Alberta: No Country for (Fat) Old Men

Last Saturday, apart from participating in the Super Size Me event, I also spoke at the 2nd Annual Endocrine Day for Family Physicians, organized by our division of endocrinology.

At this meeting Donald Morrish from our division presented a neat little update on Androgen Deficiency in the Aging Male (ADAM). This is what happens when guys’ testosterone levels drop to below 10 mmol/L with age.

Typical symptoms include sexual dysfunction (decreased libido and erection problems), osteoporosis, gynecomastia and infertility often accompanied by fatigue and low-energy levels.

What makes this issue interesting to the bariatrician is the fact that male hypogonadism is also associated with loss of lean body mass and accumulation of abdominal fat.

Indeed, there is ample evidence to support the idea that testosterone substitution in hypogonadic men will increase muscle strength and decrease visceral fat. Without substitution, trying to lose weight, build muscle or finding the energy to exercise may be impossible.

Importantly, while these benefits have been shown for replacement doses, there is no proven benefit of using supra-physiological or “pharmacological” doses of testosterone.

Similarly, while replacing low levels of testosterone is probably without risk, the use of testosterone in males with normal testosterone levels is potentially problematic.

Unfortunately, the diagnosis of male hypogonadism is not straightforward. The most commonly used assay for testorsterone measures total testosterone, i.e. both free (active) testosterone and that bound to sex homone-binding globulin (SHBG). The latter, however, is commonly decreased in obesity, resulting in a falsely low level of total testosterone.

So to really know if someone with obesity who also has low total testosterone levels truly has hypogonadism, one has to order the more expensive bioavailable or free testosterone.

This test, at least in Alberta, is not covered by the public health system and will cost the poor fellow around $45 – by no means a trivial sum.

Furthermore, once you decide to substitute testosterone (of which the most convenient gel form is also not covered by Alberta Blue Cross), you again have to monitor the free-testosterone levels at regular intervals – overall a venture that may cost around $1500 a year – definitely not cheap.

I guess Alberta is no Country for Fat Old Men.