Adrenal Hyperplasia, The Dukan Diet & Strength Training

[noramorta]

Hello,

I am female, 28, and have been diagnosed with Congenital Adrenal Hyperplasia (i.e. high testosterone, high cholesterol, high 17-hydroxyprogesterone, etc). I have always struggled with weight but have been strength training regularly for almost 10months now & have maintained an average weight of 78kg to 82kg for almost a year at a hight of 165cm with about 30% body fat. Currently I am 78kg & my waistline is 97.5cm. I am also a hiker & have summitted Mount Kilimanjaro in September 2010 where I suffered greatly of horrible cramps in my calves during the hike (later I discovered due to my condition I am prone to electrolyte imbalance during long-duration endurance activities, hence the cramps). Honestly, I haven't been eating the cleanest the past year nor have I been binging but I recently began The Dukan Diet, still strength training, and have lost 3.5 kilos & 2.5cms from my waist in the past 12days. I haven't lost this much weight nor this fast in one whole year! Now that I am committed to continue in this diet, I was hoping if someone can share whether this nutritional regime can compliment my strength training considering my condition. I have a tendency to build muscle quickly (obviously due to high testosterone) yet lose fat very stubbornly. I also am looking if someone can help shed light, or possess any knowledge of this condition of mine & what are the best tricks to work around it nutrition-wise.

Cheers,
Nora

[Lateralis17]

I read up on the diet and it seems to be a pretty good one. That mixed with weight training and cardio should produce some good results. The hardest part about dieting is sticking with it but if you make it to your goal, you can loosen the diet guidelines a great deal as long as you continue to train. As far as adrenal hyperpalsia, that is a little over my head as far as tips for dealing with it. I know that having an abundance of testosterone can be beneficial in giving energy and building lean mass. But it isn't good to have a hormone imbalance so consult a doctor or endocrineologist for treatment. Good luck I hope everything works out
Cheers

[noramorta]

Thank you so much for responding! I really appreciate it. I'm still on the diet & it seems to be working very well with me. I've lost another 2 kilos so that's a total of 5 to 6 kilos within the past 27 days. My body never really did respond to diets before as I always followed the "eat in moderation" or "exercise regularly & eat whatever" but given my circumstances, perhaps my body had a different idea. I will run a hormone check in about a week mainly to monitor cholesterol levels so yea! here's hoping.

[ryanwrthls]

Hello! Very interesting post about CAH...

The main problem with CAH is that there is an enzyme deficiency (usually 21-alpha-hydroxylase) that is usually present in the adrenal glands. This enzyme is what allows us to produce a hormone called "aldosterone", which is responsible for potassium EXCRETION and sodium uptake. Without this enzyme, your body will lose sodium and retain potassium (the excessive amount of potassium is the reason for your muscle cramping. A secondary effect is that the precursors for aldosterone "back-up" and end up shunting towards testosterone / androstenedione.

So here are the main things you should probably think about with your diet...

1) Individuals with CAH (or anyone with an excess of testosterone or growth hormone) have a higher chance of becoming diabetic later in life. This is simply because testosterone and growth hormone contribute to insulin resistance. Another factor is that your doctor has probably prescribed a regimen of cortisol, a drug that can result in insulin resistance. Try to stay away from very high-glycemic foods.

2) Individuals with CAH often develop hypertension, mainly due to the long-term regimen of cortisol they are given to treat the disorder (part of Cushing Syndrome). Try to keep the sodium low (the general recommendation is 2000mg/day).

3) Cortisol also has other side effects, such as predisposing to infection, fat redistribution, hypertension, diabetes, loss of bone mineral density.

Make sure to eat a balanced diet with multivitamins (fight infections), keep the sodium low (below 2000mg/day), try to stay away from very high glycemic foods and ask your doctor about taking calcium and vitamin D supplements (to prevent bone loss). This, along with a great exercise program will reap some great benefits for the long term!

Patients on long term glucocorticoid treatments are often given these recommendations / prescriptions ahead of time. But, in case this hasn't happened, here they are

In case you're wondering, I'm a 4th year medical student (graduating in a few months) so I have some experience in this condition in both general medical practice, obstetrics/gynecology and endocrinology.

I hope this helps you!!

Ryan

[Boss Man]

To much Corstisol can cause muscle and bone depletion and lead to Hypercortisolism, (Cushings disease).

[noramorta]

Hello! Very interesting post about CAH...

