Take a Sec (S.E.C.) to Understand the Elements of Good Skincare

Our entire “suit” of skin replaces itself approximately every 6 weeks. It does this by sloughing off old, dead skin cells on the surface of the skin, which stimulates the production of new skin cells in the deep layers of the skin. The new skin cells then undergo some changes as they migrate gradually to the surface of the skin. Once the skin cells reach the surface of the skin they are then in the category of old, dead skin cells, and they are ready to slough off. This process, known as skin cell turnover, slows down as we get older; so that the old, dead skin cells accumulate at the surface of the skin making the skin look dull and coarse. Newer skin cells are not as rapidly or frequently produced and skin loses the healthy glow it once had.

As we age many other undesirable changes begin to occur in our skin unless we take the time to encourage our skin to remain healthy. Because skin is the largest organ in the body, keeping it healthy makes a big difference in how we look and feel. Along with the slowdown in skin cell turnover there is a decrease in the production of collagen and elastin, two of the proteins that give skin its shape and elasticity. Loss of collagen and elastin leads to sagging and wrinkling. The decrease in skin cell turnover also means the skin heals more slowly and does not protect itself as well from damaging sun rays. There is a decrease in production of glycosaminoglycans (GAGS, for short) such as hyaluronan which bind water and give our skin plumpness or juiciness. Hyaluronan also participates in tissue repair and hydrodynamics, as well as migration and proliferation of cells. This extremely important polysaccharide acts as a free radical scavenger and drives collagen formation. Two of the most damaging influences for our skin are UV or ultraviolet light (sun and/or tanning bed exposure) and tobacco use (smoking). Both of these environmental exposures accelerate the changes of aging in the skin. Prolonged UV exposure creates additional signs of aging in the skin such as age spots, diffuse uneven pigmentation, spider veins and eventually dermatoheliosis or photoaging, a term usually describing the leathery, pebbly texture of skin that has been chronically and extremely damaged by the sun.

Unfortunately, the damaging effects of sun exposure do not really appear until 10-20 years into the exposure. This can make it difficult to convince a person in their 20’s that tanning will eventually result in some very ugly and unhealthy skin changes. It is often difficult to convince a person over 40 that it is the sun that has caused all of the changes they would now like to improve. I tell my patients that using really good skincare products, consistently, every day, at home is the most cost effective way to begin their journey to healthy skin. Any other treatments or procedures they choose to do will be far more effective if we prepare their skin with good skincare.

There are basically 3 elements of good skincare that everyone can incorporate into their daily routine. We use the S.E.C. acronym and advise taking a sec to improve the health of the skin twice a day.

S is for sun protection. This is an absolute must if you are serious about maintaining healthy skin. It does mean using a sunblock every day (yes, winter too—have you never gotten a sunburn in the snow?); but this is really only meant to protect you during brief forays into the outdoors, such as walking from your house to your car. When you are spending an extended period of time outdoors (walking, gardening, attending a sports event, etc.) you actually need to cover your skin with protective clothing and provide your own shelter in the form of a large-brimmed hat or parasol (no, a baseball cap is not good enough for obvious reasons—it only shades about 25% of your head and neck and exposes your vulnerable ears). The argument I usually hear in favor of sun exposure is the need for vitamin D. Vitamin D is an extremely important vitamin produced in the skin in UV light that actually behaves as a vital hormone (see previous vitamin D blog), but here’s the thing: you cannot get enough sun exposure to create adequate amounts of vitamin D in your system without damaging your skin. Normally I am all for living like a caveman or caveperson, but not in this case. Cave people had an intact ozone layer to protect them, which we do not; and cave people died by the time they reached the age of 35, which we do not. It is best to simply take your vitamin D3 as a supplement, at least 5,000 u per day as an adult, and avoid the damaging rays of the sun.

If you do nothing else, an increase in sun protection will improve your skin.

E is for exfoliation. This is a term given to the act of removing the outer layer of coarse, dead skin cells and is usually done mechanically or chemically. Mechanical exfoliation is simply performed by abrading the surface of the skin in a gentle manner. Methods of mechanical exfoliation include washing with a loofah or buffing pad, washing with scrubbing granules, or using a microdermabrasion device. Chemical exfoliation is performed by applying an agent that loosens and removes the surface skin cells. Alpha hydroxy acids (AHAs) are commonly used for exfoliation. All of the AHAs are derived from natural substances such as fruit, nuts, or milk. The most effective AHA is glycolic acid, derived from sugar cane. Glycolic acid is the smallest molecule in the AHA category, which allows it to penetrate more deeply into the skin for greater effectiveness. In a glycolic acid solution, the pH or acidity of the solution and the concentration of glycolic acid determine how strongly the solution interacts with the skin.

Whatever method of exfoliation is chosen, the end result is that the gentle removal of the outer layer of coarse, dead skin cells stimulates the creation of new, fresh skin cells in the deeper layers of the skin. There is an increase in skin cell turnover, so that more new skin cells are coming to the surface of the skin. Consistent, daily exfoliation means that new skin cells are constantly being sent to the surface of the skin. Why is this a good thing? Because new skin cells are better at making collagen and glycosaminoglycans, and new skin cells are better at protecting you from damaging UV rays. In fact, regular exfoliation can decrease your risk of skin cancer.

My personal favorite methods of exfoliation include use of Rx Systems glycolic acid wash and cream because this line has a lower pH (more acidic) and includes alpha lipoic acid, a very potent antioxidant (see previous antioxidant blog) that has even more protective effect versus UV rays; use of the Clarisonic device for cleansing because the brush is gentle and nonabrasive yet the sonic energy applied to the skin is super cleansing and stimulating; and the occasional (monthly) treatment with an in office glycolic or combination chemical peel (see previous chemical peel blog) alternating with treatment with vibradermabrasion because this is the absolute best of the microdermabrasion world (each patient has their own treatment paddle made of surgical steel and the polishing effect of the paddle is enhanced by the application of vibrational energy for maximum skin transformation.)

