[QUOTE=Bigpete757] Could you please look at two threads I have started in this forum. I am currently overweight and in very poor health due to a few issues that you are familar with. I would appreciate any feedback on my situation.
SUMMARY:
25 y.o. male
6 feet tall, 300 pounds
Used anabolic steroids 6 years ago.
For the past 4 years developed depressed mood, obesity, insomnia, lack of energy, impaired concentration.
Sought help when loss of sexual function developed.
Saw a physician and was found to have “low” testosterone, “bad” levels of estrogen, cholesterol, triglycerides.
Was treated with testosterone cream.
Recent Tests Result Range
Estradiol — 30 — 13-54
Triglycerides — 171 (h) — <150
Cholesterol, Total --- 99 (l) --- 125-200
HDL Cholesterol --- 21 (l) --- >=40
LDL Cholesterol — 44 — <130
Chol/HDL ratio --- 4.7 --- <=5.0
T3, Free --- 363 --- 230-420
Test, Total --- 246
TSH, 3rd --- 3.50 --- .40-4.50
Glucose --- 95 --- 65-99
Urea Nitrogen --- 28 (h) --- 7-25
Creatinine --- 1.26 --- .80-1.30
Bun/Creatinine --- 22 --- (Calc) 6-22
Bilirubin, Total --- 1.4 (h) --- .2-1.2
Hemoglobin A1C---4.9---% of total
Some tests were not included because they were "in the normal range".
[/QUOTE]
When a person develops a mental illness, such as depression, then most often that person has an illness affecting multiple systems in the body.
Physiologically, the underlying causes of depression include problems in the nervous system, endocrine system, immune system, and cellular metabolism. These problems are usually include NUMEROUS SMALL CHANGES which would be missed by most physicians, even if they have a full set of lab tests available to them, because they do not know what to look for.
That person is lucky if one or a few of these changes are so markedly large that a diagnosis (such as hypogonadism or diabetes) can be obtained. Then at least part of the person's mental illness can be addressed. If the person is lucky, the person will feel substantially better. If psychologically, they can then improve functioning in other areas of physiology, then hopefully they can return to full mental health. However, most frequently, unless most, if not all, of the physiologic problems associated with depression are addressed (both big and small), then the person's mental illness usually will continue.
Note that it is important to list all lab tests - including those "in the normal range" - because what is "in the normal range" is subject to interpretation. What is "normal" depends on what you are looking for. When it comes to labs, there are different ranges depending on the illness one is testing for.
For example, if one is testing for nothing in particular, the "normal range" is 65-100. But if one is testing for diabetes, then the "normal" range for fasting glucose is about 125 and below. If one is testing for pre-diabetes, the "normal" range for fasting glucose is about 100 and below. If one is testing for hypoglycemia, then the "normal" range is "65 and above". And for my purposes, if I was testing for adequate blood sugar for the nervous system function, assuming adequate capacity to produce glucose and lack of significant insulin resistance, then my "normal range" is 93-100.
The range one uses, depends on what one is looking for. Therefore, if one does not know what one is looking for, then one should include as much information as one can find. This way, someone who knows what to look for can see the problem. As a cardiologist told me when I was in training, in regard to heart murmurs: you can use as fancy a stethoscope as you want, but if you don't know what to look for, you will never find it.
In regard to depression, the most important problems are not due to problems with testosterone. Testosterone is a minor player. Unfortunately, it often is the case that a guy doesn't seek help until erectile dysfunction occurs.
In depression, some common problems (with example components) include nervous system signaling problems (norepinephrine, histamine, dopamine, serotonin, GABA, pregnenolone, DHEA, etc.), nervous system-adrenal signaling problems (norepinephrine, CRH, ACTH, cortisol, DHEA, progesterone, pregnenolone, etc.), nervous system-thyroid signaling problems (serotonin, TRH, TSH, Thyroid hormones T4, T3, etc. ), nervous system-immune system signaling problems (norepinephrine, histamine, cortisol, inflammatory cytokine signaling, etc.), nervous system-gonadal problems (LH, FSH, progesterone, testosterone, estradiol) and metabolic/nutritional problems (proteins, Vitamin A, B12, D, iron, etc.). These problems, themselves, can contribute to the development of physical health problems (such as high cholesterol, diabetes, thyroid disease, hypertension, heart disease, stroke, etc.). This is why people with mental illnesses tend to be more physically ill than those without. For the usual patient I see, their mental illness leads to a loss of 25 years off their life.
If a patient came to me with limited funds and lack of health insurance, but can afford some labs, a small useful set to consider, that would give me the most bang for the buck, which consists of commonly available lab tests, to evaluate depression and determine treatment would include:
Free T3, Total T4, TSH,
Cortisol AM, DHEA-s, (Progesterone would be important particularly in women),
Fasting Insulin,
Total Testosterone, Ultrasensitive Estradiol,
Comprehensive Metabolic Panel, Lipid Panel,
Ferritin,
Vitamin D 25-hydroxy,
Vitamin B12, Folate,
Fractionated Plasma Catecholamines (Quest Diagnostics, unfortunately, doesn't do this well enough since it doesn't have zero as a low value in its reference range).