The main problem with CAH is that there is an enzyme deficiency (usually 21-alpha-hydroxylase) that is usually present in the adrenal glands. This enzyme is what allows us to produce a hormone called "aldosterone", which is responsible for potassium EXCRETION and sodium uptake. Without this enzyme, your body will lose sodium and retain potassium (the excessive amount of potassium is the reason for your muscle cramping. A secondary effect is that the precursors for aldosterone "back-up" and end up shunting towards testosterone / androstenedione.

So here are the main things you should probably think about with your diet...

1) Individuals with CAH (or anyone with an excess of testosterone or growth hormone) have a higher chance of becoming diabetic later in life. This is simply because testosterone and growth hormone contribute to insulin resistance. Another factor is that your doctor has probably prescribed a regimen of cortisol, a drug that can result in insulin resistance. Try to stay away from very high-glycemic foods.

2) Individuals with CAH often develop hypertension, mainly due to the long-term regimen of cortisol they are given to treat the disorder (part of Cushing Syndrome). Try to keep the sodium low (the general recommendation is 2000mg/day).

3) Cortisol also has other side effects, such as predisposing to infection, fat redistribution, hypertension, diabetes, loss of bone mineral density.

Make sure to eat a balanced diet with multivitamins (fight infections), keep the sodium low (below 2000mg/day), try to stay away from very high glycemic foods and ask your doctor about taking calcium and vitamin D supplements (to prevent bone loss). This, along with a great exercise program will reap some great benefits for the long term!

Patients on long term glucocorticoid treatments are often given these recommendations / prescriptions ahead of time. But, in case this hasn't happened, here they are

In case you're wondering, I'm a 4th year medical student (graduating in a few months) so I have some experience in this condition in both general medical practice, obstetrics/gynecology and endocrinology.

I hope this helps you!!

Ryan

Hi Ryan!

Thank you for taking the time to respond. Your input is certainly informative & useful! Yes, a couple of endocrinologists recommended I take small doses of Cortisone treatment which I never did. I'm normally very wary of meds & not to jinx myself but I only ever get minor cold once a year & pretty much rarely get sick so I suppose my immunity is Ok (worth noting which part of the world I live in!). I'm currently not taking any meds except for the occasional month-long intake of multivitamins (namely Centrum).

At the moment I been focusing on The Dukan Diet & I'm in the phase where I alternate days of pure protein foods (e.g. poultry, eggs-in moderation, fish & red meat-also in moderation, lots of yoghurt & cottage cheese etc) & days of pure protein foods with non-starchy veggies. It's been 33 days so far since I started the diet & I've lost a total of 7 kilos. My energy levels are high, in spite of low carb intake, yet I'm a lot more focused & alert & I'm experiencing n overall better wellbeing. I workout at least 2 times week, mainly strength training (interval & circuit) mixed with sole cardio days. Given your advise, I suppose some of the points don't apply now. But now that you mention the long run, I wonder if being prone to diabetes still apply without the Cortisone treatment. Besides in about a month I will move into a new phase of the diet where I get to reintroduce carbs & starchy foods but in moderation - note this diet is not Atkins style that includes tons of saturated fats. I'm also doing blood tests within this week (looking at lipid profile, hormones directly linked to CAH, salt levels, complete blood picture & then some). So here's hoping my results would turn out good! Wish me luck!

Any additional input will always help!

Cheers,
Nora

[ryanwrthls]

That's great! Definitely let us know how everything goes. I'm glad I was able to clear a few things up for you anyway

The point about diabetes mainly applies to long term treatments of cortisone. There are other adrenal problems that predispose to diabetes, such as Cushing Disease (not to be confused with Cushing SYNDROME) and tumors. But you're not in the realm of these sorts of problems.

Look forward to hearing from you and good luck!

Ryan

[noramorta]

That's great! Definitely let us know how everything goes. I'm glad I was able to clear a few things up for you anyway

The point about diabetes mainly applies to long term treatments of cortisone. There are other adrenal problems that predispose to diabetes, such as Cushing Disease (not to be confused with Cushing SYNDROME) and tumors. But you're not in the realm of these sorts of problems.

Look forward to hearing from you and good luck!

Ryan

Hi!

I finally got my results in & things are looking much better but still got to work a lot harder. Update as follows:

- Within 41 days, I lost 7 kgs from 82 kgs to 75kgs. I think that's a reasonable amount of weight to lose during that time. Still doing cardio & strength training so I definitely feel leaner. Still on The Dukan Diet which helps me eat cleaner in spite of the low carb in take. Still taking Centrum multivitamin tablets daily.