C is for collagen stimulation. As I noted above, many of the more undesirable changes of aging in the skin involve a decrease in the amount of collagen produced by the skin. Therefore, when addressing fine lines and wrinkles, enlarged pores, and sagging or draping of the skin it is all about the collagen. Regular exfoliation will have an effect on collagen production, but we can do better still.

If you are young and relatively line-free you can get by with a low level collagen stimulator for maintenance and prevention such as vitamin C serum. My personal favorite is the Rx Systems vitamin C serum because it is packaged in such a way as to prevent contact with air and light until you actually use it. This is advantageous because the exposure of vitamin C serums to air and light not only begins the breakdown of the vitamin C; it actually creates free radicals that are harmful to the skin (see previous antioxidant blog.) Vitamin C applied to the skin also helps to prevent skin cancer.

The most powerful of the collagen stimulating topicals are the retinoids, or molecules related to vitamin A. I love the retinoids because they do so many things for the skin. They reverse sun damage, they stimulate collagen and so are anti-aging, they are anti-acne (and let’s face it, many of us fight both acne and lines), and they take any other product you use with them deeper into the skin. My personal favorite is Retrinál from Avene because it is a top performer when it comes to collagen stimulation, but does not have many of the undesirable side effects of the other retinoids such as redness and peeling with regular use and sun sensitivity, making it OK to use year round.

There may be a need for a fourth element of good skin care if you have pigment issues. If you have freckles or solar lentigos (superficial depositions of darker pigment indicating your skin is very sun sensitive) or if you have what is known as actinic bronzing (pigment variability with both dark and light spots from chronic sun exposure) you will want to include a lightener twice a day to encourage pigment evening and extra attention to sun protection. I have my personal favorites here as well—for a lightener with hydroquinone I like Blanche from Neocutis and for a lightener without hydroquinone I like Vibrance from Vivité by Allergan.

It may sound like a lot of effort, but taking a S.E.C. to improve your skin twice daily and maybe even adding in an office procedure once a month or so will result in skin that is healthier and skin that looks healthier. Your skin will have fewer lines and will be tighter, the pigment variations will be improved and your skin will have a new luminescence or glow.

Additional recommendations:
Use a good eye cream twice daily.
Consider a good lip treatment twice daily.
Don’t forget the neck and décolleté!

Chemical Peels

Chemical peels are an immensely popular cosmetic procedure with total chemical peel procedures done in 2009 amounting to 1,142,949 peels of varying types. Chemical peels are also known as chemexfoliation or derma-peeling, and are a technique used to improve the appearance of the skin. In this treatment, a chemical solution is applied to the skin, which causes it to react and eventually flake or peel off. The new, regenerated skin is usually smoother and less wrinkled than the old skin. The new skin also is temporarily more sensitive to the sun. Even if the flaking or peeling reaction is not seen, the skin still benefits through skin cell turnover, the surfacing of new skin cells that are better at creating collagen, better at regulating pigment, and better at protecting from skin cancer.
Chemical peels are said to have been used since ancient times, notably in Cleopatra’s Egypt women used goat’s milk or soured goat’s milk, as well as fermented grape peels on their skin. This makes sense as the lactic acid in the goat’s milk is even now considered a hydrating agent, and the resveratrol found in fermented grape skins is currently a very hot topic as an anti-aging molecule.
Some of our more modern peels were not discovered or invented until the 19th century. Two of the earliest chemical peels were phenol and trichloracetic acid, which were very powerful. Increasingly, the trend in peels is to use less aggressive, less powerful peels, in a series, to achieve good results and avoid potential undesirable side effects. Where deeper effects are wanted, currently lasers are used because of their greater precision.
What conditions are treated by a chemical peel?
Chemical peels can be performed almost anywhere on the body and are commonly performed on the face, neck, or hands. They can be used to:
Reduce fine lines under the eyes and around the mouth
Treat wrinkles caused by sun damage
Improve the appearance of mild scarring
Treat certain types of acne
Reduce age spots, freckles, and dark patches called melasma
Improve the look and feel of skin that is dull in texture and color
Who Is a Good Candidate For a Chemical Peel?
Generally, fair-skinned and light-haired patients are ideal candidates for chemical peels. Darker skin types may also have good results, depending upon the type of problem being treated. However, the risk of an uneven skin tone after the procedure is increased. Sometimes pre-treatment with a lightening agent can help reduce the risk of post inflammatory hyperpigmentation in darker skin types. There are also more gentle peels that do not carry any risk for darker skin types.

Is it safe to have a chemical peel during pregnancy?

Some peels are safe during pregnancy. Usually the peels that are safe during pregnancy are milder and less penetrating, but still beneficial.
How is a Chemical Peel performed?
During a chemical peel, a chemical solution is applied to the skin and allowed to soak in. It may or may not require neutralization. Over the next 1 to 14 days, depending on how deeply the chemical penetrated the skin, the skin flakes or peels off. This procedure destroys parts of the skin in a controlled way so that new skin can grow in its place. The chemicals used are sometimes called exfoliating or wounding agents.

The types of chemical peels differ based on how deeply the chemical penetrates and what type of chemical solution is used. Factors that may affect the depth of a peel include the acid concentration in the peeling agent, the number of coats that are applied, and the amount of time allowed before the acid is neutralized. Deeper peels result in more dramatic effects as well as higher risks, increased pain, and longer healing time.

When will the results of a peel be evident and how long will the results last?

