The goal of your initial clinic evaluation is to identify modifiable risk factors for age-related disease or NCD’s (non-communicable disease). Remember, age-related disease (or the “disease” of aging for perceptive readers) kills approximately 100,000 people daily on a global basis. 100,000 out of the 160,000 daily deaths are due to age-related, potentially preventable diseases.
So let me ask you this question: Are you next?
What steps have you taken to stack the deck in your favor, to slow your biological clock and thwart the aging process? Are you simply awaiting your first bout of crushing chest pain prior to taking action or proaction? Bad plan.
Allow us to help YOU prevent this from occurring.
How? With a systematic approach. This is not a “hormone clinic” as Anti-Aging clinics are often portrayed in the media. Bio-identical hormones are an adjunctive treatment with sometimes life-altering effects, but are only prescribed to those meeting stringent clinical and serologic criteria (and those without contraindications). You see, hormonal optimization is only a piece of the puzzle summarily referred to as HEALTH.
There are many others. If one is missing, your health may falter. Hormone balance and optimization is critical to health but so is maintenance of high insulin sensitivity and low bodily inflammation. All such factors are integral to your health but often neglected. All must be optimized in concert. And it’s not as hard as is often perceived. Why? Because medical technology affords us the ability to test for these risk factors. In fact you can test for two of the biggest—and preventable—risk factors for vascular disease from the comfort of your own home: insulin resistance (prediabetes) and hypertension (high blood pressure). And we’d prefer you do this in fact, between clinic visits. Track your progress on your path to health. Become accountable to yourself.
That is the first step.
Upon presentation to the office, you will undergo a thorough HISTORY and PHYSICAL. Firstly we want to know, in very basic terms, your health and fitness goals. Are you here broadly to become a better you? Are you looking to lose weight? Gain muscle? Thwart off degenerative diseases such as arthritis and atherosclerotic heart disease? Lost that oomph? Or are you looking for a “health snapshot?”
No matter. All patients will undergo a symptom-directed interview in an effort to better clarify your concerns in the context of your goals. Most of you thanks to the accessibility of information (which lines the pages of Get Serious for example) are educated patients. You are aware of the multitude of disease risk factors such as insulin resistance, dyslipidemia, obesity, hypertension (cumulatively known as Metabolic Syndrome), hormonal imbalance and the role of chronic inflammation in the genesis of disease. You are aware that the “disease” of aging is taking its unremitting toll. And you want to intervene pre-emptively under our guidance, averting that first bout of crushing chest pain.
DON’T BE CAUGHT OFF GUARD.
Share your concerns with our qualified medical staff.
Erectile dysfunction, although a touchy subject, may be a harbinger of an impending heart attack. Or it may simply be a matter of age-related hormonal decline or hypogonadism. That said, should you be experiencing male sexual dysfunction, strongly consider an ultrasound assessment (a integral component of the Advanced Package) to rule out peripheral vascular disease (PVD): a major risk factor for stroke and heart attack. Don’t be bashful. Being forthright could save your life, allows us to be responsive to your needs and provide you with the best care.
Dr. Osborn will provide adjunctive care and not in any way supplant that provided by your internist. A physical exam will be performed during your visit, as stigmata of existing disease are often readily apparent. The examination will include BODY ANTHROPOMETRY: Baseline body fat percentage will be established and skeletal muscle mass calculated. Visceral fat (inflammatory fat surrounding the abdominal organs) will be estimated. Why? The answer is two-fold.
One, by establishing a baseline, we can track your progress and assist you in your quest for health.
Two, serial measurements instill accountability. The proof of your hard work is manifest in the anthropometry. Liken this to a high-tech measurement of your waistline…
Equally important data are resident in one’s biochemistry and in the imaging studies. Previously, these tests were either unaffordable or technically unfeasible. No longer. The days of the Tricorder are fast-approaching. A doctor’s prowess will, in the near future, be called upon not to examine a patient, but to interpret the data spit out by “sophisticated” machines such as HAL-9000.
In that context, we move on to the next segment: LABORATORY TESTING and ANALYSIS. By the time you show up for your initial office visit, you will have already given a sample of blood for a battery of laboratory tests.
Why are labs important? Because they give you a biochemical snapshot of your physiology (or pathophysiology). Instantaneously. They are not subjective (as is a medical history); they are objective. Your labs don’t lie. Patients routinely tell me that their diets are “excellent” or that “they don’t eat a lot.” I get an entirely different story from their triglyceride levels, which are a direct relation of their diets. Excessive consumption of refined carbohydrates and animal fats equates to high triglycerides, period. The proof is in the blood. Your serum triglyceride level serves as a looking glass into your gut. I know what you’ve been eating…
As you make strides to improve your insulin sensitivity or blood pressure, you can also lower serum inflammatory markers, improve levels of vitamins with chemopreventive effects and optimize your lipid profile. But first you must establish a baseline to which future testing may be compared. This is particularly important in the context of hormone replacement therapy (HRT). It is nearly impossible to achieve optimal health without taking intermittent snapshots of the inner workings of your body to guide you.