- Total Cholesterol went down from 292 mg/dl to 218 mg/dl, LDL went down from 195 mg/dl to 149 mg/dl, Triglycerides went down from a whopping 221 mg/dl to 95 mg/dl & my HDL is stable at 50 mg/dl but did go down from 53 mg/dl. Got a bit to go but I'm still excited by the overall decrease.

- I was concerned about Uric Acid due to high protein in take but found to be just at 5.5 mg/dl, close to the limit of 6.0 mg/dl but I guess so far so good. Blood Urea, Creatinine, fasting Blood Glucose are all within normal level in fact Blood Glucose increased from 69 mg/dl to 83 mg/dl, not sure if that's a good thing.

- Calcium, Phosphorus, Proteins, Sodium & Postassium levels are all within normal level, even some increased, surprisingly like the Calcium. I wonder why, maybe all that yoghurt & cottage cheese?

- Testosterone levels still high for a female. Total Testoerone is 1.61 ng/ml but my Free Testosterone went down from 6.60 ng/ml to 4.20 ng/ml. No sure why also. Would love some input on that one!

- My main concern is that the analysis showed a mild case of Hypocromia & Microcytosis, Haemoglobin's count a little low, I've had that before but this time it went down also. I'm guessing due to overall drastic change in diet? Any tips/advice? Perhaps that explains the muscle cramps during vigorous exercise?

So yea, that's about it for now, will run another test in a couple of months or so just as soon as I reach my target weight & focus on getting leaner! I guess I'm realizing that my body works well with a low-carb diet as I've honestly never felt better, more energetic or generally "healthier".

Cheers,
Nora

[ryanwrthls]

Hey Nora --

Congrats on doing so well with your diet! 7kgs/6 weeks is a healthy way to do it.

A few things...

For cholesterol, the general goal is LDL below 100 and HDL above 50. But remember, these things don't happen overnight! You're definitely headed in the right direction. Hopefully your doctor has prescribed a lipid-modifying medication as these values are more difficult to control in CAH.

Very high uric acid levels can lead to gout, a condition in which uric acid crystals precipitate in join fluid (painful!). Usually this occurs in someone with both a xanthine oxidase deficiency (enzyme that breaks down uric acid) AND a very high protein diet. Small fluctuations in blood uric acid usually occurs because normal kidney function widely varies throughout the day...so it just really depends on WHEN the blood was drawn and what your kidney was doing at that particular time.

Low carb diets can lead to high uric acid levels, simply because without many carbs or glycogen, your body becomes forced to use amino acids from your muscles for energy. Amino acids from the proteins in your muscle are broken down to form uric acid.

High levels of cortisol can also increase blood uric acid. This is because cortisone is lymphocytic, meaning it destroys white cells which are responsible for immune function. This not only predisposes to infection, but it releases large amounts of DNA from the nucleus of the white cells (DNA is broken down to uric acid). Many people on chemotherapy also develop very high uric acid levels and develop uric acid stones and gout (called Tumor Lysis Syndrome).

But, bear in mind that the only recommendation for treatment of a high uric acid is if symptoms occur. It is not recommended to treat just high uric acid levels with no symptoms.

Blood glucose varies widely throughout the day, depending on meals, what time of day it is, if you're stressed/anxious, cortisol level, etc etc. The only time to worry about blood glucose is either when it's very high (>125) or when your HbA1C level is greater than 6.5mg/dL. HbA1C is a way to estimate what your blood glucose has been over the past 3 months (more than 6.5 means blood glucose has been more than 125mg/dL on average). It basically measures how many of your hemoglobin molecules have glucose attached to them.

Calcium is another one of those things that varies widely throughout the day. The only time to worry about it is if it's very very high (in which case you'd worry about a parathyroid adenoma). The only time you would develop high calcium levels from the diet is if you're taking in far too much vitamin D, or drinking tons of Maalox. There are other endocrine disorders that produce high calcium, but you're in the clear from those.

Your testosterone level is very interesting. It looks like your decreasing total cholesterol level has resulted in a decrease in your free testosterone (cholesterol is metabolized to sex steroids like testosterone). The testosterone in your body is either freely floating in the blood or bound to proteins (albumin and sex-steroid-binding-globulin). There's a constant gradient that occurs in this system...as testosterone is metabolized from the blood, more steroid is released from the binding proteins. When the testosterone in your blood increases, the excess is taken up by blood proteins.

