Kenneth Orbeck DO - Greenville Bioidentical Hormones Expert

Holiday Stress

Posted by Dr. Kenneth Orbeck on November 11th, 2011 | No Comments

With the holidays quickly approaching; our minds are filled with excitement, anticipation, and a sense of eagerness to join our family and friends in celebration of the events to come. But along with the excitement we are often exposed to high levels of stress. In the plans that we have to make, deadlines that we have to keep, and frequent entertainment requirements, stress can build during this time of the year to extreme levels. So how can we identify stress? And once stress is identified, what is the impact of stress on our body. Is there a way to organize a stress management reduction plan?

Stress is defined in how the body reacts to an underlying stressful event; whether external, internal, real, or imagined. When we receive a stress stimulus, our body can react in an unhealthy manner. There is both acute stressors and chronic stressors. Acute stressors affect us over the short term while chronic stress affects us over the long term. The impact of stress is certainly important regarding our physiology and health related adverse effects. It is estimated that 43% of all adults suffer stress related health effects. Over 80% of visits to primary care physicians are related to complaints or disorders that are stress related. Stress has also been linked to most of the leading causes of death which include cardiovascular disease, depression and suicide, cancer, pulmonary disease, and accidents. Stress is responsible for over 25 billion workdays that is lost annually in United States, with an estimation of over 1 million workers being absent each day with stress related complaints. The physical impact of stress is very real. When stress affects our brain, there is neural excitability which results in immunoexitotoxicity. This is a reaction between glutamate receptors in our brain and the pro-inflammatory cytokine receptors which causes toxicity in our central nervous system. There is activation of cells called “microglia” which when stimulated release excitotoxins that can cause inflammation and damage to the cells within the brain. Stress can affect our muscles and joints causing inflammation and chronic pain. Since cortisol is a catabolic hormone, it acts to reduce muscle mass and builds fat. As this progresses, chronic inflammatory states often develop. Stress affects our heart and has been linked to cardiovascular disease. Stress certainly affects our stomach and intestinal system altering the digestion and absorption of nutrients, and causes inflammation that may affect our immune system. So as you can see, the physical impact of stress upon our bodies can be quite deteriorating.

So if stress is so important regarding our health status, how can we identify the stress that is within our body? Let’s take a quick look at the origin of various stressors before we discussed the tools that are used to identify stress. Stress can be broken down into three basic origins: psychological stress, physical/ environmental stress, and physiological stress. Psychological stress is any emotional strain which results in anxiety and depression. This is where neurochemical imbalances occur which result in the alteration of various neurochemical pathways. Neurotransmitter testing from the urine will help aid in these imbalances and identify amino acid deficiencies that may be necessary in the recovery process. Physical and environmental stress is related to toxins within our environment that we are exposed to. Our world has become full of environmental toxins that are present in the air we breathe, the water we drink, and the food that we eat. Food intolerances/allergies, sleep disturbances, light cycle disruption, as well as temperature extremes are other forms of physical stress. Physiological stress can originate from chronic infection, underlying chronic inflammatory diseases, neurotransmitter imbalances, lack of sleep, glucose abnormalities/dysregulation, and chronic pain.

Now that we have looked at the origin of stress that can affect our body, let’s examine some tools used to identify stress. An important principle in any management tactic includes the measurement of what is to be managed. The principle that you cannot manage what you cannot measure is certainly true and also applies for stress management. Let’s take a quick look at some basic tools that are often utilized in the measurement of stress which will help define a treatment program. The first is called bioelectrical impedance analysis, or BIA. BIA is a test that measures several values which are related to the biomarkers of aging. These include: Resistance, which measures voltage change that is inversely proportional to total body water; Reactance, which is related to the ability of the cell membrane to store electrical charges; and Phase Angle, which is the measurement of electrical speed of current as it travels through our body’s water versus cells. BIA analysis can give biomarkers of aging which include muscle mass, basal metabolic rate, and fat mass. These are important factors when it comes to stress management as they are affected by our stress hormone, cortisol. Stress can also be evaluated by looking at cortisol in the saliva. Saliva samples are taken in the early morning, noon, late afternoon, and bedtime. Different types of cortisol patterns allow the clinician to identify the severity of the body’s response to underlying stress factors. When incorporated with other types of hormones, such as DHEAS, the information is useful in determining the severity and duration of the underlying stress response. Acute stress usually results in elevated cortisol patterns or the possibility of an irregular cortisol pattern. Chronic stress exposure or higher intensity stress results in a communication breakdown between the brain and the adrenal glands, resulting in a very low and flattened cortisol response. This commonly involves immune system imbalances, which places oxidative stress upon the brain that will eventually lead to damage. A third way stress can be measured is with heart rate variability. We typically like to see good variability in our heart rate as we proceed throughout the day. Immediate physical effects of stressors result in elevated heart rates, increased heart contractions, and an increase in active muscle blood flow and metabolic rate. Poor variability is often related to both stress intensity and duration.