There may be an almost immediate glow to the skin, followed by a period of flaking or mild dryness for a few days to a week. Once the flaking stage is over the skin is softer, smoother, clearer and more even in tone. A series of peels will be additive in effect. Depending on how deep the peel is or how many peels in a series have been done, the effects can last anywhere from 6 weeks to 4 months.

What type of care does the skin need after a peel?

The number one rule after a peel is no sun exposure, so sun block should be worn every day, extended time in the sun should be avoided and a hat should be worn when outdoors in the daytime. The skin will require extra hydration, so a good moisturizer twice a day can be helpful. Avoidance of any aggressive treatments or products for 2-5 days after a peel will allow the necessary healing to take place.

How often can peels be done?

Depending on how sensitive the skin is and how rapid the recovery is, a peel can be done every 2-6 weeks in an initial series. Once the initial series is complete, a maintenance peel can be done every 1-4 months.

Can peels be done with other treatments?

Peels can be done with other treatments or alternated with other treatments. Commonly a mask is applied immediately following a peel for increased effect; the peel allows greater penetration of the mask. Also, peels are often alternated with treatments such as vibradermabrasion (a skin polishing treatment combined with vibrational energy) or collagen stimulating laser treatments.

In summary, there are a variety of types and strengths of peels. One treatment will improve the skin, but a series of peels will create much more improvement. Appropriately chosen peels can be performed safely for all skin types and conditions. Expected results are softer, smoother skin with more even tone. Peels can be combined or alternated with other treatments for even greater effect.

Notes on the Food Revolution

Lately my mind has been on the perpetuation or should I say perpetration of an unhealthy diet and lifestyle on the children of America by the public school system. I’ve been watching Jamie Oliver’s Food Revolution on TV. For those who don’t know, Jamie Oliver is the bloke from Essex who starred in the British TV show The Naked Chef and who has now made it his mission to bring healthy eating to America’s school children. His Food Revolution was filmed in Huntington, West Virginia, reportedly the unhealthiest city in America (although, as you’ll see on the show, there are those who resent that label.)
Jamie begins by starting with a single school and campaigns to bring in fresh food, cooked on the premises every day that contain fruits, vegetables, and good quality protein. In addition, he is trying to decrease the amount of fried food, processed food and sugar offered to the students. These are relatively simple and modest goals, and you would think most people would easily see that these are valuable goals. I mean, he’s not even suggesting the food be organic (which would offer more vitamins and minerals per pound of food, but would be more expensive.) One of the remarkable aspects of the program is how difficult it is to achieve these very simple and admirable goals. Another remarkable aspect of the program is that when given a choice, the students choose Jamie’s food over the usual non-nutritious fare. The parents are often more of an obstacle than the children.
Huntington got its unhealthy reputation by 1) being located in West Virginia which has the most per capita obese citizens in the nation and 2) by having the most per capita obese citizens in the state. These statistics vary from year to year, so it is not always West Virginia in the lead; but those states that have a large percentage of the population suffering from obesity also have a large percentage of the population suffering from diabetes, heart disease, and a host of other diseases. Jamie has some very poignant interviews with some of the people of Huntington who have been quite negatively affected by obesity, either their own or that of someone they love.
Another place where you can learn about Jamie’s Food Revolution is on his website www.jamieoliver.com where you can join over half a million Americans in signing a petition that states:
I support the Food Revolution. America's kids need better food at school and better health prospects. We need to keep cooking skills alive.
The petition is mainly to make a point to President and First Lady Obama that this is an issue that Americans really do care about.
The website has tons of recipes, how to videos and advice for starting a food revolution in your own community. There’s lots of fun stuff for kids—recipes and videos just for them, for example. You see, one of Jamie’s very salient points is that many of the children living in the U.S. today are the third generation of non-cooking Americans. In other words, they have been raised on processed food, fast food, food that contains little to no nutrition, but a great many calories. Nobody in the family actually cooks, and consequently kids grow up not learning how to cook.
If you don’t have time to watch a full episode at http://abc.go.com/shows/jamie-olivers-food-revolution
you also have the option of watching Jamie do his TED talk at http://www.ted.com/talks/lang/eng/jamie_oliver.html which is also quite good. One of the most amazing things Jamie shows is a group of children who cannot identify (pardon the pun)garden variety vegetables. If they don't know what it is, do we really think they're gonna eat it?
If you don’t know by now we ARE what we eat, we ARE what we drink, we ARE what we breathe and we ARE what we do for ourselves. And as Jamie points out, most of the diseases that kill us are diet related and completely preventable. We should make an effort to spare our children. At the very least we should sign Jamie’s petition. And we should tell our friends to sign Jamie's petition.

Defy the Aging Process in 2010

Time moves in only one direction. Until we can time travel we will inevitably age chronologically, but does that mean we must age biologically?

There are certain aspects of a Healthy Lifestyle that are well publicized, notably fitness or regular exercise and diet or nutritional optimization; and by now there is no doubt that smoking is associated with a variety of health problems. No one who is serious about health and self-love can continue to smoke. This article will highlight maneuvers to combat the common disabling conditions of advanced age and will include some of the lesser known and more interesting facts regarding a healthy lifestyle and how it can help you defy the aging process.

Aging, as it turns out, is not perfectly understood. There are many theories about why aging occurs and what processes take place. Certain cultures seem to support a lengthy and functional life, but there is much left to learn. Aging is a multifactorial process.
Most people would like to avoid the disabilities that make advanced age unpleasant and expensive such as heart disease, stroke, cancer, Alzheimer’s dementia, diabetes, arthritis, osteoporosis and bone fractures, loss of mobility and loss of sight or hearing.

Current theories of aging fall into two main groups: the idea that we have a finite number of cell divisions available to us or a predetermined lifespan and the wear and tear theories that suggest that environmental damage to our systems gradually cause things to go awry.

