The Aging Athlete: Renovating and Redefining
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Transcript of The Aging Athlete: Renovating and Redefining
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The Aging Adult Athlete
The Aging Adult Athlete
David Carfagno,DO,CAQSMScottsdale Sports Medicine
Warthog PCSM 1998
David Carfagno,DO,CAQSMScottsdale Sports Medicine
Warthog PCSM 1998
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CDC Healthy People 2020
CDC Healthy People 2020
• By 2030, number of Americans aged 65 and older is estimated to be 71.5 million
• Goal 150 minutes/week of moderate intensity or 75 minutes/week of vigorous exercise or equivalent combination.
• Target 48% of population (Currently 43.5% in 2008)
• Target 35.9% of over 65 yo population (32.6% in 2008)
National Health Interview Survey, CDC, NCHS, 2008
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Continuum of Your Life
T = 10 ng/dl T = 7000 ng/dl
• Cardiac, Pulmonary, GI, Renal, Endo, Vitamins, Minerals, Mitochondrial, Derm
CPA of Physiological Metrics
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Balanced ApproachBalanced Approach
Anabolic Catabolic
Training, RT/AerobicProtein
HydrationRest
TestosteroneHGH?
Supplementation
Over/No TrainingInadequate Protein
DehydrationNo rest/stress
Low TestosteroneVitamin Deficiency
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My Life: Sports Med, Adrenaline
My Life: Sports Med, Adrenaline
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My Life: Internal Med, Pensive
My Life: Internal Med, Pensive
Men’s Health Package ~375 patientsWomen’s Health Package ~75
Executive Physical ~5 corporationsMetabolic Weight Loss Program ~10 q 3 mos
Metabolic Weight Gain Program ~ 5-10 off seasonTeam Physician Package ~25
Fatigued Athlete Package *newOsteoarthritis Package *new
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AGING PHYSIOLOGYAGING PHYSIOLOGYAs we age, our bodies will lose…. Hormones, lean mass, vitamins, strength, mitochondria….
• Strax, T., et al. Physiologic Effects of Aging. Physical Medicine and Rehabilitation Board Review. Cuccurullo S, editor. New York: Demos Medical Publishing; 2004.
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3
Scottsdale Sports Medicine InstituteScottsdale Sports Medicine Institute
•Men’s & Women’s Health Program
•Systems-based evaluation (Attention to prevention of disease and enhancement of the system)
•CardioPulmonary, GI, Renal, Endocrine, Neuro, Ortho, Derm, Cellular Fxn
•Focus on the static as well as dynamic physiology (fueling/exercise)
3
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Effects of AgingEffects of Aging
Strax, T., et al. Physiologic Effects of Aging. Physical Medicine and Rehabilitation Board Review. Cuccurullo S, editor. New York: Demos Medical Publishing; 2004.
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Effects of Aging, cont
Effects of Aging, cont
•Decr↓ # of motor units
•↑ body fat (15% increase at 30, 30% increase at 80)
•Bone density ↓ 0.5% each year after 25
•GH ↓ (155-puberty to 25 @ 55yrs)Hersch, E., and Merriam, G. Growth Hormone Releasing Hormone and Growth Hormone Secretagogues in Normal Aging-
Fountain of Youth or Pool of Tantalus? Clin Interv Aging. 2008 March; 3(1): 121-129
Strax, T., et al. Physiologic Effects of Aging. Physical Medicine and Rehabilitation Board Review. Cuccurullo S, editor. New York: Demos Medical Publishing; 2004.
