increased, life expectancy is decreased. There is a low incidence of side effects.

Dr. William Shell

The Use of Medical Foods in Clinical Practice

The medical foods Dr. Shell markets can only be sold in the physician's office. AppTrim (helps a little with obesity management), Sentra PM (sleep agent inducing delta sleep and busts of REM sleep, activates the parasympathetic nervous system at night), Sentra AM (cognitive fatigue management, increases alertness and exercise potential, used for fibromyalgia), Theramine (pain management), GABAdone, Hypertensa (reduces blood pressure), Pulmona (asthma), Trepadone, ListerV.

Neurotransmitters are produced in the body of the cell. When the electrical signal happens they are released into the cleft. Substantial numbers of the neurotransmitters are involved in a re-uptake and recycled. 5 HTP goes to Serotonin, Choline to Acetylcholine, Arginine to nitric oxide, tyrosine to catecholamines, GABA to GABA. They use a neurotransmitter precursor, uptake stimulator, neuron activator, adenosine brake inhibitor, attenuation inhibitor. Side effects are rare for these products. They are developing a nutritional food for macular degeneration, ADHD, cholesterol, etc.

As an aside, there is a black box warning on NSAIDs that is very disconcerting. NSAID induced complications are estimated to cause over 3,000 hospitalizations in Canada.

Dr. Eva Szigethy

Interactions between circadian rhythms, sleep and hormones in regulating mood.

Circadian rhythms are regulated in the body by melatonin. We get our most deep sleep in the first three hours of sleep. REM sleep is very physiologically active and is the dream cycle. People cycle at about 90 minute intervals.

It is important to go to bed at the same time and get up at the same time to protect against depression. Mood disorders and mood symptoms are common with sleep disorders. Insomnia, low DHEA, low thyroid, perimenopause, shifts in light dark cycles, cerebral incidents, genes and early life stress are high risk factors for depression.

Melatonin creates a cascade in the brain affecting the HPA axis, growth hormone and all the neurotransmitters. Inflammatory bowel disease results in a much higher rate of depression. There seems to be a correlation with depression, inflammation and insomnia.

Interventions for insomnia and depression: behavioral intervention:

1. Reduce your time in bed
2. Get up the same time each morning
3. Don't go to bed unless you are sleepy
4. If you are awake get out of bed

Pharmacotherapy for sleep:

1. Melatonin
2. Agomelatine (melatonin receptor agonist)
3. Pyrimidine derivatives (Zolpidem)
4. Sedating antidepressants (Trazadone)

Interventions for depression:

1. Hormone therapy
2. Moderate exercise
3. Mediterranean diet
4. Track circadian cycles and adjusting sleep/wake activities accordingly
5. Cognitive behavioral therapy (brings cortex back on line)
6. Interpersonal therapy
7. Psychodynamic therapy
8. Hypnosis
9. Bright light therapy (30 minutes at 10,000 lux)

Rebecca Murray, APRN, FNP, CDE

Estrogen related Cancers

Cancer begins with the disruption in the single nucleotides of the genes. Genes and environment are involved. It isn't what you eat that will kill you. It isn't your DNA that will save you. It is how the two interact. Known risks: genes, family history, age early menarche, late menopause, HRT, obesity, alcohol, first child after 30 or never having children.

Bottom line: what is the total estrogen exposure and the type of exposure during a lifetime? We all get more estrogen than we realize, due to all the exogenous (outside sources) of estrogens and xeno-estrogens (estrogen mimickers) from plastics, pesticides,etc. Within our bodies we can have endogenous (inside sources) production of estrogen, converting testosterone to estrogen. This is done through an aromatase pathway. It makes sense to look at women to see if their bodies are driving aromatase. Cortisol and insulin up regulate aromatase so it is important to test cortisol (through adrenal testing) and insulin (insulin/glucose tolerance testing). If the person is insulin resistant their insulin levels can maintain at very high levels throughout the day which up regulates the aromatase pathway. In addition, some women have polycystic ovarian disease where they have unopposed estrogen throughout their monthly cycle. This drives the estrogens and puts the person at greater risk for breast cancer. A patient can do an Estronex panel to get the ratio.

