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

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Theodore C. Friedman, M.D., Ph.D.Associate
Professor of Medicine - UCLAChief, Division of
Endocrinology, Molecular Medicine and
MetabolismCharles R. Drew UniversityIs Taking
Growth Hormone Enough?MAGIC Foundation Affected
Adult Convention February 11, 2007
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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

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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 N1 trial on yourself (try them one at
  a time and only continue if you see an
  improvement on it.
• Im fairly skeptical, but will not take someone
  off them, if patient feels they are working
  (unless they are harmful).

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Endocrinologists vs. Anti-Aging Docs

• Anti-Aging Docs
• Measure hormones with less-than-reliable assays
  (salivary or urine assays)
• Often give supraphysiological doses of
  hormones/vitamins
• May lead to high levels

• Endocrinologists
• Measure hormones with reliable assays
• Give patients a hormone/vitamin to restore levels
  to normal
• Monitor carefully and do not over-replace

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My General Approach

• Look carefully for early signs of deficiency
• Replace deficiencies until achieving mid-normal
  range
• Dont treat if not deficient
• Look at risks/benefits of treating

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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

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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

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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

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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, beta-carotene) 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

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Foods (2)

• Fruits
• Citrus may be good for weight loss
• Avoid junk foods
• Avoid night-time eating
• Do your portion control!

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Remember, Its 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
• Dont do anything else when eating, besides
  talking to your family and friends. Dont read,
  work on the computer, talk on the phone or watch
  TV

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Remember, Its 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)
• Dont 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

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Nutritional Supplementswith Antioxidant
Properties

• Vitamins
• Coenzyme Q10
• Nicotinamide adenine dinucleotide (NADH)
• Vitamin A
• Vitamin B2
• Vitamin C
• Vitamin E
• Minerals
• Copper
• Manganese
• Selenium
• Zinc
• Amino acids
• Cysteine
• Glutamine (glutathione precursor)
• Glutathione
• Methionine
• Taurine

• Hormonal
• Alpha-carotene
• Beta-carotene
• Carotenoids
• Melatonin
• Lycopene
• Miscellaneous
• Alpha-lipoic acid
• Grape seed extract
• N-Acetylcysteine
• Herbs
• Bilberry
• Garlic
• Ginkgo biloba
• Green tea
• Milk thistle
• Sage
• Turmeric

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Summary of The Effects of Antioxidantsas
Antiaging Interventions

• Vitamin E
• 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
  Alzheimers
• 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

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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 gt 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

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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 its good for
  you
• High financial benefit/risk ratio for the
  doctors office
• Low benefit/risk ratio for the patient, unless
  found to be B12 deficient

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Iron

• 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 lt 50 mg/dL
  with no evidence of anemia
• Iron replacement improved fatigue symptoms in
  patients with ferritin lt 50 mg/dL, but not in
  patients with ferritin gt 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)

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DHEA

• 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
• 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

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Florinef/Salt

• Aldosterone
• Salt-regulating hormone made
• by the adrenals
• Im 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
• Dont take if high blood pressure!

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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

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Tyrosine

• Helps with stress
• May help with cognition,
• mood and memory
• Not well studied

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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

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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

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Isocort, Adrenal/PituitaryExtracts

• 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)
• Id stay away and take what is truly needed

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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

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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

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King-Drew Pituitary Support Group

• Support groups are
• key!
• Inner-city Hospital
• English and Spanish!
• Start your own

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Chat Rooms

• Meet patients with similar problems
• You are not alone!
• Get referrals
• Sheehans
• Empty Sella
• Hypopituitarism

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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

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For More Information andTo Schedule An
Appointment With Dr. Friedman

• www.goodhormonehealth.com
• mail_at_goodhormonehealth.com
• My book on thyroid diseases
• The Everything Health Guide
• to Thyroid Disease
• Published by Adams Media
• Available at Amazon.com

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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