My introduction.....

[zkt]

My main source of fat!

As I think it should be, at least until the biochemistry of FFA conversion, specifically the palmitic to oleic pathway gets sorted out univiocally.
Btw, salmon covered with bacon aint at all bad.
I understand that you are concerned with weight reduction but my main interest here is vascular. If your doppler comes back looking like mine it might become yours too. (sick laugh), but at your age its not likely, as I`m sure you know. I`ll try to remember that youve been to med school.

So what's wrong with this diet? (not directed at IDMD but everyone else). This is almost identicle to what I was doing, with the exception of the 2 slices of bread. I dropped 20 pounds this way in a month, and my exercise was very moderate. Those 2 slices of bread can't be that bad

No, not really. 200 cal. A nice whole grain or multi-grain bread with some fiber. White bread; might as well mainline sugar, IMHO. But befor a workout the situatyion changes. Then you want insulin to increase. Thats why the bodybuilders shoot the insulin. A good insulin spike is great; under the right circumstances. Otherwise you want to fly low and slow.

 

[idmd]

Just back in from a spell of gardening, throwing my 2c in:

The huge, cavernous, stinking post-hoc-ergo-propter-hoc hole in the entire dieting-industrial complex is that poor diet and lack of exercise are themselves *symptoms* of the underlying problem. They are not in themselves the primary causes. The fact that around 97% of people who lose weight -- even those who heroically shed hundreds of pounds -- will regain all of it or more within five years is evidence of that.

Any other piece of medical advice that had a 97% failure rate would get laughed out of court, so why do we continue to bang on with this one? Because despite a growing mass of evidence pointing otherwise, we stick with medieval, or well-nigh prehistoric views on the self, and self-control, and personal responsibility, and motivation, and so on.. The advice to exercise more and eat less is spot on; the problem is that the advice tends to be "*merely* exercise more and eat less". Therein lies the problem.

The problem is not, given any particular level of exercise, *that* we eat too much, but rather that we *want* to eat too much. Successful and sustained weight loss requires us fatties to use out upper brain functions to override, FOR THE REST OF OUR LIVES, our lower brain functions. A prescription that merely tells us *to* implement such an override rather than *how* to implement it, is proving not much more effective as telling someone to stop blinking or stop breathing.

The brain of an overweight or certainly an obese person "believes" the person is supposed to be the higher weight. Inducing a calorie deficit, either by reducing calories or increasing energy output, is interpreted by the hypothalamus as the body entering a pathological situation that must be remedied or survival is at stake,

Here is a video showing the author Christopher Hitchens voluntarily undergoing waterboarding: Video Link: http://www.youtube.com/watch?v=4LPubUCJv58 Hitchens' reaction -- almost instant surrender -- is very much a lack of will power, a lack of self control, a lack of motivation. But he is doing what almost every person would do and is being controlled by his lower brain functions that mistakenly think the brain-carrying organism called "Hitchens" is dying.

Restricting food may not be as traumatic, but it is just as surely the lower brain having its way. And unlike waterboarding, where successful resistance would occur if the person could last only seconds, for a dieter to succeed they have to overcome that lower brain forever.

THAT, is obesity.

You are absolutely correct this is something that all obese people will have to deal with for the rest of their lives. There is no getting to a safe place where you can "let up" or be "normal". It will always be there...your brain will always be set to the wrong setpoint. I believe this is why fad diets fail. It's a huge departure from "normal" and people will inevitably want to return to the three macro nutrients. It requires hyper vigilance and support and even then will likely fail for most.

I'm trying to find a diet where I can realistically do it for the rest of my life. Where the feels of deprivation are minimal.

Today was:

Breakfast: 2 eggs, 2 turkey bacon, coffee
Lunch: Boston lettuce, 6 shrimp, Perrier
Dinner: grilled scallops, veggies, shrimp, salmon

I'm currently at 2000 calories and have not been hungry all day. This is doable. I have no desire to eat more. Before I would've eaten more not because I was hungry but because food was social and there....out of habit.

 

[chronological]

It requires hyper vigilance and support and even then will likely fail for most.

I think it's why this is important: National Weight Control Registry While 97% of us fail, *some* people seem to succeed. By gathering together their stories, it may be possible to find out what kinds of things create the long term success.

For my part -- attempt #926 -- I'm down 10lbs. Only another 130lb to go. Good luck with your own efforts. Oorah!

 

[idmd]

Zkt....I'm also interested in my Doppler. I found blood results from an insurance exam from 4 years ago. I was 295lbs and had total cholesterol of 180; HDL of 82 and LDL 120. Fasting glucose was 80 and BP 135/85.