The predetermined lifespan theories include the idea of genetic regulation of lifespan and the activation of transcription factors that affect metabolism, cellular energy, and the dynamic balance between cellular damage and repair. Also in this group of theories are proposals that the length of chromosomal end-caps called telomeres determine the number of cell divisions; another part of the concept of replicative senescence. Telomerase, an enzyme that functions in the repair of telomeres appears to be very important in determining lifespan. Neuroendocrine dysfunction is the decline in function of the neuroendocrine axis (brain, nervous system, endocrine glands) that results in a predictable decrease in hormonal output. Declining hormones lead to many changes of aging such as a decrease in muscle mass, decrease in immunity, impaired glucose metabolism, decrease in the sense of well being and disrupted sleep patterns.

The wear and tear theories include hypotheses of aging that involve ideas of DNA damage and repair and include the concept that oxidation and free radicals, environmental mutating influences and errors in replication cause damage to DNA. The accumulation of mutations leads to cell malfunction and death. Inflammation appears to be involved in all disease processes through the accumulation of AGE or Advanced Glycation End Products, a process by which glucose molecules react with cellular protein to create permanent cross-links that lead to disabling changes. Mitochondria are the energy sources for the cells, and through their energy production and respiration they generate free radicals and ROS (reactive oxygen species) and these molecules cause oxidative damage to mitochondrial membranes and to DNA.

Anti-aging strategies are directed toward extending lifespan or stopping the wear and tear, either by neutralizing oxidative damage, reducing AGE products, replacing missing hormones, providing the nutritional building blocks for good cellular function and maintaining good structural strength. Eventually we will probably be able to make changes in our DNA.

Stress Reduction
Stress is a killer; and worse, stress is extremely aging. Stress can be physical or mental, so anything from an illness to an injury to a highly emotional event can be a source of stress. The human response to stress is an increased production of adrenal hormones including cortisol, resulting in many metabolic changes including impaired glucose metabolism, impaired immunity, and impaired sleep. In addition, all other hormone production is affected and placed in an imbalance. Under the influence of chronic, unrelieved, cumulative stress the adrenal glands become overworked and eventually succumb to adrenal fatigue. Other affects of unrestrained cortisol secretion are slowed protein synthesis (vital for healing and tissue repair), loss of nerve cells and brain damage, bone loss, muscle wasting, increase in abdominal fat, hypertension, hyperglycemia, psychosis and premature aging and death.

Avoiding, reducing or eliminating stress is one of the single most important ways to slow down the aging process. Ways to get rid of stress are avoid negativity and emphasize the positive aspects of life (also known as optimism), maintain close friends, allow whatever happens to be OK (cultivate detachment), participate in leisure activities, take the time to resolve conflicts, seek mental activities to keep the mind active and curious, keep a pet, participate in social activities, get some physical exercise that you enjoy, meditate, perform deep breathing exercises, volunteer, and make sure you have people in your life with whom you can exchange hugs.

Diet/Nutrition/Supplements
Diet and nutrition affect every aspect of our health. What we eat provides the building blocks for our physical structure, as well as all of the functional elements of our bodies. There is vast evidence at this point that the ideal diet is a low glycemic diet. A low glycemic diet includes lean protein, whole fruits and vegetables, whole grains and excludes refined and processed foods.

If you can afford it, organic foods are best. They are higher in nutritional value, containing higher levels of vitamins and minerals, and lack toxic pesticides. Whole foods, as opposed to extracted portions of foods often contain more complete nutrition. One good example is spinach, which we know can help prevent macular degeneration, a very common cause of blindness in older people. It is unknown exactly what compound in spinach is the effective ingredient, so it is necessary to consume the whole food to get the benefits. Raw foods contain more nutrition, so minimal or no cooking of vegetables retains more of the nutritional value of the food. Even meats are better eaten rare or medium as it has been shown that women who consistently eat meats very well done have a higher risk of breast cancer. It is unwise to cook any food in the microwave as most of the nutrition is completely destroyed by this method of cooking.

Fried foods contain trans fatty acids (trans fats) which increase “bad” LDL cholesterol and decrease “good” HDL cholesterol, as well as contribute to type II diabetes and heart disease. Vegetable oils and nut and seed oils used in frying can produce large amounts of free radicals that can damage cells and contribute to inflammatory diseases, cancer, obesity and aging. Fried foods also contain acrylamide, which may be carcinogenic and has been shown to be neurotoxic. Acrylamide is particularly evident in high carbohydrate foods cooked at high temperatures (think French fries.) Olive oil is anti-inflammatory as long as it is not cooked at high heat.

Caloric restriction is the only maneuver that has been shown to extend lifespan. This can be incorporated into lifestyle by fasting for 12 hours (7PM to 7AM) three days a week. The only other molecule that may extend lifespan is resveratrol, found in red wine and available as a supplement.

Broccoli and tomatoes have anti-cancer effects. Many spices (garlic, chili peppers, and curcumin in particular) have anti cancer effects, anti-inflammatory effects, some reduce cholesterol and blood pressure, and some have been shown to reduce the risk of Alzheimer’s Dementia. Foods with high antioxidant contents such as dark chocolate and many berries, especially blueberries, are beneficial in counteracting free radicals and reactive oxygen species.

Taking a multivitamin, multimineral supplement can improve short-term memory, problem-solving ability, abstract thinking and attention span, and immunity. Vitamin A improves immunity and enhances eye health; Vitamin E reduces the risk of prostate cancer, heart attack, stroke and Alzheimer’s Dementia; Vitamin C decreases the risk of heart attack, stroke and cataracts. Vitamins A, C and E are all considered antioxidants and all have been found to enhance eye health and prevent macular degeneration and to reduce the risk of skin cancer. The B Vitamins are important for many cellular functions and especially for neurological function.