Now that stress is been identified, what can be done to limit the body’s negative response to external and internal stress factors? Here are some common areas frequently looked at when stress reduction is necessary. One area involves the assessment and management of chronic inflammation. I often incorporate G.I. testing here as gastrointestinal issues may be responsible for inflammation within the body. Common inflammatory markers include C-reactive protein, Sed Rate, and inflammatory immune markers such IL6 or IL1. There may be underlying chronic infections present such as intestinal candidiasis, mold exposure, or an underlying viral / bacterial illness which can produce inflammatory stress. Dietary imbalances are often associated with chronic inflammatory stress rosponse, which can be identified by using urinary organic acids. Any type of food allergy or food intolerance will result in a stress response which can be identified utilizing food sensitivity testing. The environment in which we live is highly toxic, and our bodies are often exposed to multiple toxins through the air, water, and food. Various markers can be utilized to identify toxic environmental exposure. Toxic metal exposure can be evaluated with heavy metal testing. Once these areas have been identified, a treatment program can be designed which utilizes the correct detoxification process. This will help reduce the internal stressors of the body. Hormonal balance is also very important. An imbalance in hormones will produce stress within our system. I often find that when we relieve toxicity through various detox programs, and balance the patient’s hormones, recovery will be optimized. One important factor in stress management is adequate sleep. Sleep affects our cortisol, melatonin, progesterone, and magnesium. During sleep our body undergoes repair and we release growth hormone which is a powerful hormone in tissue regeneration. Emotional strain must also be considered in stress issues. I frequently asked my patients to get involved in meditation, biofeedback, and activities such as tai chi or yoga.

As the holidays approach, our stress factors start to escalate. Here are some simple techniques that we can we use to calm the craze of the season? First of all, we shouldn’t sweat the small stuff. Reacting to situations like holiday lines, traffic buildup, and the heightened irritability of those around us should be minimized. Keep your routine as close to normal as possible and allow yourself a good night’s sleep. Get involved in some meditation on a daily basis and schedule time when you can reflect, be alone, and meditate on the things that matter. If you live in a warm climate take off your shoes and allow your feet to contact the earth. As our informational world with computers, cell phones, blackberries, and iPads increase; so does the exposure of electromagnetic force. Allowing your body to have direct contact with the earth helps minimize the stress factors of EMF. Watch the use of alcohol. The holiday season tends to heighten alcohol use and this can have a negative effect on both your physiological health and the ability to sleep. Finally, if you have lost a loved one, then the holiday season can be very difficult. In this situation I usually advise my patients to remember to remember. Be open about your feelings and discussed with your loved ones memories and situations that you have enjoyed about the person who is gone. Finally, celebrate wisely. Bigger is not always better, and the simple things during this holiday season will often bring you the most joy. I hope you and your family have a wonderful holiday season and I wish you blessings in the year to come.

What’s Your Diabetic Risk Score?

Posted by Dr. Kenneth Orbeck on November 5th, 2011 | 2 Comments

Diabetes has become a major health concern in the United States with a significant increase in prevalence, resulting in serious health complications regarding morbidity and mortality. The cost of healthcare in the United States is rapidly rising regarding diabetic care. Over 20 million Americans are thought to have insulin resistance, which precedes the onset of diabetes. Please see my recent blog entitled “The Down and Dirty of Diabetes”. Testing is now available to determine your diabetic risk in giving a score which can be utilized in treatment plans to prevent the onset of diabetes.

I’d like to discuss with you the pre-DX or diabetes risk score test now available. Since diabetes is a disease which is related to inflammation and oxidative stress within the body, measuring some of the stress factors and hormones can give a precise calculation of the likelihood to develop diabetes in the future. This testing is indicated for patients who are not yet diabetic but may have risk factors that lead to the onset of diabetes. Some of these risk factors include obesity, heredity, underlying thyroid disease, lack of exercise, and advancing age. After obtaining basic blood work, the recommendation of pre-DX testing may be necessary. When I look at my patients metabolic profile, if they’re fasting blood sugar becomes elevated between 100 and 125mg/dl, or their two-hour postprandial glucose is between 140 and 200mg/dl, further testing is necessary. I also consider patients with a BMI (your weight in relation to your height) of greater than 27 who have a family history of diabetes to be a candidate for this testing. I look at blood pressures that are greater than 130/85 as additional risk, or patients currently being treated with antihypertensive therapy. Lipid analysis is also important as elevated triglycerides, elevated total cholesterol, and elevated LDL are risk factors as well. Anyone who has metabolic syndrome which includes hypertension, hyperlipidemia(high cholesterol), obesity, or impaired fasting glucose are candidates for pre-DX testing. A common blood test utilized to assess the stability of blood sugar is the HgbA1c. When this level begins to climb, usually above 5.8, you have pre-diabetic risk. Levels above 6.5 usually indicate that one already has diabetes.

Pre-DX testing gives you a calculated risk score on a scale of 1 to 10. A lower score is associated with a lower risk of developing diabetes. As the risk score increases, further testing is necessary. High risk scores are correlated to a score of 8 to 10, and aggressive nutritional and exercise intervention is necessary to prevent the onset of diabetes. Interventional methods and follow-up varies according to the risk score of each patient. The risk score is calculated on the basis of underlying biomarkers. The first biomarker we look at is glucose levels at a fasting state. Fasting glucose of greater than 100 mg/dL, increases your risk of developing diabetes by as much is 70 to 80%. HgbA1c is also considered a risk factor as this increases when the glucose in our bloodstream fluctuates. There is concern when the HgbA1c is greater than 5.7. Fasting insulin is also an important measurement. Before glucose becomes abnormal, insulin rises in the bloodstream to keep glucose under control. In the initial phases of pre-diabetes, fasting insulin levels are often reported elevated. I am concerned with fasting insulin levels greater than 10 uIU/ml. Adiponectin is a hormone secreted by healthy fat cells that increases insulin sensitivity. High levels of adiponectin protect against the development of type II diabetes. Adipopnectin levels below 5.2 mcg/mL, increases your risk of diabetes. Ferritin is an iron binding protein that when consistently elevated, corresponds to the risk of developing type II diabetes. C-reactive protein is a marker of systemic inflammation. Since diabetes is an inflammatory disease, persistent elevation of CRP is a strong indicator of future diabetic developement. I’m often concerned with levels greater than 2 mg/L. Interleukin 2-Receptor Alpha (IL-2Ralpha) is a fragment of the receptor for the pro-inflammatory marker interleukin-II. This is also an indication of inflammation that may lead to the development of type II diabetes. After complete analysis of all these biomarkers, a risk score is given to each patient. This can then be utilized to develop a systematic and comprehensive approach in the treatment of glucose metabolic derangements. Certainly with the available testing that we have today, early intervention is not only critical, but essential in reducing the impact of this dreadful disease. If you or your loved ones have any of the risk factors listed above, consider further testing and obtain your pre-DX score. You can change the direction of your future health!