My diet was worse as I was always at the children's hospital living on a diet of potato chips, Reeses peanut butter cups and diet Pepsi. I was eating less and drinking less EtOH then compared to recently (I am of course drinking less now than at either time and haven't had candy or potato chips in months).

My how things have changed!

 

[idmd]

Slightly off topic....I mentioned Robert L. Jungas PhD yesterday. He did some of the original work on the effects of insulin on adipose tissue in the late 70's and early 80's. It's not as sexy as today's molecular techniques but they are interesting papers....for those of you who know where to find such things they're interesting to read from a historical perspective.

He is an incredible mind that has total mastery of not just the tress in the forrest but the universe those trees are in. Total command of the broadest strokes down to the minutia. He was a fantastic teacher as well able to make the most complex ideas accessible to all students. Even the other PhD's in the room who had heard him lecture for years admitted he was so far beyond them. Humble man too.

 

[idmd]

So went to see Dr. Hulinsky today and here's my update.

He looked at all the labs and made the following comments:

1. He sees a picture more inline with early metabolic syndrome.
2. While I DO have insulin resistance he does NOT think I need metformin at this time (opposite what the other endo said) and as a matter of fact when I asked him if he thought I was "prediabetic" he said absolutely not. The elevated C-peptide is an early warning flag but he feels getting everything else in order will sort that out.
3. He thinks based on the time since my last dose of testosterone that my LH and FSH numbers are too suppressed which is an indication that this has been going on a long time. The amount of suppression doesn't jive with the time since my last dose and even though my E2 wasn't really high it was high enough that he feels I'm converting too much T-->E2.
4. Losing weight will help all of this. Lost 10 pounds since I saw him last and BP was 130/80 today.

Going forward:

1. He wants to do 10 days Clomid and remeasure LH/FSH
2. If results are what he's expecting then 25mg Aromadex every other day.
3. Sleep study
4. Ultrasound of renal arteries and carotids
4. Continue diet and exercise
5. See him back in 2 months

He's going to treat thyroid. It's not going to solve all my problems but a little push in the right direction helps.

 

[idmd]

I do think it's funny that one (rated a top endo) said no need to treat thyroid, go on metformin now and go on TRT now and Hulinsky said treat thyroid now, no need for metformin now and don't do TRT.

The only thing they agreed on was lose weight.

 

[Structure]

So went to see Dr. Hulinsky today and here's my update.

He looked at all the labs and made the following comments:

1. He sees a picture more inline with early metabolic syndrome.
2. While I DO have insulin resistance he does NOT think I need metformin at this time (opposite what the other endo said) and as a matter of fact when I asked him if he thought I was "prediabetic" he said absolutely not. The elevated C-peptide is an early warning flag but he feels getting everything else in order will sort that out.
3. He thinks based on the time since my last dose of testosterone that my LH and FSH numbers are too suppressed which is an indication that this has been going on a long time. The amount of suppression doesn't jive with the time since my last dose and even though my E2 wasn't really high it was high enough that he feels I'm converting too much T-->E2.
4. Losing weight will help all of this. Lost 10 pounds since I saw him last and BP was 130/80 today.

Going forward:

1. He wants to do 10 days Clomid and remeasure LH/FSH
2. If results are what he's expecting then 25mg Aromadex every other day.
3. Sleep study
4. Ultrasound of renal arteries and carotids
4. Continue diet and exercise
5. See him back in 2 months

He's going to treat thyroid. It's not going to solve all my problems but a little push in the right direction helps.

He sounds like a very reasonable guy. I think testing your HPT via Clomid is a good idea, just to make sure that there's nothing unexpected happening. I would, however, make one suggestion: don't take the arimidex. I don't think he thought that one through very well. Allow me to explain myself:

As you know, every medication has associated risks. A medication is used when the benefits outweigh the risks. If your doctor's suspicion is correct (which happens to be my suspicion as well), and excessive conversion of T to E2 in adipose tissue is your problem, it will self correct as you lose weight. You are losing weight very quickly right now; supposing that you've got around 100 lbs to lose to reach your target weight, and supposing also that you end up averaging 3 lbs per week, that means that you'll reach your target weight in about eight months.

So the question then becomes: is the risk associated with arimidex worth the benefit you could get for this eight month period? Some background first.

Taking arimidex was easily the biggest mistake I've ever made, in all my life. I took it for about three months, at a very low dosage. I noticed pain by the second month, in my wrists. I discontinued all arimidex by the third month. The pain steadily continued to grow for several months until I could not use my hands at all.