Vitamin D is so important it deserves extra mention. Virtually everyone who is not taking a supplement is deficient in Vitamin D. It is difficult to get enough Vitamin D with sun exposure alone, especially in the winter months. People with darker skin color do not make as much Vitamin D in their skin in response to sun exposure and so are particularly at risk for deficiency. Likewise, as we age our skin makes less Vitamin D, so older people are at much higher risk for deficiency. Vitamin D preserves muscle and bone health, and in one nursing home study the sole act of taking Vitamin D reduced the number of falls and the risk of fracture with a fall. Since the risk of osteoporosis and bone fractures is higher for women, taking Vitamin D is especially important for women. Vitamin D prevents multiple sclerosis and is anticancer, antiviral and antibacterial.

Mineral supplements are often overlooked. Many people are deficient in Magnesium, and it is the most common mineral deficiency in women. Magnesium is important for heart health and muscle health and is calming and anxiety reducing. Taken at night it can improve sleep. Zinc is an important coenzyme for all healing and collagen building and enhances immunity. Selenium is an important trace mineral that increases HDL, decreases LDL, decreases risk of certain cancers, and enhances thyroid and pancreatic function.

Probiotics improve immunity and enhance gut health which is thought to decrease the risk of inflammation and autoimmune disorders.

Fitness/Exercise
The benefits of regular exercise and activity are numerous. A reasonable and sufficiently active exercise regimen should include at least 1 hour of vigorous or 2.5 hours of moderate activity each week, as well as strength or resistance training for at least 10 minutes, 4 times a week. It is important to enjoy whatever physical activity you have chosen, so that it is easy to continue to include it in your lifestyle.

Regular exercise maintains muscle strength and muscle mass, and bone health. Regular exercise enhances core strength, which maintains balance and prevents falls.

Regular exercise also reduces the risk for Alzheimer’s Dementia, cancer, constipation, adrenal fatigue and sleep disturbances. Regular exercise improves immunity and enhances healing.

Sleep
7-8 hours of sleep per night are required for optimum health. Sleep abnormalities are associated with depression, weight gain, and increased risk of inflammatory disorders. It is during sleep that we make melatonin, an important intrinsic antioxidant, and growth hormone. When we are asleep and our brains have electrical activity in delta and theta waves we in a very healing place. During sleep the intervertebral discs that act as cushions between the vertebrae are rejuvenated and plumped with water.

Studies have also shown that people with inadequate sleep have higher BMIs (Body Mass Indices) regardless of their caloric intake.

Hormone Health
You do not have to be aging to have a hormonal imbalance. Hormonal imbalance can occur at any age and is often associated with stress. Hormonal imbalance can show up as a wide range of symptoms including cool body temperature, warm body temperature, night sweats, anxiety, dry/brittle hair and nails, weight gain or loss, swelling or puffiness, and a lowered threshold for allergies. It is impossible to tell which hormones are out of balance without doing some tests. Usually the sex hormones, estrogen, progesterone and testosterone, as well as cortisol are checked in saliva samples. Thyroid hormones and related labs are checked in blood samples. Once levels are known, any deficiencies can be supplemented. In the case of the sex hormones, bioidentical hormones are the clear choice for reasons that are too numerous to elucidate here.

Another hormone that is frequently tested at the same time is DHEA-S or dehydroepiandrosterone sulfate, a metabolite of DHEA. DHEA is the most abundant hormone in the body and is involved in the manufacture of the sex hormones and corticosterone. DHEA is present in high levels in the brain, but declines with age along with growth hormone. DHEA supplementation may stimulate growth hormone, enhances the immune response to infection, increases insulin sensitivity, increases muscle mass, and decreases fat mass. DHEA may decrease the risk of cancer, heart disease, Alzheimer’s dementia and osteoporosis. DHEA, when taken as a supplement, is usually taken in small amounts for women (5-10 mg) and higher amounts for men (25-50 mg).

Skin Care/Sun Protection
Essential elements of skin care are regular exfoliation, collagen stimulation, and sun protection. Exfoliation can be mechanical or chemical and will increase skin cell turnover and skin health. Exfoliation also reduces the risk of skin cancer and will help the skin appear fresh and young. Collagen stimulation also helps the skin appear younger by preventing the loss of collagen and elastin that usually accompanies aging.

Ultraviolet or UV light is a mutating influence on the DNA of the skin and is the cause of essentially all skin cancer. It rapidly ages the skin by decreasing collagen and elastin in the skin, which contributes to the formation of fine lines and wrinkles and sagging skin. For adequate sun protection: wear the highest SPF you can afford, wear it all day, every day, and if you plan to be outside for more than 10-15 minutes provide some shelter for yourself (wide brimmed hat, parasol/umbrella, or stand under a structure). Wear sunglasses to protect your eyes from UV light and prevent cataracts.

Teeth/Dental Care
Poor dental health is associated with Alzheimer’s dementia, heart disease, stroke, pneumonia, and early death. Floss and brush your teeth at least 1-2 times daily, use an ultrasonic toothbrush if you can afford it, consider a plaque reducing mouthwash, see your dentist for regular cleaning and check-ups. Your dentist can also do an oral cancer screening.

Smoking
As previously mentioned, there is no doubt that cigarette smoking is damaging to your health, but did you know that people who live with smokers and have exposure to second hand smoke also have a higher risk of tobacco related disease? There is a higher rate of sudden infant death syndrome (SID) and a higher rate of childhood asthma in households with smokers. Smoking affects the entire family.

Car Safety
Car accidents are the number one cause of death in the group aged 3-33 years old, and are the third leading cause in the group aged 34-44 years old. Crash and rollover ratings can be found at www.safercar.gov to help you find a safe car. Air bags and wearing seat belts prevent neurological injuries, which can be devastating.