Is Your Elevator Stuck In The Lobby?

Posted by Dr. Kenneth Orbeck on November 4th, 2011 | No Comments

Picture yourself having a beautiful romantic day with your wife or significant other. You come home at night and sit around a quiet table having a romantic dinner. As the night progresses, nervousness and anxiety build up within your mind because of past experience you may have had regarding erectile dysfunction. If the romance in your life is going south because of issues regarding ED, there is help. ED is an inevitable part of the aging process, but there are many contributing causes which can be addressed and corrected. More than 30 million men in the United States are affected by ED, and most cases are treatable.

Although erectile dysfunction can have a detrimental effect on the romantic and sexual side of your relationship, there may be much more serious underlying medical conditions that may coexist with erectile dysfunction. I find it crucial to take an in-depth approach with the patient who complains of erectile dysfunction. ED may be a sign of dangerous blockage in other areas of the body regarding vascular diseases. Taking the time to investigate and address these issues may not only remedy the erectile dysfunction, but also may save the patient’s life. The physiology behind an erection is complex, and involves the convergence of multiple pathways involving the autonomic nervous system, the vascular system, and a cascade of hormones and enzymes. Hormonal optimization is critical in both libido and erectile function. More commonly, however, I find problems with either the vascular system or the autonomic nervous system. There are multiple treatment plans that can be initiated to address these areas if they are compromised. Please see a recent article that I wrote called “Treating Erectile Dysfunction” for further information in understanding and treating erectile dysfunction. If ED has affected your life, please seek medical attention as additional workup is recommended and your vascular health may be in trouble. A comprehensive metabolic evaluation to include screening for the risk of diabetes, hypertension, and vascular disease is important for all men with issues of ED. The good news is that treatment is certainly available, and the confidence can be restored regarding your performance in the sexual side of your relationship

The Down and Dirty of Diabetes

Posted by Dr. Kenneth Orbeck on November 2nd, 2011 | 2 Comments

With the incidence of diabetes rising in the United States, it is becoming a major health concern as diabetes causes an increase in both morbidity and mortality. The United States is currently spending more than $100 billion annually in the cost of diabetic care. Twenty to twenty five million Americans are thought to have insulin resistance, which is a precursor to the development of diabetes. The average annual healthcare cost for a single diabetic and United States is approximately $12,000 per year. Diabetes is responsible for more than 30 million doctor visits per year, making it one of the leading health concerns that we have today.

Diabetes is a disease related to oxidative stress and free radical damage within the body. This results in high levels of inflammatory chemicals, nutritional deficiencies, and lazy chemical pathways. As we continue to eat more fast food and prepackaged foods in United States, reduce our level of exercise, and utilize insecticides and pesticides as well as added hormones in our food processing, the risk of a metabolic breakdown resulting in diabetes increases. Diabetes takes on many different faces: the first is known as prediabetes. Approximately fifteen million American people have prediabetes; also called hyperglycemia, insulin resistance, or hyperinsulinemia. Pre-diabetic blood sugars range between 100 and 125mg/dL. Blood sugar must get into the cell to work efficiently in producing energy. Our pancreas manufactures insulin that drives blood sugar into our body cells. In a prediabetic state, the insulin simply cannot open the door of the cell allowing the blood sugar in. Blood sugar then hangs out in the bloodstream where it is turned into triglycerides by the liver and stored as fat in the body. New testing is now available called a Pre-DX (or diabetic risk score analysis) to assess your level of risk in developing diabetes. This analysis includes biomarkers of glucose, hemoglobin A-1 C, insulin, ferritin, inflammatory markers and hormones that allow us to determine diabetic risk. After complete analysis of these markers, patients are given a risk score which allows the physician to implement both nutrition and exercise therapy designed to prevent of the development of diabetes mellitus. Prediabetes can also lead to metabolic syndrome. Metabolic syndrome is a diagnosis related to insulin resistance, abnormal blood lipids, obesity, and hypertension. In this state, oxidative stress markers such as homocysteine are often elevated.

The second form of diabetes is called diabetes type II. This form of diabetes is rapidly rising in America. Our pediatric population rarely developed type II diabetes in years past; however, now this is a common clinical diagnosis. Prediabetic individuals often go on to type II diabetes, and this is now the most common form of diabetes in the United States today. In diabetes mellitus type II, fasting blood sugars remain at or above 126 mg/dL. As excess sugar builds up in the bloodstream, it is converted to high cholesterol and high triglycerides. The continual rise in insulin is what makes a person gain weight. In this situation weight gain is not as much related to fat intake as it is to sugar intake. Diabetes mellitus type II is about inflammatory chemicals and free radical damage which gives us low levels of protective antioxidants. This type of diabetes affects the body’s cholesterol, the hormones, and the circulation. In type II diabetes are brain misinterprets a “feel-full” hormone called leptin. Leptin tells our brain that we need to stop eating. If your brain cannot respond to this hormone properly, you will keep eating and eating giving a greater rise to blood sugars, fat storage, and weight gain.