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IronThiamine, Riboflavin, B-6Antioxidants
IL-1, IL-6LactateIGF-1
Athletes
Aging Adult
Vitamin DTestosteroneGHVitamin B-12VO2 maxMitochondrial Fxn
LDLHcys
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Aging Adult Athlete
IronThiamine, Riboflavin, B-6Vitamin DVitamin B-12AntioxidantsTestosteroneGHVO2 max
IL-1, IL-6LactateIGF-1HomocysteineLDL, TGs
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Effects of AgingEffects of AgingSarcopenia:
• Cross sectional studies of subjects >75 y.o., estimate annual muscle mass loss of 0.8-0.9% in men and 0.64-0.70% in women (Miller, et al, 2012)
• Exercise is essential for rebuilding strength and decreasing risk of falls, CV events and bone loss in elderly pts (Allen, et al, 2011)
Mitchell,W.K., Williams, J., Atherton, P., Larvin, M., Lund, J., and Narici, M. (2012) Sarcopenia, dynapenia, and the impact of advancing age on human skeletal muscle size and strength; a quantitative review. Front.Physiol. 3:260.
Allen J, Morelli V. Aging and exercise. Clin Geriatr Med. 2011 Nov;27(4):661-71.
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VO2 MaxVO2 Max• Maximal oxygen uptake. Evaluation of
Cardiopulmonary Fitness
•Measured ml O2/kg/min
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Normative ValuesNormative Values
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VO2 Decrease w/ Aging
VO2 Decrease w/ Aging
•Sedentary: non-linear loss starting in 20’s/30’s
•Active: non-linear loss upon ceasing activity
•70’s: Lose up to 22%/yr, non-linear regardless of activity
•Baseline 6-10% decline per decade regardless of activity level
Hawkins, S., and Wiswell, R. Rate and Mechanism of MaximalOxygen Consumption Decline with Aging: Implications for Exercise Training. Sports Med. 2003; 33(12):877-88
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Mech of Max O2 Consumption Decline
w/ Aging
Mech of Max O2 Consumption Decline
w/ Aging
•HR max ↓ 3-5% (regardless of exercise or sex) *major role
•Max CO reduced in athletic older adults
•Decreased LBM (up to 35% decline in VO2)Hawkins, S., and Wiswell, R. Rate and Mechanism of MaximalOxygen Consumption Decline with
Aging: Implications for Exercise Training. Sports Med. 2003; 33(12):877-88
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Mitochondrial Dysfxn
Mitochondrial Dysfxn
Mitochondria Function:
o oxidative metabolism creating energy from fat, cho, protein
o Involved with free radical formation
o Thought to be a cause of aging. Cellular death, apoptosis
o “Inflamaging”-Telomere Shortening
Melov S., Tarnopolsky MA. Resistance exercise reverses aging in Human skeletal muscle. PloS ONE, 2007.
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Mitochondrial Dysfxn
Mitochondrial Dysfxn•Endurance exercise partly
normalized age-related mitochondrial dysfunction
•Found to increase skeletal muscle- mitochondrial electron transport chain activity in older men/women
Lanza, I., et al. Endurance Exercise as a Countermeasure for Aging. Diabetes. November 2008. 57(11):2933-2942.
Menshikova, E., et al. Effects of Exercise on Mitochondrial Content and Function in Aging Human Skeletal Muscle. J Gerontol A Biol Sci Med Sci. 2006, June; 61(6): 534-540
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Hormonal “Burnout”Hormonal “Burnout”•Pic of pituitary and hormones and
low T, E, thyroid and HGH• FSH, LH: Estrogen, Testosterone (free & total)• TSH, T4/T3• Cortisol• DHEA-S• IGF-1• Female: Above + Estradiol, Progesterone, Prolactin
.
Bhasin, S., et al. Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology and Metabolism.
June 2010, Vol 95(6):2536-2559
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Testosterone Screening
Testosterone ScreeningA.M. Total & free testosterone
•Tx levels: Total <300, Free <5
• Check the whole hypothalamic-pituitary-end organ axis, determine primary vs secondary failure
• Baltimore Longitudinal Questionairre
•Araujo, A., et al. Prevalence of Symptomatic Androgen Deficiency in Men. The Journal of Clinical Endocrinology & Metabolism 92(11):4241– 4247•Bhasin, S. et al.. Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism. June 2010. Vol 95(6): 2536-2559.
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Not all libido & muscles...
Low T and CV Disease
Not all libido & muscles...