I saw a rheumatologist, who diagnosed me via MRI with severe bilateral DeQuervain's tenosynovitis. As you know, tendons heal very slowly due to low blood flow; it is not uncommon for tendons to take a year to fully heal. I did not see any improvements for a full 10 months. I am currently at the 15 month mark. I still have pain when using my thumbs; I use speech-to-text software to use the computer.

Here's the bottom line: arimidex is a breast-cancer drug, so virtually all studies have been done on women taking 1mg per day. More than half of them will get joint pain, and the most common site of pain is in the wrists (and by extension, the hands) (see: A prospective study of aromatase inhibitor-associated... [Cancer. 2010] - PubMed - NCBI). Pain is often very severe; rated as 8 or 9 on the pain scale. Many women with breast cancer choose to stop taking the arimidex because of this severe pain, despite the fact that not taking it puts their lives at risk.

You are a dentist; if you get the same wrist / thumb problem that so many people taking arimidex get (myself included), then you are done being a dentist for a year or longer. Thus, for eight months of better T levels, you are risking your livelihood, and your family's livelihood.

So is it worth risking severe, long-term pain in your hands for a benefit that your body will naturally achieve within an eight month window, especially considering the very high incidence of side effects? Absolutely not. This idea is myopic at best, and very foolish at worst...

 

[pinkman]

Damn this is scary! If arimidex is so bad then what if you're on TRT and get high estradiol? What do you do then? Another huge problem. I ask myself how is this supposed to work when there are so many TRT hurdles?

 

[idmd]

He sounds like a very reasonable guy. I think testing your HPT via Clomid is a good idea, just to make sure that there's nothing unexpected happening. I would, however, make one suggestion: don't take the arimidex. I don't think he thought that one through very well. Allow me to explain myself:

As you know, every medication has associated risks. A medication is used when the benefits outweigh the risks. If your doctor's suspicion is correct (which happens to be my suspicion as well), and excessive conversion of T to E2 in adipose tissue is your problem, it will self correct as you lose weight. You are losing weight very quickly right now; supposing that you've got around 100 lbs to lose to reach your target weight, and supposing also that you end up averaging 3 lbs per week, that means that you'll reach your target weight in about eight months.

So the question then becomes: is the risk associated with arimidex worth the benefit you could get for this eight month period? Some background first.

Taking arimidex was easily the biggest mistake I've ever made, in all my life. I took it for about three months, at a very low dosage. I noticed pain by the second month, in my wrists. I discontinued all arimidex by the third month. The pain steadily continued to grow for several months until I could not use my hands at all.

I saw a rheumatologist, who diagnosed me via MRI with severe bilateral DeQuervain's tenosynovitis. As you know, tendons heal very slowly due to low blood flow; it is not uncommon for tendons to take a year to fully heal. I did not see any improvements for a full 10 months. I am currently at the 15 month mark. I still have pain when using my thumbs; I use speech-to-text software to use the computer.

Here's the bottom line: arimidex is a breast-cancer drug, so virtually all studies have been done on women taking 1mg per day. More than half of them will get joint pain, and the most common site of pain is in the wrists (and by extension, the hands) (see: A prospective study of aromatase inhibitor-associated... [Cancer. 2010] - PubMed - NCBI). Pain is often very severe; rated as 8 or 9 on the pain scale. Many women with breast cancer choose to stop taking the arimidex because of this severe pain, despite the fact that not taking it puts their lives at risk.

You are a dentist; if you get the same wrist / thumb problem that so many people taking arimidex get (myself included), then you are done being a dentist for a year or longer. Thus, for eight months of better T levels, you are risking your livelihood, and your family's livelihood.

So is it worth risking severe, long-term pain in your hands for a benefit that your body will naturally achieve within an eight month window, especially considering the very high incidence of side effects? Absolutely not. This idea is myopic at best, and very foolish at worst...

I appreciate your input structure! I will discuss this with Dr. Hulinsky. He's told me there are many ways to skin a cat.

 

[Structure]

I appreciate your input structure! I will discuss this with Dr. Hulinsky. He's told me there are many ways to skin a cat.

You're welcome, idmd! I hope you guys work out a safe solution...

 

[LW64]

25 mg Arimidex.

That's NOT a typo?

Twenty five milligrams every other day??

 

[idmd]

25 mg Arimidex.

That's NOT a typo?

Twenty five milligrams every other day??

That's what he said. I did ask him about joint pain and he stated all the literature was on women with breast cancer at higher doses and that in his entire career at this low dose he's only seen it twice. He said he uses AI frequently and I know he does treat many transgender patients. I have no reason to doubt him but will share the article with him and remind him what I do for a living.

 

[idmd]

Sometimes I hate looking at the little screen on my phone.....yes you are correct I believe it's 0.25mg every other day (although I do not have the Rx in front of me) but I'm guessing you could've figured that out I was missing a decimal point without having to ask.