Type I diabetes( also known as juvenile diabetes) affects approximately three million Americans and occurs more frequently in children and adolescents. In this form of diabetes, the insulin producing cells in the pancreas called the beta cells, become damaged and unable to produce insulin. This is usually related to some type of autoimmune disease affecting the pancreas. In type I diabetes, blood sugar will remain elevated unless insulin is given to the patient through injections. Lack of insulin can be life-threatening.

Diabetes type I.5, also called latent autoimmune diabetes in adults (LADA), is becoming more prevalent and is related to autoimmune diabetes in adults where there is a development of antibodies against the pancreas. This type of diabetes often takes years to develop it is often misdiagnosed unless the patient undergoes a C-peptide assay. C-peptide markers give information about endogenous insulin production from the pancreas. This is a definitive test to distinguish between type I and type II diabetes. In type II diabetes, insulin levels are often high in the level of C-peptide will be normal to high as well. Type I diabetes does not have adequate insulin and C-peptide levels are low.

One of the new kids on the block is called diabetes type III. There are studies showing that insulin is produced by the brain as well as the pancreas. This confirms the connection between impaired glucose metabolism and impaired thinking. Type III diabetes could be the underlying causative factor in some people currently diagnosed with Alzheimer’s disease. As a person becomes insulin resistant, both blood sugar and insulin rise in the bloodstream, but the insulin in the brain falls below normal levels. This causes a breakdown within the chemicals of the brain and proteins accumulate called beta amyloid protiens. These are destructive compounds to the brain and are often seen in patients with Alzheimer’s disease.

The risk factors associated with diabetes or any underlying blood sugar disease include the following:

Increasing age increases the risk of diabetes. Since both diabetes and many other degenerative diseases are based on free radical damage, growing older simply allows more free radical damage to occur. This is why intermittent detoxification protocols as well as excellent nutrition is vital in the prevention of diabetes and chronic disease.

Being overweight and having abdominal obesity also increases your rate of diabetes. Your BMI (which measures your weight in relation to your height), is closely associated with the measurement of underlying body fat. An adult with a BMI between 25 and 30 is considered to be overweight, while an adult with a BMI greater than 30 is considered to be obese. Certainly in looking at the waist/ hip ratios, there is good correlation to the development of diabetes as well. Higher weights may be acceptable in individuals who exercise and have more muscle mass. Individual such as bodybuilders should utilize other methods to determine total body fat as BMI calculations are often inaccurate.

Lack of exercise is also an important risk factor in the development of diabetes. Exercise allows the insulin to become more effective and also places our body in greater demand for energy which requires blood sugar. It has been shown that just one hour of exercise per day for one week starts to increase the beta cell function in insulin sensitivity.

Heredity is important in the development of diabetes. If you have a family member who has been diagnosed with diabetes, you are at greater risk as well. This risk can be reduced by lifestyle modification.

Sleep habits are important in diabetic risk. Sleep deprivation has been shown to impair both glucose tolerance and the effective insulin. Sleep deprivation has been linked to hypertension, depression, and cardiac disease as well.

Thyroid conditions also can cause diabetes. As your metabolism becomes sluggish with low thyroid, you cannot burn fat properly and your insulin begins to rise. Autoantibodies against the thyroid can lead to thyroid abnormalities as well. These antibodies (known as TPO antibodies), have been reported in a large percentage of people with type I diabetes.

So what can be done in the prevention and treatment of diabetes mellitus? Exercise and nutrition is foundational in both the treatment and prevention of diabetes. Reducing refined carbohydrates is important and replacing these with complex carbohydrates is often beneficial. Avoiding high fructose corn syrup is certainly important. I asked my patients to stay away from artificial sweeteners such as Aspartame, Splenda, and Saccharine, and replace with Stevia or Xylitol. Nicotine should be avoided as it increases insulin resistance. Caffeine should be limited as this also increases insulin and increases stress hormones. Supplementation that has been shown to be beneficial include chromium, lipoic acid, magnesium, vitamin D, taurine, and arginine. Chromium will help decrease the craving of carbohydrates. It is inexpensive and highly effective. Alpha lipoic acid helps in the metabolism of fat and helps protect against diabetic neuropathy. Vanadium has been shown to enhance insulin sensitivity. Vitamin D supplementation is often required and I often attempt to achieve vitamin D levels greater than 70 in my diabetic patients. Good quality multivitamin and trace metals mineral supplementation is important. Hormonal balance is also important in diabetes, and testosterone has shown to be quite effective in insulin resistance. Glucose control is critical and should be monitored and regularly when treating diabetes. Then use of insulin and/or pharmaceuticals is often necessary.

Diabetes is a metabolic condition that begins with simple metabolic alterations and leads to a full-blown disease. Understanding your risk factors, modifying your lifestyle, and becoming an active component in your metabolic health, can greatly reduce your risk of the development of this dreadful disease. Proper nutrition and exercise is the mainstay in prevention, and knowing your risk is extremely beneficial in prescribing lifestyle modification. Do you know your diabetic risk? Get tested and find out!

Got Gut?

Posted by Dr. Kenneth Orbeck on October 28th, 2011 | No Comments

The practice of metabolic medicine involves the optimization of metabolic pathways to allow our body to function at its maximum performance. Among many other things, this requires the adequate supportive nutrition such as vitamins, minerals, fatty acids, and amino acids. Since our intestinal system is the gateway which allows nutrition into our body, this is foundational in any metabolic medical practice. I have personally found that intestinal health is one of the most important factors in allowing an individual optimal health and recovery from any disease.