Low T and CV Disease•Low Testosterone found to increase
mortality from cardiovascular disease
•Assoc w/ insulin resistance, metabolic syndrome, and DMII
•Tx improves lipid profile, abd obesity, insulin sensitivity
Hyde, Z., et al. Low Free Testosterone Predicts Mortality from Cardiovascular disease but Not Other Causes: The Health in Men Study. The Journal of Clinical Endocrinology & Metabolism.
January 2012; 97: 1179-1189.
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Benefits of Testosterone Replacement
Benefits of Testosterone Replacement
•Body composition – increased lean body mass (+2.7 kg) and increased fat loss (-2.0 kg) according to ACE systematic review
•Muscle strength – improvement in grip strength than placebo, but no conclusive data on LE muscle mass
•QoL – physical function quality of life questionnaires demonstrated significant improvement after testosterone replacement
Bhasin, S. Cunningham, GR. Hayes, FJ. Matsumoto, AM. Snyder, PJ. Swerdloff, RS. Montori, VM. Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical
Practice Guideline. Journal of Clinical Endocrinology & Metabolism. June 2010. Vol 95(6): 2536-2559.
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Androstenedione/Dehydroepiandrosterone
Androstenedione/Dehydroepiandrosterone
• No increase testosterone levels, strength, or
performance in clinical studies.
• Norandrostenediol/19-norandrostenedione show no
increase in young men
• May increase levels up to 35% in men
age 30-60 years & to lesser degree in women
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Adverse EffectsAdverse Effects
Males
Testicular Atrophy (↓ LH), Decreased spermatogenesis (↓ LH), Gynecomastia (↑ estrogens), Balding (↑ DHT), Dyslipidemia, BPH, Worsening of sleep apnea
Females
Acne, Hirsuitism, Aggressive Behavior, Alopecia
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Human Growth Hormone
Human Growth Hormone
“anti-aging”
OTC HGH
IGF-1
Well-being
Boron&Boulpaep, Medical Physiology, 2nd ed, 2008Juhn, MS. Sports Medicine, 2003
Thickening
IGF-1
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Human Growth HormoneHuman Growth Hormone
• Meta-analysis of 44 studies in the literature on HGH and athletes
• No beneficial in strength or exercise capacity in trained athletes.
• Side effects: soft tissue edema, arthralgias, carpal tunnel, insulin resistance
• .Weaknesses: physically fit (mean vo2 51 ml/kg/min, mean age 27 males, 36 ug/kg dosage, avg duration 20 days.
Systematic Review: The Effects of Growth Hormone on Athletic Performance Hau Liu, et al.
Ann Intern Med. 2008;148(10):747-758. doi:10.7326
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Wellness Screening of Aging Athlete
Wellness Screening of Aging Athlete
•Beyond the standard PCP guidelines?
•USTASK Force guidelines, are they enough to preserve health? Improve?
• Identify the aging athlete
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SSMI MEN’S AND WOMEN’S HEALTH
PROGRAM
SSMI MEN’S AND WOMEN’S HEALTH
PROGRAMInitial Medical Evaluation- 4 hoursInitial Medical Evaluation- 4 hours
History & PhysicalHistory & Physical
Labs may include one or more of the following-Labs may include one or more of the following-
Routine Wellness labs (CBC, CMP, Lipids, PSA) Routine Wellness labs (CBC, CMP, Lipids, PSA)
Hormonal evaluation (Testosterone, Estradiol, Hormonal evaluation (Testosterone, Estradiol, Prolactin, FSH, LH, AM Cortisol, DHEA, IGF-1)Prolactin, FSH, LH, AM Cortisol, DHEA, IGF-1)
Vitamin testing (30+ micronutrients), Genetic Vitamin testing (30+ micronutrients), Genetic MetricsMetrics
Resting Metabolic Rate, Resting Metabolic Rate, Fatigued athlete screening…training and fueling diary
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Annual Medical Evaluation- 60 minsAnnual Medical Evaluation- 60 mins
VO2 submax testing, DEXA Scan Body VO2 submax testing, DEXA Scan Body Composition Testing (GXT/PFT when Composition Testing (GXT/PFT when indicated)indicated)