 

[answerman]

I'm a patient of Hulinsky. Taking 1 mg arimidex E3D. Been 2 months, no issues. e2 dropped from 64 to 30.

 

[idmd]

I'm a patient of Hulinsky. Taking 1 mg arimidex E3D. Been 2 months, no issues. e2 dropped from 64 to 30.

My other question for him is my E2 was 31 even after taking exogenous test....isn't that already in the ball park and likely down even more since all the effects of exogenous test are gone? I guess I'm wondering where is he hoping to get me with the AI - cant too low of E2 be problematic? Isn't 31 a decent E2?

 

[Structure]

That's what he said. I did ask him about joint pain and he stated all the literature was on women with breast cancer at higher doses and that in his entire career at this low dose he's only seen it twice. He said he uses AI frequently and I know he does treat many transgender patients. I have no reason to doubt him but will share the article with him and remind him what I do for a living.

Remember: risk analysis. What is the cost, and what is the benefit? Do you really need to take this risk for just 8 months of benefit when the potential for loss is so great?

And as far as rarity goes, there are plenty of us on this very site that have reacted poorly to AIs. When you react poorly, you unfortunately react very poorly.

Lastly: take a look on pubmed or Google scholar; you will see that aromatase inhibitors are notorious for causing these problems. The current theory is that plasma levels of E2 may correlate well with aromatase activity in adipose tissue, but do not correlate well with aromatase activity in the tendons. In other words, taking an AI will lower your plasma E2, but exactly what it is doing to the aromatase in tendons is anyone's guess, as blood tests cannot measure this.

Like I said: the biggest mistake I've ever made...

 

[idmd]

So my options are:
1. Lose weight with absolutely no benefit of raising my testosterone (I was originally at a testosterone level of 170ish) including living with the extreme fatigue, exercise intolerance, moodiness, general disinterest in life all while having my body physiologically fighting my efforts. This also assumes that my low T is entirely due to obesity which Dr. H said it may or may not be.
2. AI which would temporarily help correct the underlying pathophysiology temporarily lifting my mood, fatigue, increasing my interest in life all while improving my body's physiology making weight loss easier but I have a 50% chance of losing my practice and being homeless if my joints start to act up.
3. Go on TRT which doesn't really address my underlying cause, will shut down my HTPA, probably lead to E2 issues anyway, shrink my nuts, throw off a couple other hormones and guarantee I need to supplement for the rest of life.

I now know why hypogonadism sucks.....there just ain't too many great options. SWEET!

 

[LW64]

See what the clomid does without an AI. It might help you get your T level back and in the meantime you can move forward with your diet and weight loss.

 

[Structure]

See what the clomid does without an AI. It might help you get your T level back and in the meantime you can move forward with your diet and weight loss.

An excellent suggestion. You could use this over the next 8 months while you lose the weight, and then go natural. Your T will increase without shrinking your testicles, which will help with mood and energy.

Furthermore, it would probably be more effective than an AI for assisting your exercise efforts; a recent study indicated that men who raised their T via the use of an AI did not see similar body compositional changes as did men who raised T through other means, despite having similar T levels (see: http://jcem.endojournals.org/content/94/12/4665.full.pdf): (Testosterone: More Is Not Always Better) J Clin Endocrinol Metab 2009;94(12):4665-7.)

"In the same study of im testosterone noted above, Page et al. (14) also found that testosterone therapy was associated with beneficial changes in body composition, including an increase in lean mass and a decrease in fat mass. Interestingly, a previous report by Burnett-Bowie et al. (3) using body composition data from the same anastrozole trial found no effect of anastrozole on either lean or fat mass. This finding raises the question of whether the body composition changes associated with testosterone therapy may also be mediated, at least in part, via aromatization to estradiol. As noted by the authors in their previous publication (3), there is evidence from rodent and human studies supporting a role for estrogen in regulating body composition. Thus, male mice with inactivation of either estrogen receptor alpha or the aromatase genes have increased fat mass (15, 16). Moreover, Vandenput et al. (17) found that in orchidectomized rats, estradiol not only prevented bone loss but also increased lean body mass and inhibited the orchiectomy-associated increase in fat mass. Studies in men with prostate cancer have found that treatment with bicalutamide (an androgen receptor blocker that increases estradiol levels) results in smaller increases in fat mass compared with treatment with a GnRH agonist (which reduces both testosterone and estradiol production) (18). Combined with the data from the anastrozole study (3), these findings indicate that aromatization of testosterone to estradiol may be critical not only for skeletal preservation but also for beneficial effects on body composition."​