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. Matthew Andr MDIU Health Bloomington
MDWeightWoRxBeWell Grant-Centerstone
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2. Physical Activity
.
4. Medical Treatment
.
2. Endocrine/Hormone management
3. Ps chiatric treatment
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’
Com liance
Readiness
Medications
Saboteurs
Discipline
Evolution???
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We have the SAME genetics as those whose geneswere selected for in a “calorie poor” environment.
It believes there will be a famine tomorrow
No “Weight Set Point.” The heavier the better
Energy “Savings Account”
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-
Not about Body Building
’
Not about maximizing hormone levels
’ -approximating “normal”/optimal function indisordered bod s stems
“Too much” can be just as bad as “not enough”
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$$$
CALORIES
SocialTIME!!
IN
Ps chMetabolic
(Hormones)
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Insulin Leptin
NPY
Ghrelin Glucagon
Amylin
c…
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10%
20 PHYSICAL
70%
ACTIVITY
RATE
CALORIES
OUT
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Obesit is a result of ener imbalance. Loss of
Homeostasis. Hormones are substances released from
speci ic p aces in t e o y to cause speci iceffects in different tissues
“ ”
Innumerable hormones involved with weightmana ement.
Improper hormone balance can be a majorcause of weight gain and hinder weight loss.Pro ems arise rom too muc an too itt e.
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Thyroid
Testosterone
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Require high levels of insulin to controllucose.
This causes a reflexive hypoglycemia and leads
to overeatin , es eciall of carboh drates
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Glucose & Insulin Levels in Insulin Resistance
Glucose Insulin
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Hypoglycemia Hyperphagia/carbohydrate cravings
Cortisol release
Increased Fat Storage (incr. lipoprotein lipase) Fatigue
Disrupts other hormone systems
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Delayed rise in glucose due to prolonged digestion Gives insulin more time to work at lower levels
Exercise
Pushes glucose into cells Increased muscle mass improves Insulin Sensitivity
Medications
Metformin, Januvia, Vytorin, Byetta
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Bi uanide. Used for over 50 ears
Can treat AND prevent Diabetes Decreases diabetes risk by one third!!!
Mechanism: Drives glucose into cells and
inhibits glucagon conversion on glycogen to.
Have to have healthy kidneys
Treatment of choice in Insulin ResistanceS ndromes
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anuvia On l za Trad enta et al.
DPP4 inhibitors DPP4 is an enzyme that breaks down GLP-1
They increase GLP-1 Activity
GLP-1: an incretin: released from the gut afteroo n a e o ass s appropr a e nsu nrelease, inhibits glucagon, and SLOWSGASTRIC EMPTYING.
Low risk for hypoglycemia
Safe but subtle and ex ensive!
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“ ”
These are ANALOGUES of GLP-1. , ,
loss, Expensive
Can cause lots of Nausea and vomitting ifclient overeats
Low risk for hypoglycemia
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Energy/Glucose Utilization, Body Temperature,Catecholamine sensitivity, Heart Rate, Fatutilization, Growth, Memory and Concentration
Produces T4 (which the body converts to T3) Production controlled by the pituitary gland
and its release of Thyroid Stimulating
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Low Th roid can be a ma or barrier to wei ht
loss. Low Thyroid Symptoms:
Cold Intolerance, Low BBT
Goiter (from TSH overstimulation)
Menorrhagia
Edema
“Brain Fog” Heart arrythmias
epress on
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Hashimoto’s is Most Common Assessed b levels of TSH lon er half-life than
T4 and T3)
Problem: What is a “normal TSH??” Major debate in Endocrinology currently
Normal values 0.34 mIU L to 5.6 mIU L
What is an Optimal TSH?
Probabl less than 2.0 Some sa less than 1.0
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Iodine Supplementation Synthetic T4 (Synthroid)
Synthetic T3 (Cytomel)
Natural Thyroid (Armour) Compounded Formulations (specific ratios,
individualized per patient)
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Osteoporosis and Osteopenia Dexa Scans, NTx Ratio
Cardiac problems, arrhythmias, cardiomyopathy
Wasting of lean tissue Anxiety
Tremors
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Imbalances in E and P are common during thiseriod.
Estrogen Dominance very common
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New Name?