Lab and Test reviewLab and Test review
Rx for Testosterone based on Endocrine Rx for Testosterone based on Endocrine Society’s Guidelines (see attached)Society’s Guidelines (see attached)
Rx dispensed based on individual Rx dispensed based on individual preference:preference:
Intramuscular InjectableIntramuscular Injectable
Topical Cream or GelTopical Cream or Gel
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Quarterly lab reviews- 30 minsQuarterly lab reviews- 30 mins
Labs may include one or more of the Labs may include one or more of the following following
Testosterone, Estradiol, Vitamin Testosterone, Estradiol, Vitamin TestingTesting
**Certain tests/supplements not **Certain tests/supplements not covered by most insurance planscovered by most insurance plans
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Management:Exercise Implications for VO2 Decline
Management:Exercise Implications for VO2 Decline
•VO2 max significantly greater in active indiv
•CV system adaptable to training at any age
•Strength training to increase LBM-related drop in VO2
Hawkins, S., and Wiswell, R. Rate and Mechanism of MaximalOxygen Consumption Decline with Aging: Implications for Exercise Training. Sports Med. 2003; 33(12):877-88
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•Prescribing Exercise (Elite vs. WW)
•Progression, periodization, adaptation, taper, rest, recovery
• iMETT (portable metabolic testing)
•VO2, AT
•Optimal HR-zones
• Indices to reflect stages (labs, Vit, iMETT improvements)
•ACSM recs: 150min mod aerobic activ/wk
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Management:Mitochondrial Dysfxn
Management:Mitochondrial Dysfxn
o Low Intensity days as we age
o Remove eccentric loading to reduce muscle damage, i.e. 3x/week circuit RT, recovery enhanced.
o Endurax-Combo of Endurance and Resistance. Starting? Initiate with RT to train mitochondria then add Endurance
Melov S., Tarnopolsky MA. Resistance exercise reverses aging in Human skeletal muscle. PloS ONE, 2007.
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Testosterone Tx – ACE Guidelines
Testosterone Tx – ACE Guidelines
Injectables: TestosteroneEnanthate vs. Cypionate
• 150-200 mg IM q 14 daysor 75-100 mg IM q 7 days
Topicals: Typically 1-2%• Fortesta, Androgel, Axiron
• 5-10 g of T gel delivering 50-100mg T q 24 hrs
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Vitamin testingVitamin testing
VITAMINSVitamin AVitamin B1Vitamin B2Vitamin B3Vitamin B6Vitamin B12BiotinFolatePantothenateVitamin CVitamin DVitamin K
AMINO ACIDSAsparagineGlutamineSerine
MINERALSCalciumMagnesiumManganeseZincCopper
ANTIOXIDANTAlpha Lipoic AcidCoenzyme Q10CysteineGlutathioneSeleniumVitamin E
FATTY ACIDSOleic Acid
SPECTROX™for TotalAntioxidant Function
IMMUNIDEX™Immune Response Score
CARBOHYDRATE METABOLISMChromiumFructose SensitivityGlucose-Insulin Metabolism
METABOLITESCholineInositolCarnitine
• Replete with Fuel based (Healthy Food Shopping)• Symptomatic, add supplements.
• Recheck 3 months
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Continuum of Your Life
Where do you want your levels to be?T = 10 ng/dl T = 7000 ng/dl
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Provocative Dialogue
Provocative Dialogue
• “Treating Everyone Fairly doesn’t mean treating everyone the same”
• What is normal
• What is true measure of performance enhancement?
• What role do unique bodies play in this issue?
• 18 yo athlete with testosterone level of 1500 vs 35 yo athlete, same sport with 300?
• What about our non-professional athletes and active population? How far do you go with treatment in a solid clinical, evidence based setting?
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In my opinionIn my opinion
We have the populationAnd the 360 approach.
We need researchOnthe
Athletes we manage,who want to
push the upper limits of normal
on existing replacement Testosterone…