The Latest Guidelines For Male Hormones | Part 3

Table of Contents

Introduction

When the body is functioning properly, it is due to the hormones working on each organ and body system for individuals to achieve overall health and wellness. In males, the lead hormone is testosterone, and when hormones get off-balance it can cause problems to the male body. Hormones naturally decline due to age and chronic illnesses can also affect hormones causing individuals to be in pain and disrupting everyday activities. Part one explains what happens when there is low testosterone in a male body and part two explains what are the causes for low testosterone. Over the last decade, many of our patients asked complex and insightful questions about hormone replacement therapies. By referring patients to qualified and skilled providers who specialized in hormone wellness services, we advise our patients, appropriately, to refer to our associated medical providers based on their examination. We find that education is the key to asking valuable questions to our providers. Dr. Jimenez DC provides this information as an educational service only. Disclaimer

What Is Hormone Replacement Therapy?

In older males, hormones naturally decline due to age and the testosterone levels start to get off-balance when there is an overproduction from the adrenal glands. With hormone replacement therapy or HRT, it can help regulate and replenish testosterone levels in the body. Not only that but HRT can even help prolong the progress of prostate cancer and lower the overproduction of androgen hormones from the adrenal glands.

New Guidelines Presented at the American Academy of Anti-Aging.

Download

Testosterone Replacement Therapy & Erectile Dysfunction

Erectile dysfunction is a common complaint that older males go through when they age. Testosterone replacement therapy or TRT shows promising potential by replenishing low testosterone levels and improving erectile dysfunction.

Review of studies done on TRT and ED. (Rizk et al, 2017)
The recently published Testosterone Trials – a set of RCTs of 790 men with late
onset hypogonadism randomly assigned to either testosterone gel or a placebo –
demonstrated that after 1 year of treatment that men who used testosterone gel
had an IIEF-ED score 2.64 points [95% Confidence Interval (CI): 1.06 – 4.02]
greater than men who had been assigned to the placebo arm
“The available literature supports a role for TRT in men with low testosterone
levels, ED, and low libido, with symptomatic improvement in these men.”

TRT and Cognitive Function

Since testosterone correlated with cognitive function, TRT improves it. High free testosterone, was associated with better performance on tests from memory, executive function, and spatial ability. Not only that, TRT can reduce the risk for Alzheimer’s and improve cerebral blood flow.

Androgen supplementation in elderly
hypogonadal men improve spatial cognition
and verbal fluency
In elderly men without dementia, it may reduce
working memory errors
Testosterone or DHT therapy in men aged 34 to
70 years improved verbal memory and spatial
memory respectively

Testosterone and Alzheimer’s

Alzheimer’s disease is a progressive neurological disorder that causes the brain to shrink and is one of the most common causes of dementia. Alzheimer’s can cause a person to decline their thinking, behavioral and social skills while also affecting their ability to function independently.

TRT prevents the production of beta-amyloid precursor
protein in men
– Gouras GK et al. Testosterone reduces neuronal secretion of
Alzheimer’s beta-amyloid peptides. Proc Natl Acad Sci USA 2000 Feb
1;97(3):1202-5
Alzheimer’s male patients TRT treated improved over 1 year;
control group deteriorated
– Tan RS A pilot study on the effects of testosterone in the hypogonadal aging male
patients with Alzheimer’s disease. Aging Male. 2003 Mar;6(1):13-7

Testosterone Replacement Therapy can have a beneficial impact on males which includes:

Erectile Dysfunction
Cognitive function in Alzheimer’s
Bone Mass Density
Body composition
Metabolic parameters
Maybe blood pressure

Testosterone and Inflammation

Testosterone therapy created a more anti-inflammatory profile by lowering fewer inflammatory cytokines like TNF and IL-1 beta. TRT can cause the body to produce more anti-inflammatory cytokines like IL-10 and even help lower total cholesterol.

Inflammation plays a central pathogenic role in the
initiation and progression of coronary atheroma
and its clinical consequences.
Cytokines are the mediators of cellular
inflammation and promote local inflammation of
the arterial wall, which may lead to vascular
smooth muscle apoptosis, degradation of the fibrin
cap and plaque rupture

The Baseline Testing for Testosterone Deficiency

The guidelines recommend collecting an early-morning sample to compensate for the natural diurnal variation in testosterone levels. But for men 45 and older, this is unnecessary. About 2569 men at Minneapolis VA looked at testosterone levels based on age throughout the day. Only the youngest men (<45) had significant differences based on age and the different tests to detect testosterone deficiency include:

Blood testing (serum)
– Total/free testosterone
– SHBG
– DHT
– DHEA
– Estradiol
– LH/FSH
24-hour urine testing
Saliva testing
Blood spot testing
Dried urine test

Methods of Testosterone Therapy

There are many methods of testosterone therapy for males that have low levels of testosterone. This includes:

Transdermal patch
Topical Testosterone
Injectable Testosterone
Oral
Pellets
Clomiphene
HGH

