Caveat - Nutritional Supplements

1. 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

2. 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

3. 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 N=1 trial on yourself (try them one at a time and only continue if you see an improvement on it. • I’m fairly skeptical, but will not take someone off them, if patient feels they are working (unless they are harmful).

4. Endocrinologists Measure hormones with reliable assays Give patients a hormone/vitamin to restore levels to normal Monitor carefully and do not over-replace 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 vs. Anti-Aging Docs

5. My General Approach • Look carefully for early signs of deficiency • Replace deficiencies until achieving mid-normal range • Don’t treat if not deficient • Look at risks/benefits of treating

6. 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

7. 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

8. 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

9. 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

10. Foods (2) • Fruits • Citrus may be good for weight loss • Avoid junk foods • Avoid night-time eating • Do your portion control!

11. Remember, It’s 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 • Don’t do anything else when eating, besides talking to your family and friends. Don’t read, work on the computer, talk on the phone or watch TV

12. Remember, It’s 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) • Don’t 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

13. 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 Nutritional Supplementswith Antioxidant Properties

14. 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 Alzheimer’s 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

15. 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 > 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

16. 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 it’s good for you • High financial benefit/risk ratio for the doctor’s office • Low benefit/risk ratio for the patient, unless found to be B12 deficient

17. 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 < 50 mg/dL with no evidence of anemia • Iron replacement improved fatigue symptoms in patients with ferritin < 50 mg/dL, but not in patients with ferritin > 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)

18. 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

19. Florinef/Salt • Aldosterone • Salt-regulating hormone made by the adrenals • I’m 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 • Don’t take if high blood pressure!

20. 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

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

22. 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

23. 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

24. 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) • I’d stay away and take what is truly needed

25. 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

26. 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

27. King-Drew Pituitary Support Group • Support groups are key! • Inner-city Hospital • English and Spanish! • Start your own

28. Chat Rooms • Meet patients with similar problems • You are not alone! • Get referrals • Sheehan’s • Empty Sella • Hypopituitarism

29. 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

30. For More Information andTo Schedule An Appointment With Dr. Friedman • www.goodhormonehealth.com • mail@goodhormonehealth.com • My book on thyroid diseases • “ The Everything Health Guide to Thyroid Disease” • Published by Adams Media • Available at Amazon.com

31. 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