A Total T4 is crucial to obtain since it gives me an idea of how much thyroid hormone a person may need. The other values only give me an idea of how the other systems interact with thyroid hormone. For example, if the brain is healthy enough to produce TSH, then TSH tells me how much of a thyroid hormone deficit it is running.
From a behavioral point of view (not an endocrinologist or internist point of view), my own observations as to the approximate lab criteria for suboptimal thyroid function (i.e. the hypothyroidism of mental illness) are:
Free T3 < 3.3
Total T4 < 8.0
TSH > 2.0
These reflect peripheral not brain levels of thyroid hormone. There can be a disparity since the brain and the rest of the body are separate compartments walled off by the blood brain barrier. Only a drastic maneuver such as a lumbar puncture and analysis of central nervous system fluid would tell the difference. In some illnesses, these values can be very different. The brain can be hypothyroid but the body can have enough. This can lead to persistent energy or mood problems and brain dysfunction through brain-related mechanisms.
In psychiatry, even if one isn’t hypothyroid, thyroid treatment can still be done to help improve mood. Under some circumstances, such as bipolar disorder, a hyperthyroid state stabilizes mood.
Generally, thyroid treatment is risky without adequate nutritional support and without consideration of nervous system-adrenal function and treatment of problems there if indicated. It isn’t something one does without medical supervision and monitoring.
Often, a person with a mental illness only seeks treatment when the illness becomes severe enough that significant nervous system-adrenal function problems occur. Until then, the system can compensate for problems in the rest of the system. Once adrenal cortex output of cortisol, DHEA, pregnenolone, progesterone, etc. is compromised by the mental illness, often as a result of severe stress (chronic or traumatic), then a person cannot adapt to problems in the rest of the system. Thus, it is often highly important to address nervous system-adrenal function problems at the onset. Some of these problems can be called “adrenal fatigue”. But this ignores the large nervous system component, which is as important to simultaneously address, for which psychiatric medications are available. A pure adrenal supportive treatment in some people is not enough.
Obesity contributes strongly to mental health problems. Fat cells secrete leptin in an attempt to stop a person from eating. But when ignored, excessive leptin is also an inflammatory signal. Fat cells also secrete other inflammatory signals when they are full. This is one reason obesity can lead to an increase in inflammatory conditions such as asthma, cardiovascular disease, arthritis, etc.
Diet has to be addressed when one is obese. There is really no option in this matter. Calories in vs. Calories out determines weight. One cannot gain weight out of thin air. A person should become determined to stick with some diet regimen – any one if it involves reduced caloric intake – would significantly help if only one stuck to it. If one cannot stick to a diet, then it would be useful to consider trying a set-and-forget diet such as the Medi-Fast diet, where pre-packaged meals limit what one has to think about in doing the diet. Just follow the simple meal instructions. There are many pre-packaged meal programs such as those from Weight Watchers, Jenny Craig, etc. Having a nutrition adviser would be helpful if one needs help sticking to the diet plan. Gastric bypass is for those persons who absolutely have no willpower to stick to a diet. A gastric bypass is a physical handcuff to prevent a person from sticking food in their mouth. It is simply surgically forced starvation.
Tuning up and improving one’s system may help improve the ability to burn calories to reduce weight. Improving one’s energy level, motivation, mood, etc. can help one on the way toward weight loss. But even then, it still comes down to the number of calories one ingests.
One interesting observation about obesity: Under stress, most people overeat. Some call this comfort eating. However, some people stop eating. I estimate this is about 1 in 9 people. Why do some people become anorexic under stress and most do not? One reason is that eating stimulates the sympathetic nervous system – the stress system. Thus eating increases stress. This is why you can help keep yourself awake while driving by munching on sunflower seeds, for example. The nervous system decides which of two bad options it will do – to overeat to address caloric desires – such as when one is hypoglycemic as a result of stress, or to stop eating to avoid further increasing stress. If one is overweight, there is something to be said about episodic fasting to reduce stress or how one can significantly improve one’s mood through lowering caloric intake.
Even without consideration of reduced caloric intake, nutritional problems are a big contributing factor in the development of mental illness. Optimizing nutrition has to be part of the treatment.
In regard to sexual function, even if testosterone is optimized, sexual problem can still remain if the other problems in the system are not addressed.
In regard to cholesterol, outside of an inherited problem with excessive cholesterol production, high cholesterol indicates that one has one or more hormonal deficiencies involving thyroid or the steroid hormones. Note that Vitamin D is also a steroid hormone.
Take care.
Dr. M