REMOTE LABORATORY CONSULTATIONS WITH DR. OSBORN ARE NOW A REALITY! CLICK HERE FOR DETAILS.
Knowing Your Risk Factors for Disease is an Essential First Step Towards Prevention
Listed below are those laboratory tests that you will undergo prior to your initial clinic evaluation and at points thereafter. Acting as benchmarks of health, such tests reinforce patient accountability.
- C-reactive protein (high sensitivity)
- CBC (with differential)
- Lipid panel
- Basic metabolic panel
- Hemoglobin A1C
- FSH and LH
- Testosterone (free and total)
- Sex hormone-binding globulin (SHBG)
- Thyroid panel with TSH
- Reverse T3
- Thyroid peroxidase
- Thyroglobulin with Anti-TG Ab
- Vitamin D3
* Prostate-Specific Ag: MALES only
** Progesterone: FEMALES only
You’re only as old as your arteries, right?
Think about it. The majority of us die cardiovascular deaths.
According to the World Health Organization (WHO), heart attack and stroke killed 17.5 million people in 2012, that is 3 in every 10 deaths. Of these, 7.4 million people died of ischemic heart disease and 6.7 million from stroke. Scary isn’t it?
Here’s the kicker: Many of these deaths are preventable. Just as we can assess your biochemistry and establish risk factors for disease, so too can we image your vasculature (blood vessels) and quantify the amount of athererosclerotic disease present. The same goes for your heart. How well is your ticker functioning? Do you have peripheral vascular disease or PVD? For those wishing to delve deeper and further identify potential disease risk factors, the clinic offers a thorough cardiovascular assessment inclusive of carotid artery screen, echocardiogram, aortic diameter (aneurysm survey), femoral artery atherosclerotic burden and flow.
This segment of the Advanced Package essentially evaluates “the irrigation” system of the body.
Whether or not the so-called “end-organs” such as the heart, kidneys and eyes functional optimally is a function of blood flow, clean pipes if you will. The brain (the most important organ to a neurosurgeon) in fact demands 20% of total body blood flow at any given moment.
You read that right: The quantum computer between your ears needs a lot of juice. Even a transient alteration in blood flow, seconds in duration, can manifest as a TIA or stroke. And what predisposes you to this? Guess. Atherosclerotic disease and resultant arterial narrowing, akin to the accumulation of gunk in your car’s cylinders or fuel line, the byproduct of usage. Humans similarly accumulate residue on arterial walls that progressively narrows the blood vessels supplying vital organs. At a certain blood flow-threshold, organ dysfunction results.
Here’s the good thing: Ultrasound technology affords us the ability to not only see, but quantify and track one’s plaque burden over time. Do you have an atherosclerotic aneurysm of the abdominal aorta (AAA)? We can tell you. If so, is it of critical size? Does it meet treatment criteria or should it simply be managed expectantly? Ask these questions now. Allow us to give you the answers. Establish a baseline to which future studies may be compared. Aging is an insidious process. For this reason, there is ample time for intervention and more specifically, risk factor modification.
Framingham Score: the origin of the word "risk factor."
These results will be analyzed in the context of your FRAMINGHAM SCORE, a risk assessment tool for estimating your 10-year risk of having a heart attack. The scoring system is based on the massive data accumulated from over 5,000 subjects during the Framingham Heart Study.
“The Framingham Heart Study is the origin of the term risk factor. Before the Framingham Heart Study, doctors had little sense of prevention. In the 1950s, it was believed that clogging of arteries and narrowing of arteries (atherosclerosis and arteriosclerosis) was a normal part of aging and occurred universally as people became older. High blood pressure (hypertension) and elevated serum cholesterol (hypercholesterolemia) were also seen as normal consequences of aging in the 1950s, and no treatment was initiated. These and further risk factors, e.g., homocysteine, were gradually discovered over the years.” [Source: Wikipedia]
Your FRAMINGHAM SCORE is an estimate of the probability that you will develop symptomatic cardiovascular disease within 10 years, inclusive of myocardial infarction (heart attack), angina, heart failure and sudden cardiac death.