So, until such time as we can manipulate our DNA and exchange genes we don’t like for more favorable ones, it pays to be happy; eat and sleep well; drink red wine in moderation; take antioxidants, vitamin and mineral supplements; exercise regularly; protect yourself from the sun; avoid cigarette smoke; take care of your teeth and drive safely!

Looking To Lose The Spare Tire?

63% of Americans are overweight with a Body Mass Index (BMI) of 25 or greater. How do you know if you are overweight? You can calculate your BMI, which is based on your height and weight (divide your weight in kilograms by your height in meters, squared); or you can go to one of many websites with BMI calculators and simply input your weight and height (pounds and feet and inches) and it will do the math for you (Google "BMI calculator"). A BMI under 18.5 is considered underweight (most models), a BMI of 18.5 to 25 is considered normal or healthy, a BMI above 25 is considered overweight, and a BMI over 30 is considered obese. BMI is not accurate in very muscular individuals who are heavy for their height but do not have much fat. A DEXA scan is a much more accurate way to determine BMI or percentage of fat in body composition.

Overweight people are more likely to have diabetes, heart disease and hypertension, stroke, dyslipidemia (elevated levels of cholesterol and/or triglycerides), liver and gallbladder disease, sleep apnea and respiratory problems, osteoarthritis, gynecological problems and certain types of cancer (endometrial, breast, colon). North Carolina, where I live, was number 8 on the nation's top 10 most obese list with 29% of its citizens being obese in 2008. Estimated direct and indirect health costs for North Carolina's obesity epidemic in 2006 were $57.37 billion for adults and projected costs for 2011 are $75.64 billion.

What are some of the reasons for being overweight? Bottom line, the calories taken in exceed the calories expended; and, no matter how much we would like there to be a magic way to avoid calorie restriction and exercise, they always come into play when we are talking about weight issues. But other factors can also be a part of the picture. Hormonal imbalance can cause weight gain. For example, polycystic ovary disease, menopause and hypothyroidism (low thyroid hormone) can all be associated with weight gain. Stress, with its elevated levels of cortisol, can be associated with weight gain. Lack of sleep can cause weight gain--people who sleep less the 7-8 hours per night have an elevated BMI compared to those who sleep 8 hours or more regardless of their caloric intake! Common medications associated with weight gain are antidepressants, anti-diabetes drugs, oral contraceptives and steroids.

Sometimes we are doing everything right, but we have that one problem area that just won't seem to cooperate with our workout. We have the love handles, the muffin top, the spare tire or the saddlebags that don't respond to diet and lifestyle changes. Some of the latest technology is geared toward losing the problem area or sculpting, losing some inches and gaining some encouragement and enthusiasm for continuing on the path of the virtuous. There is a bewildering array of procedures and techniques available, so here is a brief summary of what is new and not so new.

Oldest among the body sculpting techniques is liposuction. Liposuction has progressed over the years from a procedure requiring anesthesia and often blood transfusions to the current state-of-art liposuction with tumescent anesthesia using microcannulas, which allows the procedure to be done with the patient awake and with little scarring. Newer additional modifications include various assist technologies such as ultrasound, laser or water jets to make the liposuction easier for the surgeon and more efficacious for the patient (allows suctioning of more fat, faster.) One of the problems with liposuction is that along with the fat there are blood vessels, lymphatic vessels, connective tissue, fibroblasts, etc. that are disrupted by the procedure and can take 6 months or more to fully heal. The tissue located just under the skin neither looks nor feels normal for 6 months or more.

An even more invasive procedure for body sculpting is abdominoplasty or "tummy tuck" which is fairly major surgery, requires general anesthesia, and, again, will take 6 months or longer to fully heal.

Non-invasive (non-surgical) methods have been added to the list of available techniques, and one that has been around a long time is mesotherapy, also called lipodissolve, lipostabil, lipolysis or injection lipolysis. With this technique multiple injections are given in multiple sessions to "melt away" unwanted small areas of fat. Some of the problems with this technology include the lack of a standard ingredient list for the material injected, and the FDA currently views this procedure as "unapproved drugs for unapproved uses." Lipodissolve was banned in Kansas in 2007 by the Kansas State Board of Healing Arts, in part due to complaints about the procedure; and three medical associations have issued health warnings cautioning against the use of injection lypolysis, including the American Society of Plastic Surgeons (ASPS), the American Society for Aesthetic Plastic Surgery (ASAPS), and the American Society of Dermatologic Surgery (ASDS). If that's not enough to dissuade you, I don't know what is.

Other non-invasive devices include one that utilizes mild electrical frequencies in conjunction with heat and vibration to "minimize fat", but is supposed to work by reducing cellulite and toning muscles. The manufacturer is vague about its mechanism of action and does not present any clinical studies. It is non-invasive, requires 6 initial treatments, as well as regular maintenance treatments and is basically a non-medical device that is marketed to salons and spas (read ineffective.)

Yet another non-invasive device combines massage and laser to activate fibroblasts in the skin in order to temporarily reduce the appearance of cellulite. Results are not sustained, and treatments must be repeated on a regular basis to maintain the look.

A very popular non-invasive device for cellulite reduction and body shaping uses radio frequency (RF) and infrared light with suction and tissue manipulation (rollers that spread out the skin as the energy is being delivered.) What, no kitchen sink? The theory here is that the combination of infrared and RF energies increase the oxygen delivery to the cells by heating the skin, which increases the metabolism of stored energy, i.e. fat, thereby reducing the size of the fat chamber or cell. The recommended number of treatments is 8-16 (!) with supporting treatments every month thereafter as results are not sustained. There are no studies to support this theory of the mechanism of action, and the manufacturer does not have studies to indicate expected and measurable results.