Intestinal health can be quite complex, however, and a systematic approach must be utilized to achieve successful outcome. Gut health is influenced by many factors. This includes environmental toxins, pharmaceutical agents, friendly versus non-friendly bacteria, the possibility of underlying pathogens such as yeast and parasites, and the integrity of our intestinal lining which allows for both nutrient transport and the barrier of intestinal toxins. If the integrity of this intestinal lining has been compromised, our immune system is altered and an inflammatory condition begins to exist within our body. Approximately 70 to 80% of our immune system lies within the gut. Since there is only a one cell layer dividing the inside of our intestinal area from the rest of our body, the integrity of this barrier is extremely important. A break in this barrier will allow an inflammatory condition which can set up our body for many types of inflammatory and immune modulated diseases. It is important to note that the same organ system which delivers nutrients into our body, also allows for the removal of toxins out of our body. This system is highly complex and requires proper maintenance in the form of optimal nutrition as well as reducing toxic load.

The four foundational pillars of G.I. health include digestion and absorption, elimination, microbial balance, and gut integrity. Our dietary habits are extremely important and require a good nutritional source within our foods. We must limit processed foods that we consume, ingest foods with a low toxic burden, and maximize foods with a high nutritional content. I often utilized fresh seasonal foods within my patient’s diet, and increase foods that are very colorful which makes them antioxidant rich and anti-inflammatory. Fiber consumption is important as well. As there are many diets endorsed today, the Mediterranean diet seems to be fairly well balanced giving the body its basic nutritional needs. Eating habits remain very important and are often sacrificed in today’s society. We should spend more time with our food and reduce rushing through our meals. Eating regular meals is also vital. Chewing adequately is important as this is the beginning of digestion in our mouth through mastication and oral enzymes. Food allergies, intolerance, and sensitivities must be considered and eliminated to reduce inflammatory conditions within the gut and within the body. Gluten / Gliadin sensitivity and immune reactions must also be analyzed as this is associated with many types of inflammatory and immune related diseases. Allergy and gluten testing is foundational in the practice of integrative and metabolic medicine.

As food exits our mouth down the esophagus, it enters our stomach for continual digestion. Low stomach acid is very important for the continual digestion of protein as well as the absorption of minerals and vitamins. Reduced stomach acid occurs as we age and often is resulting from the use of many acid blocking medications in society today. Common symptoms of hypochlorhydria (low stomach acid) is bloating, a sense of fullness after eating, multiple food allergies, intolerance to supplements, chronic intestinal parasites or yeast, acne, and weakened / cracked fingernails. I often see many types of diseases such as asthma, dermatitis, diabetes, gallbladder and liver disease, thyroid disease, and different autoimmune conditions related to hypochlorhydira. As food exits the stomach it passes into the small intestine where it is combined with pancreatic enzymes and bile salts for further digestion. Pancreatic insufficiency reduces the ability of further breakdown in our digestion of protein and fatty acids. This results in abdominal discomfort, decreased absorption of nutrients, abdominal distention and flatulence, as well as fatty stools which may be foul-smelling. The small intestine is responsible for transport of nutrients into our body. The intestinal mucosal integrity is vitally important in this process. When this delicate cell layer is damaged, intestinal permeability or leaky gut will occur. This is commonly associated with different types of inflammatory bowel diseases. Various immune modulated diseases such as rheumatoid arthritis, Crohn’s disease, or ankylosing splondylitis can occur. Food allergies, psychological and dermatological conditions, and underlying infections are also common. Testing for intestinal permeability and mucosal integrity is very important in the function of integrative healthcare. Toxic burdens within our food and water must be addressed for proper intestinal health as well as proper metabolic function within our body. Toxic burdens are present in the food we eat, the water we drink, and the air we breathe. Please refer to an article that I recently wrote called Today’s Toxic World for further information on toxic burden and its effects.

After proper functional testing and understanding the state of one’s intestinal health, rebuilding the digestive health of our body requires a systematic approach. There are four basic components to this process. The first is the removal of any allergens or toxins. I often use an elimination diet or detoxification protocol to remove this toxic load. After addressing any underlying harmful organisms through stool testing; any pathologic bacteria, parasites, or yeast organisms must be removed. We then should assess acidity and pancreatic enzymes that are necessary for continual digestion. The bowel often requires re-inoculation with friendly bacteria. This requires various species such as Bifidobacterium, Lactobacillus, and Saccharomyces to allow for continual further digestion of food and transport. As previously stated, gut integrity remains vital to intestinal health. Repairing any breakdown within this mucosal layer is necessary to allow for proper intestinal absorption, elimination, and reduction in inflammation.

As you can see intestinal health can be fairly complex. With proper functional testing and accurate assessment, a systematic approach can be outlined for optimal outcome. Bowel health remains vitally important to the overall health of our body. It is often quoted that we are what we eat, and I certainly agree with this statement. Ask yourself the question: what toxic exposure do I have and what has it done to my intestinal health? A healthy gut allows for a healthy body.

Is Your Ticker on Testosterone?

Posted by Dr. Kenneth Orbeck on October 27th, 2011 | No Comments

Did you know that there is a link between low testosterone cardiovascular disease? In looking at coronary risk factors as reported in cell biology and vascular biochemistry and 2011, testosterone deficiency has been reported as a significant risk factor. Sub-optimal testosterone increases the risk of hypertension, obesity, insulin insensitivity, and diabetes. Multiple links have been reported between that of low testosterone and cardiovascular disease. Cardiovascular disease has actually been shown to be an immune- inflammatory condition, and immune modulation is certainly important in the treatment and prevention of cardiovascular disease and vessel plaque. While LDL is important in cardiovascular disease and cardiovascular protection, it is the oxidation of LDL that allows for the formation of vessel wall plaque. Any inflammation within the body or inflammation in the immune system allows for greater oxidation of LDL. As LDL becomes oxidized, it signals the immune system to attack similar to that of any bacteria or virus. When this occurs, the macrophages of our immune system engulf the LDL, which then forms a foam cell that is highly atherogenic. The heightened immunity which allows for this to occur is through our cell mediated immunity or TH1. We can actually measure this heightened response of our cell mediated TH1 immunity through various markers. These markers include C-reactive protein, IL-6, IL-1B, and TNF. Inflammatory states which gives rise to these markers are independent risk factors for coronary artery disease.