Genetic markers show how well hormones are metabolized. If estrogens are up regulated to Quinones they are very aggressive carcinogens. Supplements to help redirect estrogens are DIM (active metabolite of indole-3-carbinol), curcumin, black cohosh, DHEA, antioxidants, omega 3, rosemary, reserveratrol , sulfurophones. B12 is a huge methylator which is needed to process the estrogens. Glutatione S-transferase (GST) cannot eliminate estrogen metabolites. This genetic mutation is connected to many cancers. The sulfurophanes up regulate the glutathione pathway. This is done with NAC, l-glutamine, glycine, magnesium, SAMe, methionine to assist with glutathione and methylization.

Supplements to balance hormones: DIM, flaxseed, omega 3, black cohosh, chaste berry, reseveratrol, B6, B12 folic acid , calcium/magnesium and iodine.

Sites for testing: Genova diagnostics www.gdx.net and Metametrix

William Stilling

bstilling@parsonsbehle.com

Health Care Reform and How it Relates to Age Management Medicine

The presentation covered discussion of the bills that are being considered in Congress as of fall of 2009. The chaos of the system is vast. Costs to run the system are very high (30% of health care costs are administrative) because the system is so complicated. With Medicare, only 2% of the costs are administrative. Sadly, 62% of personal bankruptcies are due to health care costs. 750,000 Americans traveled to other countries to receive health care in 2007. This represents $16 to $19 billion dollars. Statistics show that each person pays about $8,000 for medical care annually including insurance premiums and additional fees not covered by insurance.

The Kaiser Family Foundation will give an update on the proposed legislation. Also look at Health Insurance Exchange/Connector programs to be able to compare policies.

Dr. Dan Lukaczer

The Role of Gastrointestinal Dysfunction of Chronic Disease

Dr. Lukaczer is involved with the Institute of Functional Medicine. Gut health issues, including leaky gut, affect a wide range of systemic dysfunction and autoimmune disorders. 70% of the population has gastrointestinal (GI) symptoms or diseases. Healthy guts have adequate digestive enzymes, good epithelial barrier, healthy mucus and proper diet. Fix the gut by improving diet, supporting digestion, and proper flora.

So what is the gut? A hollow tube that is about 30 feet long. The inside of the gut is really the outside of the body. The surface area of the gut is 300 square meters. This surface area is accomplished due to the vast area of the microvilli. Mucins protect the gut and enzymes and digestive secretions keep the gut tight and keep incomplete proteins from crossing the gut barrier.

The intestinal barrier is only one cell thick. If the villi is damaged then macro cells get through the gut and into the blood stream. In some cases, smaller molecules cannot get through the cell for nutrition. Alcohol and NSAIDs can cause this.

Gastrointestinal flora has over 400 species of microbes. Most of these are in the colon. These microbes have many activities that are necessary such as vitamin K synthesis. They also support the immune system. Secretory IgA binds and neutralized all sorts of microbes.

We can do saliva testing to look at GI immunological defense. Triggers of GI dysfunction: nutrient insufficiency, medications, virus and bacteria, alcohol, low HCl, enzymes, bile, food allergies, emotional issues, travel, hypoxia. Consequences: inflammatory responses, breach of the mucus causing leaky gut, increase in circulating immune complexes. Antigens cross the gut barrier. T cells call for B cells. B cells create antibodies and inflammation results as well as immunological mediated responses. How to assess and treat GI dysfunction: consider food additives, food, medications, invaders-pathogens, inadequate digestive capacity, nutrient insufficiency and the connection with stress.

Functional medicine uses the 5R program: evaluate, individual intervention and normalize the GUT functions. Look at what needs to be removed, replaced, re-inoculate with pre and probiotics, repair and regenerate the lining and rebalance the life style of the patient.

1. Remove stressors: biomechanical, emotional factors, food allergies, xenobiotics, pathogens. Can use the elimination diet. Eliminating food antigens helps a number of systemic diseases like eczema, arthritis, Crohn's disease, Irritable bowel, migraines and dermatitis. IgG food allergy testing (Elisa) and check for things like blastocystis.
2. Replace digestive secretions: digestive enzymes, fiber, intrinsic secretions.
3. Reinoculate with probiotics and prebiotics: bifidobacteria, lactobacillus, inulin and FOS. Giving 3.6 trillion of probiotic daily (3% of the total in the gut) was very helpful in the research.
4. Repair: provide nutritional support, mucosal lining support, whey, immunoglobulins, antioxidants, fish oil and glutamine.
5. Rebalance: using the right nutrition and life style changes to maintain success.