The latest technology uses a cold laser or low level laser therapy (LLLT) to emulsify fat within the fat cells and create a small pore in the fat cells, allowing fat to flow out of the cells to be taken up and eliminated by the body's lymphatics. Initially used to facilitate healing and decrease pain, this laser was discovered to liquefy and release fat and was used to assist liposuction. It was then realized that it works to reduce inches even without liposuction as once the fat is released from the fat cells it is accessible to the body's systems for elimination. This technology has been well studied and has been shown to result in a sustained loss of fat. This translates to an average loss of 5-6 inches or a drop in 2-7 dress sizes. It involves no discomfort, no surgery and no down time. Additional benefits include a reduction in cholesterol, LDL cholesterol and triglycerides for most people. Studies are currently underway to see how long this effect lasts. There is also a decrease in the hormone, leptin, which results in a decrease in appetite.

The best course of action is to follow a low glycemic diet and to get moving. Get active! Sleep 8 hours a night and destress through meditation or one of the biofeedback or holosync devices available (the subject of another blog.) Make sure you do not have a hormonal imbalance and review your medications with your doctor. Lastly, if you just need a little sculpting, there are many techniques available.

For more information contact Dr. Lisa Hogan at Youthology, Aesthetic & Anti-Aging Medicine, 919-847-1495 or lisa@youthology.md or visit http://www.youthology.md/.

Vitamin D, Steroid King of the Vitamins

Vitamin D has long been known for its role in preventing rickets in children and as a required element for the intestinal absorption of dietary calcium. We are now finding vitamin D to be important in protecting the body from a number of diseases. Vitamin D deficiency has been linked with stroke, cardiovascular disease, osteoporosis, osteomalacia, several types of cancer, some autoimmune diseases such as multiple sclerosis, rheumatoid arthritis, and types 1 and 2 diabetes, depression and schizophrenia.

Vitamin D has a chemical structure very similar to some of the most important hormones in the human body; and, in many ways, behaves very much like a hormone, a steroid hormone. It binds to specific vitamin D receptors (like a lock and key) in target tissues and turns on specific genes. We know it has profound effects on immunity seen as antiviral and antibacterial effects. It maintains muscle and bone health to such a degree that, in one study, nursing home residents who were given vitamin D supplements had fewer falls than their supplement-free fellow residents. Those on the vitamin D supplementation had fewer fractures when they did fall, compared to the supplement-less residents. No other interventions were performed; just the addition of vitamin D supplements.

Humans begin the process of making vitamin D in their skin when it is exposed to sunlight. Ultraviolet light acts on a cholesterol based molecule in the skin to produce vitamin D3, which is technically a prohormone or precursor to a hormone. Our skin is capable of producing 30,000 units of vitamin D per day. Granted, this would require us to live like cave people, that is, nearly naked and outdoors all day. There is reduced endogenous vitamin D production at times of the year with reduced ultraviolet light (winter), and that is the reason that winter is the season for colds and flu. Also, due to concerns about sun damage and skin cancer, many Americans have limited sun exposure all year. (Let's face it, when we lived as cave people we didn't live long enough to get skin cancer; and we had an intact ozone layer.) The vitamin D produced in the skin is then hydroxylated in the liver to form the 25-hydroxy metabolite that is the main circulating form of the prohormone (still a prohormone). 25-hydroxy vitamin D has a long half-life (hangs around a long time) and is stored in the adipose or fatty tissue. This metabolite is ultimately transformed in the kidneys to form 1, 25-dihydroxy vitamin D--at last, the active form of the hormone.

Formation of active vitamin D is regulated by the parathyroid glands, 4 small glands located near the thyroid glands. When there is a vitamin D deficiency the parathyroid glands work overtime to stimulate the kidneys to produce more of the active form of vitamin D. For this reason, levels of active vitamin D can appear normal, or even elevated, in the presence of a deficient state. In order to truly measure vitamin D status the precursor to the active form of vitamin D is measured to determine the total bioavailability of vitamin D.

Many vitamin D supplements are actually vitamin D2, which is not found in animals. Ergosterol, a compound in fungal cell membranes, is exposed to ultraviolet light to manufacture vitamin D2 commercially. Vitamin D2 is metabolized and activated in the body much like vitamin D3, but it acts for a shorter time and is less active in the body than vitamin D3. Vitamin D2 has to be given in larger doses and more frequently to maintain adequate levels of vitamin D. Given enough vitamin D2, the body's production of vitamin D3 is decreased (suppressed). If vitamin D3 (what humans make) is measured in a person who is taking vitamin D2 (what fungi make), levels can appear low, as if there is a vitamin D deficiency. The take home message is that if you are taking vitamin D2, then you need to measure vitamin D2 levels when you are checking vitamin D levels.

Who Is At Risk For Vitamin D Deficiency?

Elderly people are at risk for vitamin D deficiency for several reasons. As we age, we make less vitamin D precursor in the skin, and our parathyroid glands do not function as well as they once did. Vitamin D deficiency is associated with osteoporosis and muscle weakness, as well as muscle and joint pain.

Dark-skinned people (including children) are at risk for vitamin D deficiency because they require much longer exposure to ultraviolet light in order to create enough circulating vitamin D compared to more fair-skinned individuals.

People who live at latitudes far from the equator (greater than 35 degrees latitude) or those who have limited sunlight exposure due to their work environment or their cultural rules of dress are at risk for low vitamin D levels.

Anyone with musculoskeletal pain (pain in the muscles, joints, or bones) should be tested for vitamin D deficiency because patients with diagnoses of fibromyalgia, low back pain, non-specific musculoskeletal pain, and hypothyroidism are often found to have low vitamin D levels. Supplementation improves symptoms.