Of course, the goal is to identify and preemptively treat the known risk factors (upon which the score is based) prior to your first cardiovascular event. Similar scoring systems exist for dementia. Would you be surprised if I told you that risk factors for dementia are nearly identical to those for coronary artery disease? You shouldn’t be. Both are age-related diseases; the only difference is geography. One affects the pump, the other “the most complex object in the known universe,” your brain. That said, preventative measures for cardiovascular disease are virtually identical to those for dementia. These should be implemented as early as possible given the long prodromal phases of both cardiovascular disease and Alzheimer’s type dementia (AD).
In fact, neuropathological evidence suggests the pathological changes associated with AD may begin as early as the 4th decade of life, but overt clinical symptoms do not present until years later during the 7th, 8th, and 9th decades of life.
With the advent of computerized testing, we are better equipped to detect early stages of possible Alzheimer’s disease, often referred to as Mild Cognitive Impairment or MCI. MCI is an intermediate stage condition between normal cognitive functioning and Alzheimer’s disease or other types of dementia. The probability of a person with MCI transitioning to Alzheimer’s disease is approximately 10% to 15% per year. The proverbial wheels have been set in motion. The key therefore lies in early detection, intervention (through risk factor modification) and continued longitudinal assessments.
Accordingly, the Advanced Package includes a computerized COGNITIVE ASSESSMENT. The neurocognitive testing identifies cognitive impairment by comparing your results to normative data for particular tests:
- Executive functions
- Visuospatial skills
- Reaction time and
- Attentional control
Static impairments in any of the testing modalities, while problematic, are far less concerning than those that decline over time. This in fact, is the hallmark of neurodegenerative disease. It is critical therefore to establish a baseline to which future studies will be compared. You track your blood pressure over time, right? Well, your cognitive function, your processing power, is no different. Consider it yet another measurable “vital sign” which can be assessed serially and tracked.
Putting the Pieces Together
Synthesizing the collected data inclusive of both imaging and physical examination findings (in the context of your complaints) is the final step. Dr. Osborn will formulate a personalized TREATMENT PLAN incorporating those modalities detailed in the pages of Get Serious: Nutrition, Exercise, Stress Reduction and Hormonal Optimization.
Various pharmaceuticals may be prescribed as well. Why? I know you’ve “never been diagnosed with hypertension,” but what about prehypertension? One is classified as prehypertensive with a systolic blood pressure of 120 to 139 mm Hg or 80 to 89 mm Hg diastolic blood pressure. This intermediary category between normotension (normal blood pressure) and hypertension was carries with it an increased risk of heart disease or stroke. In fact, a meta-analysis of 61 prospective studies indicated that mortality from ischemic heart disease and stroke in individuals aged 40 to 89 years increases in a log-linear relationship with BP, from levels as low as 115 mm Hg systolic and 75 mm Hg diastolic. [Huang Y, et al. Prehypertension and incidence of cardiovascular disease: a meta-analysis. BMC Medicine 2013, 11:177].
In English? Even slight elevations in blood pressure (chronically) are associated with increased risk of cardiovascular disease.
And here’s the kicker: It’s silent, flying under the radar and wreaking havoc on your blood vessels. But not if it’s discovered and treated aggressively, stopping it in its tracks.
Choose to be Healthy
How? Proper mindset and lifestyle modifications: good nutrition (conducive to weight loss), daily exercise, stress reduction and smoking cessation. The majority of prehypertensives will respond well to such non-pharmacologic measures that be presented firstly therefore. In the event of treatment failure, the patient will be placed on low-dose anti-hypertensive therapy. Again, the key is risk mitigation.
This is also accomplished through hormonal optimization, as declining levels of sex hormones are associated with age-related disease. Does this prove causality? Absolutely not. But it’s certainly not a spurious relationship. Hormonal decline may be, to a great degree, driving the changes collectively known as “aging.” Or, the decline in hormone levels may be the result of the aging process. No one knows for sure.
This decline may be tempered by exercise. Growth hormone and testosterone in particular may potentially be restored to their youthful levels. Truth-be-told however, this occurs in only a minority of individuals for a variety of reasons. Stress wreaks havoc on the endocrine system for example, countering the effects of exercise. No sleep? The damage is compounded further as cortisol (stress hormone) levels rise and sex hormones plummet. Fatigued, flabby, and forty, you no longer can keep up with your children. But there is hope: HRT or hormone replacement therapy.
I know, you’ve heard that hormones are dangerous, and more specifically that they cause cancer. That if you take testosterone for example, you’re destined, as a male, to develop prostate cancer. Nothing could be further from the truth! This is a myth. No, it’s an outright lie. If taking testosterone causes prostate cancer, then why don’t all adolescent males develop the disease? Their hormones are raging, right? Damn right. This claim therefore defies logic and well… reality.