Recent studies have allowed us to evaluate testosterone and immune modulation. When testosterone is optimized, there is a reduction in IL-6, IL-1 B, and C-reactive protein. This indicates a down regulation of our cellular mediated immunity and balances our immune system. When this happens, LDL is less likely to be oxidized, and there is cardiovascular protection. Since many autoimmune diseases such as rheumatoid arthritis behave in a similar fashion, testosterone replacement has been beneficial in these areas as well. Animal studies designed to look at testosterone in experimental atherosclerosis, confirm both plaque reduction and stabilization with testosterone replacement.

In looking at the clinical effects of testosterone optimization and cardiovascular disease, these patients showed increased treadmill time, a reduction in the frequency of ischemia and chest pain, a reduction in the use of nitroglycerin, and improvement in the symptoms of congestive heart failure. The non-cardiovascular clinical effects included more energy, a reduction in clinical depression, a better sense of well-being, improvement in both bone density and muscle strength, and improvement in memory. Testosterone has been clearly linked to improvement in abdominal obesity. Abdominal obesity in men causes an increased risk of cardiovascular disease in insulin resistance that is linked to low testosterone.

Although testosterone is often regarded as a hormone to improve sexual function in men, many other beneficial effects have been clearly documented to improve quality of life and reduce end-stage disease such as cardiovascular disease, insulin resistance, and diabetes. Testosterone is a powerful immune modulator and reduces inflammatory stress on the body. Optimal levels of testosterone with careful monitoring and properly delivered, can certainly enhance the quality of your life and help you live better and live longer.

“Dem Bones, Dem Bones”

Posted by Dr. Kenneth Orbeck on October 20th, 2011 | No Comments

Did you know that the first symptom of osteoporosis is a broken bone? Osteoporosis is now considered to be the second leading public-health concern to that of only cardiovascular disease. Morbidity and mortality from fractures increase by over 20% after a hip fracture. Did you know that most fractures occur in women with osteopenia, who have not been diagnosed with actual osteoporosis.

As we age, hormones that continue to increase are cortisol, FSH, LH, and parathyroid hormone known (PTH). Bone is active and alive metabolically and provides a storage system for the calcium within our body. This calcium concentration is in a steady equilibrium and governed by three very important hormones: parathyroid hormone from the parathyroid gland, calcitonin from the thyroid gland, and calcitrol from the kidneys. The most important of these three hormones is the parathyroid hormone. There are detectors within the parathyroid gland to monitor calcium. As our blood level calcium decreases, this triggers the release of parathyroid hormone which acts directly on the osteoclasts of our bone to release calcium into the bloodstream (known as resorption). Continual stimulation of parathyroid hormone on the bone will cause a reduction in the bone density and weakening of the bone. Calcitonin, on the other hand, will directly stimulate osteoblasts which builds bone.

Osteoporosis is also link directly to immunosenescence. Immunosenescence is a consequence of chronic immune system stimulation which produces inflammation in our body from pro-inflammatory cytokines. One way to measure this inflammation is with C-reactive protein. Studies show that there is an inverse correlation between levels of CRP and bone mineral density. As our hormones decline, inflammation begins to increase. This leads to an imbalance between bone formation and bone loss, resulting in the development of osteoporosis. Osteoporosis is a disease characterized by a reduction in bone mass, a reduction in the bone structure, and an increase in both bone fragility and in fracture risk. There is also a direct link between bone loss and the loss of muscle mass called sarcopenia. In fact, the impact of osteoporosis involves the loss of muscle, the loss of collagen, and the loss of bone. Recent studies involving individuals with muscle loss(sarcopenia), show that these individuals have the same or even greater fracture risk as someone with osteopenia. As we age, there is often a reduction in total energy expenditure. Along with reduced physical activity, there is a reduction in the basal metabolic rate. As caloric intake is maintained, a progressive decline in muscle mass will occur with an increase in fat mass. Although a person’s BMI may still be and the normal healthy range, the patient may actually have sarcopenic obesity. This is where the body mass may be preserved, but there’s a greater amount of fat and less amount of muscle.

New therapies in both the treatment and prevention of osteoporosis and osteopenia are encouraging. Bio-Identical Hormonal optimization remains foundational in the treatment and prevention of bone and muscle loss. The two greatest risk factors for developing osteoporosis are aging and estrogen deficiency. Estrogen has a direct inhibition of osteoclastic activity reducing bone resorption. Progesterone and testosterone are direct stimulators of osteoblasts and maintain and build bone. Certainly bio identical hormonal optimization as well as proper nutritional supplementation should be instituted at an early enough age to prevent both osteopenia and osteoporosis from occurring. Nutritional supplementation is also an important factor in both osteoporosis reversal and prevention. Vitamin D together with calcium helps protect older adults from osteoporosis. Vitamin D also helps maintain skeletal calcium balance. Boron is important in preventing in alleviating both osteoporosis and osteoarthritis due to its effects on calcium metabolism. Strontium, along with calcium, work together in calcium absorption which is important in both the prevention and treatment of osteoporosis. Strontium also stimulates the production of cartilage. Vitamin K is important in bone health as vitamin K facilitates the transport of calcium from the bloodstream into the bone. Individuals with low vitamin K have been shown to have increased circulating levels of osteocalcin. This has been shown to be associated with increased bone loss in postmenopausal women.

