Transcript Theodore C. Friedman, M.D., Ph.D. Endocrinology of Fatigue

Theodore C. Friedman, M.D., Ph.D.
Associate Professor of Medicine - UCLA
Chief, Division of Endocrinology,
Molecular Medicine and Metabolism
Charles R. Drew University
Is Taking Growth Hormone Enough?
MAGIC Foundation Affected Adult Convention
February 11, 2007
Caveat - Nutritional Supplements
• Multi-million dollar enterprise
• Not regulated by the FDA
• Do not have to be shown to be beneficial
(unlike medicines)
• Only rules
– Cannot be dangerous
– Cannot make false claims (lots of it “may help decrease X”)
• Lots of health care providers know more than me
about supplements and use them a lot
• Little published articles on them
Caveat - Nutritional Supplements (2)
• Some health care providers order less than scientific
tests (urine for neurotransmitters) and then sell you a
supplement package based on these results.
• Many of my patients have pocketbooks full of
supplements costing thousands of dollars/month.
• If each one worked so well, we do you need to take so
many
• Conduct an N=1 trial on yourself (try them one at a
time and only continue if you see an improvement on
it.
• I’m fairly skeptical, but will not take someone off
them, if patient feels they are working (unless they are
harmful).
Endocrinologists vs. Anti-Aging Docs
• Endocrinologists
– Measure hormones
with reliable assays
– Give patients a
hormone/vitamin to
restore levels to
normal
– Monitor carefully
and do not overreplace
• Anti-Aging Docs
– Measure hormones
with less-thanreliable assays
(salivary or urine
assays)
– Often give
supraphysiological
doses of
hormones/vitamins
• May lead to high
levels
My General Approach
• Look carefully for early signs of
deficiency
• Replace deficiencies until achieving
mid-normal range
• Don’t treat if not deficient
• Look at risks/benefits of treating
Exercise
• Hypopit women have decreased exercise
ability
– Possibly due to low muscle mass, strength and/or
deconditioning.
• Testosterone and/or GH deficiency may play
a role
• While exercise benefits everyone, I think it is
especially helpful for hypopit patients
• Should start gradual, work up
• Some exercise is better than none
Exercise (2)
• Aerobic-walking, treadmill, bicycle,
aerobic videos, dancing, jazzercise
• Weights
– start with 5 pound dumbbells
and do a few sets each day
• *Flexibility-yoga or Pilates
– One patient suggested that as she
started GH, her osteoporosis was
eliminated
– Her bones got stronger, her joints
got stiffer
– Pilates especially helped her
Sleep
• Growth hormone deficient patients
have disturbed sleep
• May be improved with GH treatment
• Go to sleep at about the same time
each night
• Wind down before going to bed
• Avoid night time caffeine, alcohol and exercise
• Fall asleep too late?
– Get morning light, avoid afternoon light
• Fall asleep too early?
– Avoid morning light, get afternoon light
• Melatonin (0.5 mg is probably best dose) is safe and usually effective
• Poor sleep associated with weight gain
Foods
• Eat foods with nutrients/anti-oxidants/vitamins,
not isolated nutrients/anti-oxidants/vitamins
• Healthy foods have other not yet isolated nutrients
• Most studies using anti-oxidants (Vit A, C and E, betacarotene) have been disappointing
• Vegetables
– Orange veggies are good (beta-carotene)
• Sweet potatoes, carrots
– Green leafy vegetables
• Careful! Goitrogens if eaten in excess
in primary thyroid disorders
– Tomatoes
• Lycopenes
Foods (2)
• Fruits
– Citrus may be good for weight loss
• Avoid junk foods
• Avoid night-time eating
• Do your portion control!
Remember, It’s Not Only What You Eat, But
How You Eat
• Savor your food - Enjoy each bite - Look forward to your
meals
• Eat 3 meals a day. If you want to skip a meal, skip dinner (but
no late night snacks to make up for it!)