Dr. Chip Watkins

Understanding the HPA axis connection to Hormone Imbalances

It is important to look at the neurotransmitters and the adrenal hormones. Use amino acid precursors to build up the level of neurotransmitters. Seratonin is mostly in the gut (95%) and much less in the brain (2%). It is critical with the treatment of depression and anxiety. 5 HTP assists with this.

The thyroid is linked with this whole process of serotonin. Research has shown that thyroid function must be adequate for serotonin processing. Cortisol also affects serotonin. High levels of cortisol lowers serotonin uptake. Too little cortisol also affects serotonin.

GABA is the most inhibitory neurotransmitters. There are GABA receptors on glutamate neurons. GABA induces calm but it doesn't cross the blood brain barrier well. Options are theanine, lactium, taurine, inositol and progesterone.

Catecholamines are the excitatory neurotransmitters. This includes dopamine, norepinephrine and epinephrine. Dopamine is important for motor, cognitive function and memory. It can also be inhibitory so it is a regulator.

There is a relationship between the excitatory and the inhibitory neurotransmitters. SSRIs increase the dopamine transporter and reduce dopamine function. Adrenal stress plays a big part in all of this. The adrenal hormones include DHEA, cortisol, epinepherin and norepinepherin. DHEA could be a biomarker for aging since it tends to decrease with age. It is a GABA antagonist and increases the firing of serotonin. It also protects us against glutamate. DHEA increases neuronal plasticity. Dr. Chip uses 5 mg a day at the most of DHEA and recommends monitoring the levels. He will not use if there is a history of hormonal cancer.

Another hormone, estrogen, moderates the dopamine and serotonin. Estrogen dominance causes a cascade of issues with the thyroid. Dr. Chip has found that in menopause, if the neurotransmitters get balanced, the estrogen will balance. Stress comes in and everything shifts to make cortisol stealing from pregnenalone. The sex hormones are bypassed. It is evident that all of the hormones do an incredible dance together. Imbalance perpetuates imbalance.

Dr. Alvin Lin

Mortality Studies

Cardiovascular disease and cancer are the two most prominent killers. How can we help reduce mortality? Research studies have shown the following:

Aspirin: If you have heart disease research shows that aspirin reduced mortality by 13% but you will double your risk for gastrointestinal bleed.

Blood Pressure: the lower the blood pressure the lower the mortality. The lower the blood pressure the better the outcome.

Body mass index: Normal body mass – around 25- gives longer life. Above and below optimal levels have increased mortality.

Cardiorespiratory fitness: regardless if you smoke, BMI, waist circumference, etc if you are fit you will have longer life. (10.9 METS)

Diet: High intake of fresh fruit, root vegetables, legumes and seeds reduces total mortality. This is compared to the western diet of french fries, red meats, sugars, processed meats, dairy, desserts and white flour. The Mediterranean diet gave longer life as well. Mediterranean diet is moderate alcohol, vegetables excluding potatoes, legumes, fruits and nuts, whole grains, fish, olive oil and less meat and dairy.

Exercise and physical activity: Any physical activity gave longer life. Even 20 minutes three times a week of vigorous activity makes a difference.

Fish oil: The lower the serum omega 3 levels the more likely to suffer sudden death.

Glucose: High blood sugar gave increased all cause mortality. For a 1% increase above 5% for HgbA1c accounts for 28% increase of death.

Muscle strength: Strong quadriceps and grip strength gives lower mortality including cancer mortality.

Testosterone: The higher the endogenous testosterone lowered all cause mortality including cardiovascular disease and cancer.

Tobacco: If you quit smoking you have to survive 20 years be in the same category of non-smokers. It increases the risk of death by 5-10 years.

Vitamin D: High vitamin D lowers all cause mortality. Sunscreen, blocking the body's ability to assimilate vitamin D, has made many people vitamin D deficiency.

The actual causes of death in the early 1990's were from top to bottom: tobacco, diet, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles and at the bottom of the list illicit drug use.