Anyway, the decrease of your free testosterone is likely due to both your decrease in weight and decrease in total body cholesterol (more body fat promotes more steroid hormone synthesis. This is why young female gymnasts don't go through puberty until very late...they simply don't have the body fat to create estrogen!).

The most likely cause of your low hemoglobin and small, pale red cells (microcytosis, hypochromia) is iron deficiency due to heavy menstrual cycles (common in CAH). Iron deficiency is very common and easily treated. DO NOT go overboard on adding iron to your diet. There's a delicate balance...your body has no way of getting rid of/metabolizing excess iron in the body, so it ends up accumulating. Some people with thalassemias (a hereditary defect that prevents proper hemoglobin formation) develop hemochromatosis because of excessive iron supplements and blood transfusions (iron overload leading to "bronze diabetes", pituitary dysfunction, congestive heart failure and liver cirrhosis). There are drugs to remove iron (deferoxamine), but I wouldn't rely on this.

I wouldn't worry too much about your hemoglobin, as it is typically lower for females, especially in CAH. As long as you're not below 7, you're doing fine. I'm assuming your multivitamins contain iron if not, then I would recommend it. This will help with fatigue (more hemoglobin means more oxygen-carrying capacity). This COULD cause cramping when you exercise, but it must be very severe for a low hemoglobin to cause cramps. In other words, you'd likely be hospitalized for other problems before you'd feel cramps.

It is more likely that cramping is due to dehydration and electrolyte changes during vigorous exercise. Cramping due to a low hemoglobin would have to be extremely severe. A moderately low hemoglobin would just increase the frequency and duration of "burning" during exercise. This is because the muscles are in a more anaerobic environment, producing more lactic acid than normal (lactic acid is responsible for the "burning").

One thing I like doing is getting the powdered gatorade from the store and spiking my water with some powder. That way I can control the amount of sugar in the drink. That should help prevent cramping.

Thanks for sharing!!

Ryan

[Boss Man]

To my knowledge the body has no enzymes to breakdown Uric Acid, it gets rid of it with water stores.

There is an Enzyme called Xanthine Dehydrogenase, that converts the Xanthines in Methylxanthines into Uric Acid, but no specific enzymes per se.

Judging by the name Xanthine Oxidase, (admittedly it's a new one on me), I'd suggest it oxidises Xanthines, which I would consider not the same as removing or possibly dissolving Xanthines.

Also Nitrogen in Amino Acids converts to Uric Acid, but I'm 99.9% certain not the Amino Acids themselves. Not being critical, just clarifying that to people, as how you worded it may lead to misinterpretation .

Too much Cortisol can lead to Hypercortisolism, (A.K.A Cushings disease), which is not pleasant and is a big indicator of bad bone density and muscle condition and can cause a rounded face, possibly because of the potentially substandard condition, of muscles and bones in the face.

Agreed about the Parathyroid, the Adenoma from memory causes Hyperparathyroidism, which would send Calcium and potentially Phospherous regulation activity out of kilter and I believe increases Calcium to the blood more, possibly causing Calcification, (Arterial stiffening) and possibly Ventricular stiffening in the Heart as well.

[ryanwrthls]

The drug we use to treat gout or tumor lysis syndrome is called "allopurinol", which is a drug that inhibits the enzyme xanthine oxidase. The enzyme converts xanthine (an excretable substance) to uric acid. Diets very high in proteins cause a buildup in uric acid, which then precipitates in joints (gout).

Blocking the enzyme prevents uric acid formation, allowing the precursors to be urinated out at xanthine.

Xanthine oxidase is a REVERSIBLE enzyme. In other words, it can convert uric acid to xanthine, but it also converts xanthine to uric acid. Blocking the enzyme eliminates the uric acid part of the equation because uric acid is the downstream product. If uric acid is very high, the enzyme is overloaded because xanthine will also be very high. Blocking the enzyme prevents the formation of uric acid all together, allowing xanthine (something that can not precipitate out as a salt) to be released in the urine.

With the parathyroid adenoma, those patients develop neurological symptoms before developing calcification of tissues. I actually had a patient with this a few months back...she was having seizures, lethargy, muscle cramping. We took her into the operating room and removed the single parathyroid adenoma and she was fine.

Calcification of tissues will only occur when both calcium and phosphorus are high simultaneously. Parathyroid hormone causes the excretion of phosphorus and the resorption of calcium from the kidney. However, vitamin D excess will increase both phosphorus and calcium, which could potentially lead to tissue calcification (calcium forms a salt with phosphate, therefore you need high calcium and phosphate in order to precipitate into tissues).