• Eat only when hungry. Eat only enough to be no longer
hungry (not to be full)
• Eat only in your kitchen, dining room or lunch room table
• Don’t do anything else when eating, besides talking to your
family and friends. Don’t read, work on the computer, talk on
the phone or watch TV
Remember, It’s Not Only What You Eat,
But How You Eat (2)
• Eat slowly - Chew slowly - Take small bites –
Put your utensils down between bites
• Put a small portion on your plate and remove
the serving platter/cooking dish back to the kitchen
• Never eat directly from the common pot (it is also unsanitary)
• Don’t leave food in front of you. This is especially important at
restaurants, where there is usually bread on the table. Ask for
the bread to be removed
• Sip water between each bite. This will fill you up and slow
down your eating
Nutritional Supplements
with Antioxidant Properties
Vitamins
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Coenzyme Q10
Nicotinamide adenine dinucleotide
(NADH)
Vitamin A
Vitamin B2
Vitamin C
Vitamin E
Minerals
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Copper
Manganese
Selenium
Zinc
Amino acids
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Cysteine
Glutamine (glutathione precursor)
Glutathione
Methionine
Taurine
Hormonal
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Alpha-carotene
Beta-carotene
Carotenoids
Melatonin
Lycopene
Miscellaneous
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Alpha-lipoic acid
Grape seed extract
N-Acetylcysteine
Herbs
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Bilberry
Garlic
Ginkgo biloba
Green tea
Milk thistle
Sage
Turmeric
Vitamin E
Summary of The Effects of Antioxidants
as Antiaging Interventions
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No decrease in total cardiovascular mortality
No reduction in risk of stroke
Inconsistent data on the effect on lipids
Inconsistent data on the effect on cognition
Insufficient evidence in the treatment of Alzheimer’s
disease
• Inconsistent data on all-cause mortality
Vitamin C
• No decrease in total cardiovascular mortality
• No reduction in risk of stroke
• Inconsistent data on lipid profile
Carotenoids
• Inconsistent data on risk of stroke
• Increase in all-cause mortality
• Increase in cardiovascular mortality
Vitamin D
• Vitamin D deficiency is quite common,
especially in Northern latitudes in winter
• Older lower limit of normal (10-20 ng/dL) 25-OH Vitamin D
may be too low
• Recent data suggest that levels > 30 ng/dL are optimal
• Vitamin D deficiency may manifest as aches and pains and
fatigue, some of the symptoms hypopit patients have
• Treatment is fairly easy
– 50,000 iU of vitamin D/week for 6 weeks
• High benefit/risk ratio
B12
• B12 deficiency is more rare, especially if
no malabsorption or pernicious anemia
• Many health care providers give B12
regardless of levels
• Requires coming into the office for a weekly
or monthly shot
• I find patients with sky-high levels of B12
– this may not be bad, but I doubt it’s good for you
• High financial benefit/risk ratio for the doctor’s office
• Low benefit/risk ratio for the patient, unless found to be B12
deficient
Iron
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Ferritin-low iron stores
Anemia is a late sign of low iron
Most menstruating women have low iron stores
Iron is needed for thyroid hormone synthesis
BMJ article looked at iron replacement in patients with fatigue
and ferritin < 50 mg/dL with no evidence of anemia
• Iron replacement improved fatigue symptoms in patients with
ferritin < 50 mg/dL, but not in patients with ferritin > 50 mg/dL
• Aim for a ferritin around 70 mg/dL
• See 1st page of goodhormonehealth.com for article on iron
replacement (ferrous sulfate probably not the best option)
DHEA
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DHEA and DHEAS made by adrenals
Most widely used supplement in US
Under control of the pituitary
Measure DHEAS, take DHEA
Most hypopit patients have low DHEAS levels
May help with energy, cognition
Does not have its on receptor, probably works through androgen receptor
I think testosterone is better
– DHEA may help some patients with low levels
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Easy for women to get acne when taking
Men may get high estrogen levels and enlarged breasts (gynecomastia)
Available over-the-counter, but content varies dramatically
25 mg is a reasonable dose in women
Florinef/Salt
• Aldosterone
– Salt-regulating hormone made
by the adrenals
• I’m finding that many patients with
hypopituitarism have hyporeninemic
hypoaldosteronism
– Pituitary may make a factor that regulates renin
from the kidney
• Low aldosterone results in low blood pressure, high pulse,
dizziness on standing, palpations, brain fog, fatigue
• Don’t take if high blood pressure!
