Received Date: August 25, 2015 Accepted Date: September 10, 2015 Published Date: September 18, 2015
Citation: Leake JP, Greenberg TD (2015) A 21st Century Physician Model for Caring for Aging Patients. Endocrinol Metab Syndr 4:197. doi:10.4172/2161-1017.1000197
Copyright: © 2015 Leake JP, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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“The doctor of the future will give no medication, but will interest his patients in the care of the human frame, diet and in the cause and prevention of disease.”- Thomas Edison
The process of aging well hinges on sound nutrition, exercise, and sleep practices from early in life. Hormones may augment efforts to improve those practices in the aging hormone deficient state.
As physicians we are the contact of many people through their life’s journey. Medical school and residency give us a lifelong foundation for building our knowledge base to serve patients. It is not possible for medical school to cover all topics related to patient care, but there are vacuums of education that need to be filled if we are to truly serve those we care for in life, both professionally and personally. Nutrition and exercise are variables that dramatically impact life long healthy, and are especially important in aging, but not covered in depth in most curriculums. Hormones, which decline in both men and women, beginning in most people by age 35, are discussed but only in the context of extreme conditions and rare syndromes. However, there is a role for optimizing gender specific hormone levels, or minimizing their rate of decline, that is also neglected in our medical school education, but impacts roughly 50% of our lifespan. This text is created to address those educational deficiencies so that we may share the current body of knowledge, address topics that are unsettled in the literature, and give insight from a deep and focused clinical experience.
Testosterone replacement therapy can be a very effective means in not only improving a patient’s health but also improve many quality of life measures. The context in which testosterone replacement therapy is administered however makes a profound difference in the effectiveness of this approach. Our experience in testosterone replacement therapy is almost exclusively done in conjunction with a high quality aggressive lifestyle intervention. In fact, in the manner in which we use Testosterone, it is perhaps more accurate to think of it as an adjunctive therapy to nutrition and exercise. A sound approach to nutrition is perhaps the single most effective means a patient can choose to improve their health and wellness. Exercise comes in a close second, as it is perhaps the most effective way to lower the body’s state of inflammation. The analogy that I often use in describing our approach to our patients is that nutrition is their charcoal and exercise is their match. With those two they can build a fire and cook up an excellent recipe for health and wellness with those two measures. Hormone replacement therapy, and especially in the case of Testosterone, functions much like lighter fluid. It’s an augmenter, an accelerator and enhances the effectiveness of our efforts in the realm of improving nutrition and exercise habits. The effects are synergistic, complimentary and overlapping. Because many of the symptoms of poor nutrition, poor exercise habits and hypogonadism overlap, it’s not always clear what contribution each domain makes to the eventual improvement in the patient’s condition. At the end of the day, I think it matters not if the patient improves their health and wellness and reduces their risk for future disease. Once again, it’s important to keep this context in mind as we discuss the clinical administration of Testosterone replacement therapy.
A 21st century Physician model
By next century we are hopeful that we will be able to look back at today’s approach to healthcare and be astonished at how antiquated and ineffective our efforts were. While we have made many advances in science, the art of delivering healthcare is far behind. Fee for service models, patients not incentivized to invest and maintain their own health, and 3rd party payers incentivized to not pay, are all contributing factors in the global fiasco of ineffective healthcare.
Nutrition is by far the most important modifiable element in aging well. It sounds simple but it is not. Conflicts of interest start at the top, with the FDA and USDA. The FDA is tasked with protecting the consumer but allows a multibillion dollar industry of nutraceuticals to thrive, virtually unregulated. It allowed transfats to be put into food, far longer than it should have. Though transfats have been nearly banned, interesterified fats are now being placed in food products for similar reason. Intesterified fats have been shown to contribute to lower HDL, higher LDL and increased blood glucose levels; all disease markers going in the wrong direction. The USDA is burdened with the impossible task of promoting US agriculture (which includes heavily lobbied sugar, beef and dairy industries); while simultaneously advising the consumer with recommendations of daily intake of food products such as sugar, protein, dairy and fruits/vegetables. Misconceptions about nutrition include the idea that calorie counting is useful. It is not. Nor is a calorie a calorie.
The varying fats, proteins and carbohydrates are both calories sources, inefficiently processed, and messengers or molecules that signal the digestive system and brain how to respond to the ingested food. Many compassionate and intelligent clinicians have also concluded that will power is not central to the solution of the epidemic of obesity, and here we differ. Genetically, we are programmed (some more efficiently than others), to store available calories, in the event of a lack of available calories. Both education and self-discipline are central to changing how we perceive constant bombardment of food availability. Because the obese are metabolically altered by poor nutrition, with chronic inflammation and hormonal imbalances, the challenges of managing their body fat are greater.
However, weight maintenance, after body fat loss, will inevitably require a component of reshaping how food is perceived. Self-discipline is required in the reshaping because of the ubiquitous nature of food, especially highly palatable energy dense (nutrient poor) foods. Plus, isn’t it disempowering not to be accountable for one’s actions? We compassionately disagree with those who say that weight loss is not within the sphere of control of the patient. We recognize the central role of ‘liking’ (hedonics) in appetite regulation, and recognize that desiring a food product can be similar to desiring a drug, though there are fundamental differences. Not surprisingly, we now know we can learn to like foods like spinach, kale and broccoli. MRI’s studies show it.