Ryan

[noramorta]

Wow guys thanks a lot for the valuable & insightful information. I have to confess, I had to Wiki a couple of your terms down there! I mean, that's some heavy stuff & really all I want to do is get lean & stay healthy & get my levels down but I know some won't be so easy.

Just a couple of inputs:

- Knowing I'm on a high protein diet, I been drinking tons of water & urinating regularly. Do you think my Uric Acid levels are still too high? May I should share what kind of foods I eat every day.

- I haven't been prescribed any medication to control lipids. At this time in my life, I'm very anti-meds & only have been consuming multivitamins, only because. So I'll opt to go solo until I do another round of tests.

- When I took the tests I been fasting for 12hrs. Stopped eating/drinking from 10pm through the night & got my blood drawn at 10am in the morning. Does does that make any sense Blood Glucose-wise?

- Regarding the Iron bit, you'd be surprised to know that I have very low & short periods. I barely have any of the issues most girls complain about like cramps & pain & can't-get-out-of-bed-syndrome. The only prominent symptom I experience is at least one day of blues with massive mood swings a week or 10 days before my period starts. Upon my period I actually get energized & feel great & can hop freely to the gym. I experience nothing, not heavy at all & my flow only lasts a day or two & fizzles out in a total of 4 to 5 days. But it has been regular. Aprox every 25 to 27 days. So not sure how the iron deficiency applies here?

- The only time I experienced the major cramps was during my Kili attempt. Perhaps altitude is a contributing factor also? worthing noting it was about a little under 6000m. I intend to continue climbing mountains in the future so it is also a concern of mine how best I should prepare my body to be able to experience altitude in a less painful way as I did with Kili.

Thanks guys for the regular & useful inputs!

Looking forward to more.

Cheers,
Nora

[ryanwrthls]

hey there...

I wouldn't worry too much about your uric acid. It really takes lots and lots of protein over many years to actually develop gout if you don't have a genetic defect in xanthine oxidase (overactive). It was actually a disease of royalty in the old days (they were the only ones able to afford meats and cheeses!).

Fasting glucose is used to diagnose diabetes. The most common criteria to diagnose diabetes type 2 are to have a fasting glucose level greater than 126 on two separate occasions. Glucose normally increases slightly in the morning because of the cortisol and growth hormone surge that occurs a few hours before waking up from sleep. But overall, glucose varies widely throughout the day, regardless of any disease process, if it even exists.

There are honestly so many causes of iron deficiency. One common type is called "anemia of chronic disease". Most of the time we can't figure out what the problem is...we only know that the patient has had a condition for many years (and it really could be any condition). This type of anemia appears as iron deficiency on a blood smear (hypochromic, microcytic anemia), but total iron stores are normal (the iron becomes trapped in the bone marrow). This could be sorted out with a simple iron panel.

The heavy menstrual period was just a guess as many women with hormonal imbalances develop heavy periods (but definitely not universal!).

There are ways to avoid altitude sickness. One way is to ask your doctor about a medicine called "acetazolamide". This drug essentially balances the acid-base status of your blood (it involves stabilizing bicarbonate ion in the blood). Sometimes this can be used for altitude sickness and general fatigue at high altitudes.

There are also small "oxygen tanks" that you can put in your pocket and take up the mountain with you (I saw these at a mountain climbing shop once). Basically it's just 100% oxygen in a bottle...I'm not sure if it works or not...it's just a curious thought.

Other things you can do are just to train at higher altitudes. For example, jogging or biking on the mountainside. Training regularly at higher altitudes increases the activity of "erythropoeitin" (EPO), a protein secreted by the kidney in response to low pressures of oxygen in the blood. EPO circulates through the blood, into the bone marrow and stimulates the formation of new red blood cells. If you train at high altitudes, your EPO level will gradually increase, and your red blood cell count will increase. This allows for an increased oxygen carrying capacity in the blood.

In fact, people who grew up in high altitudes have thicker bones (more bone marrow) and a higher hematocrit because their bodies have become accustomed to low pressures of oxygen.

I think some intense trainers use synthetic EPO ($$$$$) to increase their hematocrit...leading to more oxygen delivery and quicker training results. I'm pretty sure it's a banned substance in most sports....thoughts on this one?

I know we use EPO for people with kidney disease (who can't make their own EPO) and others with bone marrow failure.

Ryan

[Boss Man]

Appreciate the clairifcation Ryan and the comments .

[ryanwrthls]

hey no prob dawg I do this stuff for a living, lol.

Ryan