Florinef/Salt (2)
• May want to measure renin, aldosterone
• In patients with low blood pressure, may want to give Florinef
(synthetic aldosterone) and/or salt
• Short-term side effects of florinef include headache and leg
swelling
• Salt can be added to food or salt tablets
• Watch blood pressure carefully
Tyrosine
• Helps with stress
• May help with cognition,
mood and memory
• Not well studied
Licorice
• Active ingredient glycyrrhiza
• Only black licorice (European)
• Only helps if on cortisol replacement
(hydrocortisone)
• Inhibits 11beta-HSD2 which breaks down cortisol
• Will allow both endogenous and endogenous cortisol to work
longer
• Do not take if on prednisone!
• Watch for high blood pressure
Omega-3
• Ratio of linoleic acid (omega-6 fat) and linolenic acid
(omega-3 fat) important
• Too much omega-6 fat = inflammation and damage
to organs
• Omega-6 fat in fried foods, snacks and other foods with corn oil
• Omega-3 fat in fish (ocean caught, not farmed), walnuts, fruits and
vegetables
• Can supplement Omega-3 fat
• Omega-3 fat fortified ice cream and margarine have lots of fat and
calories
• Better to eat foods high in Omega-3 fat
Isocort,
Adrenal/Pituitary
Extracts
• Isocort is dessicated adrenal gland
– contains very potent hormones (cortsiol, aldosterone, DHEA, DHEAS,
testosterone
• These are absorbed when taken orally
• The adrenal equivalent of Armour, but adrenal hormones are much
more dangerous
• Adrenal extracts may also have bioactive hormones in them
• Pituitary extracts are probably not bioactive when taken orally (ACTH,
GH, LH, FSH, prolactin, TSH)
• I’d stay away and take what is truly needed
Selenium
• Mineral found in soil, may be depleted in US
• Severe selenium deficiency in Africa leads to goiter and
hypothyroidism
• Selenium supplementation may decrease inflammatory activity in
patients with autoimmune thyroiditis
• Selenium during pregnancy and in the postpartum period reduced
thyroid inflammatory activity and the incidence of hypothyroidism
(JCEM, Feb 2007), even if the patient was not selenium deficient
• Patients with selenium deficiency have decreased T4 to T3
conversion, which is reversed by selenium
• 200 mcg /day
Supplement Summary
• Vitamin D, salt, iron, licorice and
selenium helpful in select patients
• The jury is still out for other
supplements, especially in patients
with hypopituitarism
• More studies are needed
King-Drew Pituitary Support Group
• Support groups are
key!
• Inner-city Hospital
• English and Spanish!
• Start your own
Chat Rooms
• Meet patients with similar problems
– You are not alone!
• Get referrals
– Sheehan’s
– Empty Sella
– Hypopituitarism
Ask the Expert “Chats”
• Possibly MAGIC can host
• Time of chat is publicized
– Patients sign up to ask questions
• Doctors respond
• Transcript of Chat is posted on website
For More Information and
To Schedule An Appointment With Dr. Friedman
• www.goodhormonehealth.com
• [email protected]
• My book on thyroid diseases
– “ The Everything Health Guide
to Thyroid Disease”
– Published by Adams Media
– Available at Amazon.com
A BIG Thanks!
• To Magic Foundation for inviting me and doing great
work!
• To Dianne Tambourine for hosting a great conference
• Stacey Teruya for assistance with graphics
• Lynne Drabkowski and Erik Zuckerbraun for their help
with my patients