There is no doubt that the maintenance of our musculoskeletal system is vital as we age. Both bone loss and muscle loss have serious consequences not only in the quality of our life, but also in the morbidity and mortality associated with bone fractures. Bone mineral density testing through DEXA scans is highly encouraged and should be routinely checked in the management of your bone health. What is your fracture risk? By undergoing the proper osteoporosis diagnostic profile, you can find out and begin treatment before it’s too late.

Menopausal Madness

Posted by Dr. Kenneth Orbeck on October 13th, 2011 | No Comments

Are you a woman of middle age or maybe even older who feels like your health is just slipping away? If everything up north is now going south, and you have lost your overall vibrancy and spark of life, hormonal imbalance may be your problem. With all the conflicting reports regarding hormones and replacement, it is no wonder it drives most women crazy. There is little doubt that hormones are highly effective in age management, as they directly enhance cellular communication and turn on genes that are responsible for our overall metabolic health. Symptoms of hormonal decline may include hot flashes, night sweats, vaginal dryness, incontinence, and memory issues. Patients often become depressed and tearful. There may be sleep disturbance, headaches, and generalized aches and pains. Women may also become fatigued and become highly sensitive to chemicals and noticed an increase in allergies. There may be weight gain in the waist and hip area as well as decreased libido. Hormonal decline is often associated with mood swings, nervousness, irritability, and generalized anxiety. Symptoms may also include decreased stamina, reduce muscle size and strength. There may be swelling or puffiness in the eyes and face. These are just a few symptoms of hormonal decline or imbalance.

Since WHI study was released in 2002, there has been increasing controversy regarding the replacement of hormones and their safety. Many additional studies since that time are now available, and continued research has allowed us to clear up many of these issues. It has become quite clear that the type of hormone used is very important, and when using the same hormone that the body makes (also called bio- identical hormones), the efficacy and safety of hormonal replacement is greatly enhanced. Let’s just take a look at a few of the hormones that your body would typically need as you enter into menopause. These sex hormones include estrogen, progesterone, and testosterone. Estrogen is in three forms: Estrone or E1, Estradiol or E2, and Estriol or E3. Estradiol is the most potent of these hormones and declines in postmenopausal women. Estrogen is highly responsible for memory, as it directly stimulates acetylcholine in the brain which is a memory neurotransmitter. Progesterone balances estrogen and has receptor sites throughout the body which makes it important in the overall management of hormonal replacement. Unlike progestin, which is synthetic in nature and contains an acetyl group, progesterone is the body’s natural form which has been shown to enhance safety. Testosterone is also very important in women’s health. It is one of the most powerful anabolic hormones, and will help the body build muscle and burn fat. Cortisol is a catabolic hormone, and is known to build fat and reduce muscle size and strength. Cortisol must be kept under control and checked during hormonal balancing as it often rises with age as well as the body’s exposure to stress.

So if hormones are important in age management medicine, what about the issues of safety. There has been a great concern regarding hormone use and blood clots (such as heart attack and stroke), cardiovascular disease, and cancer particularly in the breast. In reviewing the latest literature, the following conclusions can be made to date: Estrone, or E1, increases both thrombosis and cancer risk. Estradiol, or E2, may be pro-thrombotic when taken orally, but there has been no pro-thrombosis reported in transdermal delivery. Estriol, or E3, has no reported increase in thrombosis. For these reasons, I generally do not use oral estrogen over the age of 35. I have not seen any good studies on the use of transvaginal estrogen, and I’m often concern regarding the male partner’s exposure to estrogen in this application. Synthetic progestins have been shown to increase the risk of breast cancer, while natural progesterone does not seem to show this increased risk. Oral progesterone may have a more calming effect as its metabolite can cross the blood brain barrier and stimulate the calming neurotransmitter in the brain called GABA. Transdermal progesterone, although an adequate form of delivery, does not seem to have these calming effects. Testosterone is usually given transdermally across the skin, or injected subcutaneously or into the muscle. Testosterone, as well as estrogen, can also be applied utilizing pellet therapy. Testosterone is typically not given orally as it may have effects on the liver. Transdermal delivery of testosterone must be used with some caution as an enzyme in the skin can convert testosterone to DHT, this may increase the risk of hair loss, oily skin, and/or acne.

So let’s take a brief overlook in the risk of breast cancer and cardiovascular disease using hormone replacement. In cancer risk, bio-identical Estradiol and Estriol appear to be safe. Adding progesterone is good and reduces the risk of breast cancer, while synthetic progestins increase the risk of cancer. In cardiovascular disease, oral estrogen increases thrombosis and cardiovascular risk, and should be avoided as a women approaches 35 years. Transdermal estrogen is protective against cardiovascular disease. Bio- identical progesterone reduces the risk of cardiovascular disease, while synthetic progestins increase the risk. There appears to be no difference in risk with either oral or transdermal use of progesterone. Low levels of testosterone increase the risk of cardiovascular disease in men, while low levels in both sexes increased risk of bone loss and the loss of muscle mass.

I hope this clears up some issues regarding hormone replacement therapy and safety. If hormones are used appropriately which includes proper laboratory testing in dose management, following hormonal metabolites for safety, and the addition of nutritional supplements when needed, hormonal optimization can certainly improve the quality of your life.

Vitamins: Good, Bad, or Indifferent?