TRT: Transdermal Patches

Transdermal Testosterone Patches are available in 2-mg and 4 mg preparations and the typical starting dose is 4-mg/day; can increase to 8-mg or decrease to 2 -mg as needed. What you need to do is:

Applied at night to a clean, dry area of skin on the back, stomach, upper arms, or thighs.
Sites should be rotated daily, allowing 7 days before re-applying to the same site
Side effects:
– Skin irritation, vesicle formation, contact dermatitis,
headache, and depression

TRT: Gel Formulations

Testosterone Gels are topical testosterone and can be applied in the morning to the shoulders, abdomen, or upper arm; preferably at the same location every day. What you need to do:

Use gloves or wash hands after application- They will have hormone on hands for 4-12 hours
Allow gel to dry (10-15 min) before covering with clothing
Wait 4 hours prior to showering or swimming
Wash with soap and water if skin-to-skin contact with another person
anticipated
– Dosing: 1% or 1.62% generally available
– 5 grams (50 mg testosterone) daily, can be increased to 7.5 – 10 grams as needed or 40.5 mg of the 1.62%, can be increased in increments of 20.25mg
Side effects: acne, headaches, emotional lability, nervousness, gynecomastia, mastodynia, insomnia, hypertension, hot flashes, polycythemia, and increased PSA
– Local skin irritation occurs much less frequently than with patches
– Major issue is transference
– Substantial variation in absorption

Injectable Testosterone

Injectable testosterone esters in oil are slowly absorbed from the lipid
phase. There are different esters absorb at various rates giving them different
half-lives:

T cypionate 12 days
T enanthate 10.5 days
T propionate 4.5 days

The longer-acting esters may convert more readily to estrogen and peak levels after IM use are greater than topical use but so is peak-trough fluctuation. There are two types of testosterone injections, there are testosterone enanthate or cypionate injections. What these two injections do are:

Commercially available or compounded
Q2 weeks 200mg IM (Older method)
– Supraphysiologic levels followed by low levels
– More aromatization to estradiol
– Less DHT than transdermal
Weekly dose 100mg IM
– Better physiologic, stable levels
– Less aromatization to estradiol
Bi-weekly dose 25-50mg IM or SQ (more irritating)
– SQ may have more consistent levels (Shippen)
– SQ is generally preferred by patients and achieves similar levels as IM

Testosterone Undecanoate Oral

The adverse effects are approved 3/2019 and have a BID formulation taken with food. The dosage is about 237 mg bid up to 396 mg bid (avail as 158, 198, and 237 mg soft gels). By taking testosterone undecanoate orally it is best to know that it can increase BP (Black box warning of the risk of major cardiac events), it can bypass the liver because it is absorbed through lymphatic circulation and it can avoid skin irritation (patches), transference (Topicals), pain (injections).

Testosterone Pellets

Testosterone Pellets can offer the longest duration of action with prolonged zero-order, steady-state characteristics. They can last 3 to 6 months depending on activity and stress level and are about 75mg per pellet and are measure 3.2 mm (1/8 inch) in diameter and approximately 9 mm in length.

Usages on testosterone pellets:

150mg to 450mg SQ Q 3-6 months
Insert 2 pellets for every 25 mg of testosterone propionate injection needed
weekly
Potential drawbacks:
– Minor office procedure
– Risk of infection and pellet extrusion
– Inability to remove pellet if a contraindication to testosterone therapy develops

Clomiphene

Clomiphene citrate is used off-label to attempt to increase sperm density in men with oligospermia or azoospermia and normal to low serum testosterone concentrations. Clomiphene is also used for testosterone deficiency in men who wish to preserve or improve fertility. Clomiphene is a weak estrogen receptor antagonist that stimulates increased pulsatile GnRH secretion from the hypothalamus and subsequent pituitary gonadotropin (FSH, LH) release. There have been multiple studies that suggest clomiphene citrate can improve semen parameters in patients with oligo-, oligo astheno-, and azoospermia. Clomiphene dosing includes:

25 – 50 mg every other day or 12.5 mg QD
Clomiphene given by 2 different dosing regimens were compared in 89 oligospermic men. The group receiving clomiphene 25 mg every other day showed a greater overall sperm improvement response (80%) than the group receiving clomiphene 25 mg daily for 25 days (50%). Increases in sperm concentration and total sperm count were significantly greater with the lower dose regimen. Pregnancy rates in the study were not significantly different during the 6 month
follow-up period (Homonnai et al, 1988).
May raise Testosterone levels w/ less impact on libido than Testosterone

Clomiphene side effects include:

Flushing, vasomotor, abdominal bloating, discomfort,
distension, nausea, vomiting, headache, visual disturbance, breast pain
Serious side effects: acute pancreatitis, functional visual loss, psychotic
disorder, a disorder of menstruation, hyperstimulation of ovaries,
hypertrophy of ovary, ovarian cancer
Watch out for pituitary apoplexy
Contraindications: liver disease or dysfunction, endometrial carcinoma,
ovarian cysts (not polycystic ovarian syndrome), undiagnosed uterine
bleeding, pregnancy