Estrogen and progesterone have fallen under similar scrutiny, but the merits and flaws of the Women’s Health Initiative (WHI) study however will not be discussed here. Suffice it to say that many women are being deprived of bio-identical hormone replacement therapy, which not only can improve quality of life, but also prevent osteoporosis and its associated morbidities. Part of the problem stemmed from the fact that oral estrogen was utilized in the WHI study, as opposed to a transdermal (routed through the skin) preparation.
Transdermal estrogens, on the other hand, are not metabolized by the liver and do not appear to increase the risk of blood clots according to the recent Kronos Early Estrogen Prevention Study (KEEPS). So stop the madness people! Do not make rash medical decisions based on a flawed study. Instead, discuss the option of HRT with Dr. Osborn. It’s not for everyone, but can make a dramatic difference in the lives of those who opt in.
ARE YOU A CANDIDATE?
Men are easy, women are a bit more complicated, particularly pre-menopausal women.
Yes, they too are eligible; it’s not just for women with hot flashes. In fact, progesterone levels start declining at around age 35, before estrogen! And there are many manifestations of progesterone deficiency: abnormal menses, headache, depression, mood swings, insomnia and loss of bone mineral density to name a few. Experienced any of these? Most women have. And they’re treated with Advil, Prozac and Ambien. Hormone deficiency is rarely considered. It certainly hasn’t been integrated into most medical school curricula.
Physicians are taught that the prostate is a hormone sensitive gland. Testosterone in particular, was vilified in the context of prostate cancer. It “caused” prostate cancer. In actuality, elevated levels of estrogen, not testosterone, may play a major role in the genesis of prostate cancer. And guess what happens to estrogen levels in males as they age? They increase! Males assume the hormone profile of females as they age. Testosterone plummets as estrogen levels rise. Does your husband or boyfriend have “man boobs?” This is often a function of elevated estrogen levels, something easily remedied.
Women, estrogen, progesterone and testosterone.
In women, estrogen, progesterone and testosterone levels fall, placing them at risk for age-related disease as their risk for developing heart disease and related conditions accumulate. This decline can be tempered by hormone replacement therapy, the goal of which is two-fold: restoration and balance. And this is where medicine becomes equally an art, as it is a science. It is sometimes tricky to balance one’s hormones and often times, requires trial, error and lots of patience.
Your hormonal regimen will likely be different from that of your sister. Although you may look alike, her biochemistry is undoubtedly distinct from yours. While you may feel great with a certain dosage and frequency of transdermal estrogen, she may be unresponsive to that particular regimen, or she may have undesired side effects. It’s not about restoring blood hormone levels to normal, as so-called “normal” estradiol levels span a wide range. That being said, your optimal level may be on the opposite end of the “normal” spectrum than that of your sister. Who cares? How you feel is much more important than the actual hormone level. This requires that all-important body mindfulness. You must be in touch with your body, and your doctor must be responsive to your needs.
The same is true for men.
Men have it a bit easier though, go figure. Progesterone is typically not much of a concern, so there is no balancing act between it and estrogen (estradiol). Males typically respond very well to restoration of serum testosterone levels and concomitant normalization of estradiol levels. Bring one up, the other down and voilà, a biochemical restoration of a youthful hormone profile, and often times, a new lease on life. As mentioned above, men too have to be on the same page as their doctors. Hormones do have side effects, although they can be minimized, if not eliminated, by providing your doctor with accurate feedback. An open communication line is mandatory prior to the start of a hormone replacement regimen.
SO HOW DO YOU GET STARTED?
Firstly, you must meet clinical criteria. This is not a “hormone” clinic; one simply doesn’t show up and receive a prescription for testosterone. Provided you meet clinical criteria, have correlative laboratory studies and lack contraindications to HRT, Dr. Osborn will explore this treatment option with you.
Remember, the restoration of a youthful hormone profile is only part of the puzzle. Supplemental testosterone for example, will have far lesser effects in the context of poor diet, poorly regimented exercise (or lack thereof), lack of sleep and other psychological stressors. Contrary to popular belief, it is not a cure-all and certainly does not supplant any of the other requisite factors for health. That said, restoring a youthful hormone profile and more specifically that critical balance, not only has the potential to make you feel great, but also may impede the aging process.
Hormonal balance is associated with health, while lack thereof is associated with disease. Vigorous exercise, proper nutrition and stress reduction techniques tip the scales in favor of a balanced, youthful hormone profile. Along with that come a sharper mind, a more shapely body, better sex and increased energy levels. Any takers?