the aging athlete: renovating and redefining

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The Aging Adult Athlete David Carfagno,DO,CAQSM Scottsdale Sports Medicine Warthog PCSM 1998

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What happens as athletes age? The physiological changes are important to note, so that training, recovery and overal healthcare can adapt to maximize the athlete's performance year after year. Dr. David Carfagno offers a unique insider's perspective, as a practitioner of sports medicine, internal medicine and a competitive athlete.

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Page 1: The Aging Athlete: Renovating and Redefining

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

Page 2: The Aging Athlete: Renovating and Redefining

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

Page 3: The Aging Athlete: Renovating and Redefining

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

Page 4: The Aging Athlete: Renovating and Redefining

Balanced ApproachBalanced Approach

Anabolic Catabolic

Training, RT/AerobicProtein

HydrationRest

TestosteroneHGH?

Supplementation

Over/No TrainingInadequate Protein

DehydrationNo rest/stress

Low TestosteroneVitamin Deficiency

Page 5: The Aging Athlete: Renovating and Redefining

My Life: Sports Med, Adrenaline

My Life: Sports Med, Adrenaline

Page 6: The Aging Athlete: Renovating and Redefining

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

Page 7: The Aging Athlete: Renovating and Redefining

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.

Page 8: The Aging Athlete: Renovating and Redefining

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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

Page 9: The Aging Athlete: Renovating and Redefining

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.

Page 10: The Aging Athlete: Renovating and Redefining

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.

Page 11: The Aging Athlete: Renovating and Redefining

IronThiamine, Riboflavin, B-6Antioxidants

IL-1, IL-6LactateIGF-1

Athletes

Aging Adult

Vitamin DTestosteroneGHVitamin B-12VO2 maxMitochondrial Fxn

LDLHcys

Page 12: The Aging Athlete: Renovating and Redefining

Aging Adult Athlete

IronThiamine, Riboflavin, B-6Vitamin DVitamin B-12AntioxidantsTestosteroneGHVO2 max

IL-1, IL-6LactateIGF-1HomocysteineLDL, TGs

Page 13: The Aging Athlete: Renovating and Redefining

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.

Page 14: The Aging Athlete: Renovating and Redefining

VO2 MaxVO2 Max• Maximal oxygen uptake. Evaluation of

Cardiopulmonary Fitness

•Measured ml O2/kg/min

Page 15: The Aging Athlete: Renovating and Redefining

Normative ValuesNormative Values

Page 16: The Aging Athlete: Renovating and Redefining

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

Page 17: The Aging Athlete: Renovating and Redefining

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

Page 18: The Aging Athlete: Renovating and Redefining

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.

Page 19: The Aging Athlete: Renovating and Redefining

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

Page 20: The Aging Athlete: Renovating and Redefining

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

Page 21: The Aging Athlete: Renovating and Redefining

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.

Page 22: The Aging Athlete: Renovating and Redefining

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.

Page 23: The Aging Athlete: Renovating and Redefining

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.

Page 24: The Aging Athlete: Renovating and Redefining

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

Page 25: The Aging Athlete: Renovating and Redefining

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

Page 26: The Aging Athlete: Renovating and Redefining

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

Page 27: The Aging Athlete: Renovating and Redefining

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

Page 28: The Aging Athlete: Renovating and Redefining

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

Page 29: The Aging Athlete: Renovating and Redefining

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

Page 30: The Aging Athlete: Renovating and Redefining

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

Page 31: The Aging Athlete: Renovating and Redefining

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

Page 32: The Aging Athlete: Renovating and Redefining

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

Page 33: The Aging Athlete: Renovating and Redefining

•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

Page 34: The Aging Athlete: Renovating and Redefining

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.

Page 35: The Aging Athlete: Renovating and Redefining

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

Page 36: The Aging Athlete: Renovating and Redefining

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

Page 37: The Aging Athlete: Renovating and Redefining

Continuum of Your Life

Where do you want your levels to be?T = 10 ng/dl T = 7000 ng/dl

Page 38: The Aging Athlete: Renovating and Redefining

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?

Page 39: The Aging Athlete: Renovating and Redefining

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…