All children need adequate vitamin D levels to prevent rickets and allow normal bone development. Infants who are breast-fed, especially those breast-fed by vitamin D deficient mothers, may not be getting enough vitamin D. Maternal supplementation is one solution. Cod liver oil is one of the few foods that provide a good amount of vitamin D and is a great supplement for infants and children. (Your grandmother was right!) Vitamin D deficiency in infants and children is associated with the development of childhood type 1 diabetes.

Overweight or obese people have lower levels of circulating vitamin D because their vitamin D can be bound up in fat stores.

Why Measure Vitamin D?

Vitamin D deficiency can be completely asymptomatic (at least for awhile), and so is often detected as part of routine testing. Deficiency is simple to detect. Supplements are inexpensive and easy to obtain and can improve health status and prevent more serious diseases.

What Is a Healthy Level of Vitamin D?

Levels under 32 ng/ml have traditionally been thought to indicate vitamin D deficiency; and, by anyone's standards, do represent vitamin D deficiency. This accepted standard was originally developed in relation to prevention of rickets. As it turns out, a minimal amount of vitamin D will prevent rickets; and many experts now agree that levels should be higher than 50 ng/ml (and probably 75 ng/ml) for optimal health. Research is in progress to establish more definitive requirements.

Who Needs Supplements, And What Type Is Best?

It is likely that most Americans are vitamin D deficient and need supplementation unless they are already taking it. A simple blood test will detect deficiency, and supplements are widely available. Vitamin D3 is the same as our own natural vitamin D and is more bioactive than vitamin D2 with less risk for toxicity. Supplements that contain probiotics are better absorbed and are good for the digestive system. There is good evidence that daily supplementation of 1000 to 5000 u of vitamin D3 is optimum.

For more information contact Lisa Hogan, MD at Youthology, Aesthetic & Anti-Aging Medicine at 919-847-1495 or lisa@youthology.md or visit www.youthology.md.

Bioidentical Hormones: What Are They And Are They Right For You?

As we age, our hormone production declines in predictable fashion; and it begins earlier than you might think. By the time we are in our thirties and forties our production of sex hormones may be low enough to cause serious symptoms. Although both genders produce all of the sex hormones, men produce predominantly testosterone and women produce predominantly estrogens and progesterone. The sex hormones are familiar to most people as the hormones that determine our gender, our secondary sexual characteristics as we mature and many aspects of our fertility.

But did you know that virtually all of our organs and tissues have receptors for the sex hormones, which means that these tissues respond to the sex hormones. Testosterone, estrogen and progesterone have profound effects on the health of the muscles, bones, cardiovascular system, brain, eyes and other endocrine systems, to name a few. So, not only do we have unpleasant symptoms with hormonal decline, but also it is detrimental to our health.

Until 2002 women were prescribed the synthetic hormone Premarin, conjugated equine estrogens or CEEs, derived from the urine of pregnant horses; Provera, the synthetic medroxyprogesterone acetate or MPA; or Prempro, a combination of the two. Usually, this prescription was issued long after menopausal symptoms had been evident, and usually without any lab testing. One dose was prescribed for every woman.

In 2002 the Women’s Health Initiative (WHI), a study led by the National Institutes of Health looking at the effects of Prempro on cardiovascular health, osteoporosis and cancer, was abruptly terminated just 8 years into the study. The study already showed an increase in the risk of heart attacks and stroke and breast cancer. These study results were widely publicized in the popular press with the result that millions of women suddenly stopped taking their hormone replacement either by their own decision or on the advice of their doctors. Hormone replacement has come to be viewed with fear, and women are basically told you just have to “tough it out.” (Often antidepressants are prescribed.) This is much like telling a diabetic to “tough it out” without insulin.

As for men, symptoms of hormonal decline are often not discussed, not addressed and are largely ignored. Men might be given a prescription for erectile dysfunction, but this does not preserve muscle, bone, heart and endocrine health the way testosterone would.

For women, is there an alternative? And, if so, is it really any better or safer than the out of favor synthetic hormones? The short answer is yes, bioidentical hormones or hormones that are natural versions of human estrogens and progesterone are very different form the synthetics and are more safe. They are usually prescribed on an individual basis, i.e., different dosing for different needs of different women, with lab testing to determine the level of need and the response to therapy.

First of all, women feel better on the bioidentical hormones. Secondly, there are numerous studies showing that bioidentical hormones are protective for the cardiovascular system in several different ways (increased coronary artery blood flow, decreased arterial plaque, decreased arterial spasm, and a favorable influence on lipids), thereby decreasing the risk for heart attack and stroke. Additionally, the synthetic, MPA, has been shown to increase insulin resistance (type II diabetes) compared to bioidentical hormones, which adds to the cardiac risk. Also, because bioidentical estrogen is given transdermally, there is not the increase in clotting factors, inflammatory proteins and risk of thromboembolism (blood clots) seen with synthetic CEEs given orally.

Perhaps most alarming is the known increased risk of breast cancer in women on MPA and the known carcinogenic (cancer causing) components and metabolites of CEEs. The natural estrogen, estriol, has been shown both experimentally and clinically to be associated with a decreased risk of breast cancer. Bioidentical progesterone has an anti-proliferative effect on breast tissue, meaning it has an anti breast cancer effect, which is opposite to the effect of the synthetic, MPA.

The results of the WHI study make sense intuitively—one glance at the path by which our sex hormones are made reveals that small changes in the sex hormone molecules can completely change their function and effects. It should come as no surprise, then, that synthetic hormones that differ from our natural ones have completely different effects on the various tissues of our bodies.

There are many other good reasons for both women and men to be on bioidentical hormone replacement therapy including preservation of muscle and bone health, prevention of Alzheimer’s disease, prevention of eye disease, preservation of urinary tract health, and preservation of libido and zest for life!