Posted by Dr. Kenneth Orbeck on October 12th, 2011 | 3 Comments

Headline news and USA Today stated that vitamins and supplements might actually increase mortality in elderly women. Are vitamins and nutrients really safe? Can natural products such as vitamins minerals and nutrients actually cause harm?

After reviewing the article that USA Today is referring to, the only supplement that was found increased mortality was that of iron. The other nutrients studied included calcium and it was actually shown to reduce the risk of mortality. It has been well documented that elevated levels of iron and ferritin can in fact increase cardiovascular disease. This is one of the reasons why nutrients have to be carefully monitored by your physician to make sure dosing is adequate and appropriate. The remaining vitamins that were studied did not show an increase in mortality, but were shown to be beneficial. These include calcium, vitamin D, vitamin C, vitamin E, and B- complex vitamins.

In practicing nutritional and metabolic medicine, nutritional deficiencies are core to the intervention in patient’s underlying metabolic derangements. Our body is made up of multiple enzymatic pathways which require coenzymes and cofactors. Multiple vitamins and nutrients are needed in order for the process to work effectively. While I try to have my patients obtain this through natural organic dietary measures, supplementation is often required. This article is actually encouraging to me because it shows that nutrients have powerful and effective measures. Nutrient deficiencies can certainly cause a breakdown in multiple metabolic processes which relate to end-stage disease, morbidity, and mortality. Utilizing functional and integrative testing such as nutritional and vitamin analysis, the correct formulation can be prescribed in a safe and effective manner.

It is often quoted you are what you eat. I certainly agree with this statement. What we ingest in the form of nutrition has a great affect on how our body functions and how our body can also repair. With our processed food today, nutritional deficiencies are certainly common; and nutritional supplementation is highly effective and very safe if monitored appropriately and prescribed under the correct guidelines. Make sure that if you’re taking nutritional supplementation, you are guided by someone with knowledge in that field and you take high quality nutritional products. Your life may depend upon it.

Cholesterol- “To Be or Not To Be”

Posted by Dr. Kenneth Orbeck on October 6th, 2011 | 4 Comments

Do you ever wonder why some individuals with lower cholesterol have heart attacks and coronary artery disease while some individuals with higher cholesterol do not? Is there more to heart disease than cholesterol alone? While cholesterol certainly has been proven to be a major risk factor in coronary artery disease and heart attacks, the latest research certainly shows there is much more to the equation.

Cholesterol is often named a bad guy and many pharmaceutical drugs have been manufactured to lower its value. But is cholesterol really important in the body? Cholesterol is a precursor to all of our steroidogenic hormones, also known as sex hormones or anabolic hormones. Cholesterol is metabolized into pregnenolone, which is responsible for the making of all of our anabolic sex hormones. With the blocking of cholesterol and lowering cholesterol to sub optimal values, we block the important manufacturing of many of the hormones that our body needs. So if cholesterol is in fact needed in our body, how do we combat the risk of coronary artery disease?

Vascular aging and metabolic cardiology is an area of great interest among those who are working in metabolic medicine. The basis of cardiovascular disease in recent studies has been shown to involve inflammation and oxidative stress. This is also known as autoimmune vascular dysfunction. Oxidative stress involves reactive oxidative species also known as ROS. These are messengers that set off signals of inflammation through genes that can cause inflammation and damage to our blood vessels. When looking at standard lipid profiles, typical measurements of total cholesterol, LDL, HDL, and triglycerides are often obtained. But what is the rest of the story?

Recent research in biochemistry and lipid management has allowed us to create testing which is much more comprehensive. This testing is known as expanded lipid profiles. We now know that LDL, often called bad cholesterol, must undergo oxidation to be damaging to the vessel wall. This involves the process of oxidative stress that is listed above. Two markers often looked at in advance lipid management to measure oxidative stress are C-reactive protein and homocysteine. When elevated these markers often indicate inflammation within the blood vessel and higher risk of atherosclerosis. Advance lipid testing also allows us to look at both the core particle size and number as well as the density of HDL and LDL. Research has shown us that small dense LDL is much more dangerous than larger buoyant LDL. Let’s take to individuals with the same LDL total cholesterol number. One individual has larger LDL while the other has smaller LDL. The individual was smaller LDL can have up to 70% more particles and be at much greater risk for coronary artery disease. HDL can also be fractionated, and buoyant HDL is more protective against atherosclerosis.

Cholesterol management should involve in-depth analysis prior to reaching over-the-counter for a quick fix. With expanded lipid profiles that are now available to anyone, the management of cholesterol and coronary heart disease risk can be performed accurately and safely. The goal in lipid management should include LDL reduction, making sure LDL is not dense, stabilized endothelial vessel lining, and reduced oxidative stress. Analyze HDL for its protective characteristics as extremely high HDL is often dysfunctional and not cardioprotective. Risk factors of heart disease greatly increase with elevation of C-reactive protein and LDL combined. When therapeutic intervention becomes necessary, always consider some natural alternatives. Omega 3’s have been shown to be very protective and reduce the risk of cardiovascular disease. Vitamin K2 as MK-7 has also been shown to reduce atherosclerotic plaque. Resveratrol and N-acetyl cysteine have been shown to block oxidative stress. Niacin, also known as vitamin B3, has been shown to be effective in lowering the VLDL(triglycerides) and lowering dense LDL. Oral estrogens have been shown to lower dense LDL and are often an important consideration in postmenopausal women. Plant sterols have a role in cholesterol management as well. So if you are wondering if cholesterol in your body is doing you any harm, seek advanced lipid testing and with your physician outline a treatment program that is both comprehensive and safe in lowering your risk of cardiovascular disease.

Kenneth Orbeck DO – Greenville Bioidentical Hormones Expert