Insulin Related Sex Hormone Dysfunction Extremel common 4-12% of the o ulation.
(much higher for sub-acute forms)
Leading hormonal cause of infertility High insulin increases GnRH pulse frequency,
raising LH, lowering FSH.
Waldstreicher et al. 1988 Morales et al. 1996
MacArthur et al. 1958, Yen et al. 1970
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Weight Gain Anovulation
Acne
Hirsutism Insulin Resistance/Hyperinsulinemia
Edema
rregu ar pa n u per o s Infertility
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PMS-type symptoms
Edema
Insomnia
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approach menopause. Often P falls farther faster than E. Es eciall if
excess adipose tissue, which produces E)
Occurs des ite monthl c clin .
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Women’s Health Initiative
At least safe, at best, effective for breast cancer
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Think PMS More Serious Risks
Headaches (migraine) Fluid Retention
Endometrial/BreastHyper plasia
Breast Tenderness
Weight Gain (hips)
varian ysts
Insulin Resistance
a gue
Anxiety Endometriosis
Fibroc stic Breasts
Dysmenorrhea
Decreased Libido
Infertility Blood Clots
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Weight Loss High Fiber Diet
Reduce insulin resistance
Avoid extrinsic Estrogens: soy, chemicals, pesticides
Replace/Augment Progesterone itself
Can use progestins (but have significant risks) Natural progesterone
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Males lose about 3% Free T er ear after 40.1
Functions pertaining to weight: Increase lean mass, decrease body fat
Increases insulin sensitivity
Deficiencies lead to fat accumulation, insulin
Can increase appetite
Debate on what are “normal” levels
–. , , – .
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WHI: 2002. Stopped early due to 0.3%/yr riskincrease in breast cancer for women takinPremarin and Provera.
Millions of women told to sto hormones Instructed “smallest dose for shortest time”
Results were extra olated to all hormones
Why??? Not evidence based to do so.
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April 2011 JAMA2011;305(13):1305-1314.
Health Outcomes After Stopping Conjugated
Women With Prior HysterectomyAndrea Z. LaCroix, PhD; Rowan T. Chlebowski, MD, PhD; JoAnn E. Manson, MD, DrPH; Aaron K. Aragaki, MS; Karen C.
ohnson,MD,MPH; Lisa Martin, MD; Karen L. Mar olis, MD, MPH; Marcia L. Stefanick,
PhD; Robert Brzyski, MD, PhD; J. David Curb, MD, MPH; Barbara V. Howard, PhD; CoraE. Lewis, MD, MSPH; Jean Wactawski-Wende, PhD for the WHI Investigators
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HRT is it safe?
April 2011 JAMA2011;305(13):1305-1314.
Estrogens Among Postmenopausal Women WithPrior Hysterectomy
Andrea Z. LaCroix, PhD; Rowan T. Chlebowski, MD, PhD; JoAnn E. Manson, MD, DrPH; Aaron K. Aragaki, MS; Karen C.ohnson MD MPH Lisa Martin MD Karen L. Mar olis MD MPH Marcia L. Stefanick PhDRobert Brzyski, MD, PhD; J. David Curb, MD, MPH; Barbara V. Howard, PhD; Cora E. Lewis, MD, MSPH; Jean Wactawski-Wende, PhD for the WHI Investigators
Premarin only over placebo
ew u e nes
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Multiple New Agents ,
Risks: irritability, erythrocytosis, elevated
No evidence it causes Prostate Cancer. Somethat it decreases it. Can make an active cancer
grow faster Will raise E2 levels as well, close monitorin
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In oun er males <45-50 , can use a ents toincrease endogenous Testosterone production
omi rima ex Clomid – a SERM. Raises LH and FSH
Arimadex – Aromatase inhibitor raises LH
HCG (Human Chorionic Gonadotropin)
Functions like LH in the male Increases T production, partial estrogen reducer
Tends to cause wei ht loss h othalamic moa??
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C closet.
New medication for diabetes. Increases DA activity in the hypothalamus Moves lucose into cells Improves pp glucose w/o increasing insulin! Seems to increase glucose utilization
particularly helpful in circadian misalignment (night shiftworkers).
Scranton, et al, BMC endocrine disorders 2007 Jun 25;7:3