Weighing in on the global epidemic of obesity, we are struck by how conceptual models are massively influential. When we get them wrong, things go awry quickly. As clinicians, we are well aware that conceptual models we have today are often soon outdated. It is the nature of progressive science. The peer review process and skeptical scientists keep our models evolving. We are among the latter. Time is of the essence in recognizing and correcting failing models.
In the case of obesity, we got it wrong in a big way and only recently have we seen correction of some of the misinformation, but still no real impact on the sprawling epidemic. We used to believe dietary fat contributed to obesity. And, as opportunistic as the food industry is, they began to market low fat foods. What they failed to tell the consumer is that to compensate for lost palatability, sugar was added, as well as artificial colors and flavors. Previously upward trending obesity rates then skyrocketed. Processed food became the norm for people’s diets. Processed food is better described as highly palatable, energy dense, nutrient poor foods. They have no place in a sound nutritional plan.
As recently as the 1950’s physicians advised against exercise, believing it would over stress the heart. Now, we know this is generally not the case (exceptions noted). However, many now have the misconception exercise is a significant part of the solution to obesity. It is not. One cannot exercise one’s way to significant reductions in fat. As a point of reference, the exercise industry’s growth has paralleled the expansion of obesity. Exercise has not even come close to solving the obesity epidemic. There is significant evidence that exercise is central to aging well, but not the answer to obesity. A sound exercise program for the aging adult consists of aerobic fitness, resistance, flexibility and balance training. Exercise improves quality of life substantially, and, secondarily, it reduces mortality.
As recently as 2002, physicians were advising female patients that estrogen and progesterone hormone replacement therapy was unsafe. This advice was provided despite decades of literature data and clinical experience that showed otherwise. The 2002 Women’s Health Initiative’s (WHI) interpretation of data was wrong and sparked a highly charged (and not scientifically founded) rejection of hormone replacement therapy for women. Each year since, more data has emerged showing how wrong the interpretation was, but to the detriment of a missed decade of women that did not receive the benefits of HRT, such as reducing osteoporosis, cardiovascular disease and death. Now we know Hormone Replacement Therapy (HRT) for aging women is safe and have convincingly shown a similar, if not better, safety profile of HRT for men with testosterone use.
As we know, getting the conceptual model right is central to practicing good medicine. New and evolving concepts that need to be a part of each clinician’s model of wellness include understanding how adipose tissue is an endocrine organ, deposit for energy storage, and serves as a major source of pro-inflammatory cytokines. And how muscle is also an endocrine organ, an engine for burning ingested calories and serves as a major source of anti-inflammatory cytokines.
Most importantly, an overarching theme of aging well, like most of medicine, is executed by anticipating and preventing decline. Thus, we introduce a new concept on an old theme, the Leake-Greenberg Window of Opportunity.
‘Patients who are not burdened by significant endothelial dysfunction (vascular disease) or hormone resistant states (insulin, incretin, leptin) are eligible for primary prevention therapies, such as nutritional, exercise and hormone replacement therapies.’
While any patient still can benefit from application of these strategies, their effectiveness and safety are often compromised in a secondary prevention setting.
The aging patients now encounter a wide array of offerings for ‘anti-aging’, which is an absolute disservice to the community of aging patients. Too often the offering reinforces the same model of ‘quick fix’ that promotes fee for service and lack of patient accountability. These services distract patients from true wellness and aging gracefully.
Decline in the efficacy of the endocrine system is the common trend as we age; inevitable in fact. Those changes are best managed preventatively, rather than after the appearance of frank disease. Waiting contributes to the difficulty in reversing preventable problems and contributes to the failure of conventional treatment strategies.
Central to our model are the three cornerstones of a solidly built lifestyle; good nutrition, effective exercise/sleep and individually optimized hormone replacement therapy. Sound nutrition is central to aging well, and that begins with zero processed foods. Exercise is central to maintaining independence and preventing frailty, not to mention hundreds of other benefits. Finally, individuals’ ‘normal’ hormone levels should be maintained for as long as possible through life. The study of hypothyroidism serves as a model for why ‘normal’ levels must be individualized. The allosteric set point for an optimal hormone level is an individual phenomena based upon many factors including; genetic receptor polymorphisms, co-regulators of receptors, intracrine effects and pharmacodynamics. For these and other reasons, reliance on a model based upon a Gaussian distribution of non-hospitalized adults to define a deficiency state as only those in the lowest 2.5% of the population based norm is inadequate, and should be abandoned.
On the more artful side of practicing medicine as clinicians we are obligated to keep each willing patient in the game. For each person aging is a unique journey. While compliance is king and produces the best results, if a patient becomes discouraged and steps away from the playing field, no progress will be made. We acknowledge it may take years or decades to achieve ambitious goals. To that end, even the most accomplished participant needs educated and effective coaches. Sometimes a coach is a trusted personal friend, a partner, a clinician or a team of experts. But regardless of the source, all of us in training need the coaches for support when we slip and to help us achieve new personal bests when we are strong.