HCG

HCG does not negatively impact fertility/sperm count as testosterone often does and does not cause testicular atrophy. Surprisingly it is identical to LH with some FSH activity stimulating testosterone production by the testicle. HCG Dosing includes:

1000-3000 units intramuscularly 2-3 times weekly SC
Some use along with Testosterone for testicular preservation at doses from 500-1500 IU / week. No clear references for this.
Antibody production against the hCG is possible
– Most protocols recommend 2 months on and one month off hCG

HCG side effects and precautions include:

Anaphylaxis
Do not use in cancer or tumors
May cause water retention
VTE has been reported
Intracranial lesions
Prostate cancer or other androgen-dependent neoplasms
Do not use orally, contains benzyl alcohol
Administration of chorionic gonadotropin can stimulate the production of antibodies.
In rare cases, these antibodies may result in resistance to treatment by binding chorionic gonadotropin

Conclusion

All in all, hormones play a functional role in the body. When there are unwanted pathogens that entered the body and cause harm it can lead the body to be off-balance. In this case with hormones, when the unwanted pathogens cause the body to overproduce hormones, it can cause chronic illnesses that can cause pain and affect a person’s overall health and wellness.

Disclaimer

Planks For Spine Support and Back Pain Prevention

Dr. Alex Jimenez

focused sportswoman doing plank exercise at home in living room

Regularly doing planks can support/strengthen the spine and prevent back pain no matter the fitness level. It’s estimated that 70% of adults will experience back problems and pain. One of the best ways to keep the spine healthy is by strengthening the core muscles. The more these muscles are built up, the healthier the body will become. The plank position activates the entire core taking the pressure off of the spine.

Core Anatomy

The core is the center of the body. It contains all the muscles surrounding the torso. These muscles work together to:

Stabilize the body during movement.
Prevent injury when engaged in physical activity/exercise.
Provide spinal support.

The core is split into two groups of muscles: The inner core and the outer core.

Inner Core

The inner core consists of:

Multifidus Muscles

Located in the deep layer of the back on either side of the spinal column.

Quadratus Lumborum

The deep abdominal muscle in the lower back sits on either side of the lumbar region of the spine.

Transversus Abdominis

Located between the lower ribs and the top of the pelvis.

Pelvic Floor

This base group of muscles stretches from the tailbone to the pubic bone.

Diaphragm

A dome-shaped muscle that rests below the lungs.

Outer Core

Rectus Abdominis

These are more commonly known as the abs.

External Obliques

These muscles are located on either side of the rectus abdominis.

Internal Obliques

These muscles are located below the external obliques, inside the hip bones.

Erector Spinae

These muscles surround the spine and extend up both sides of the vertebral column.

Planks and Back Pain Prevention

When the core is not strong enough, the spine and back muscles overcompensate to keep the body standing correctly. Studies have shown how planks effectively activate the muscles responsible for spinal stabilization. The exercise targets the entirety of the core and strengthens the shoulders and glutes. Strengthening these muscles improves posture, helping to alleviate back problems and pain. However, it’s recommended to talk to a doctor before beginning a plank regimen if back pain is present. If done incorrectly, they could aggravate the back muscles.

Proper Form

Choose an area clear of furniture where the whole body can stretch out. Follow these steps:

Begin with hands and knees on the floor.
Extend the legs back while keeping the elbows directly below the shoulders and the wrists below the elbows.
Keep the head down, looking at the space just above the hands.
Engage the abs and keep the body rigid.
Imagine a perfectly straight line from the neck to the toes.
Hold the position for 10 to 60 seconds, depending on fitness level.
Lower the body gently to the floor.
Make sure not to curve the back as curving means that the abdominal muscles are being engaged, and tilting the head up can strain the neck.
Both can lead to injury, which is why maintaining proper form is essential.

Plank Variations

There are variations of this exercise for different levels of physical fitness. Once the modified and full plank has been mastered, various planks can target other areas of the body. These include:

Side Plank

These involve shifting the weight to one forearm while extending the other arm into the air.

One-arm Plank

These involve lifting one hand off the ground, then alternating.

Single-leg Plank

These require lifting one leg off the ground, then alternating.

Walking Plank

These shift the right hand and foot evenly, then bring the left hand and foot to the full plank position.

Reverse Plank

These require facing the opposite direction and pushing upwards towards the ceiling.

Anybody can work up to a plank at any age at any fitness level; it just takes time. Once achieved, it is a great way to keep the body’s core strong, healthy and helps prevent back problems.

Body Composition

Band Lateral Raise

The lateral band raise is an excellent workout for the shoulders. It works out the lateral deltoid, anterior deltoid, and serratus anterior.

Grasp one band in one hand.
Step on the free end with the opposite foot.
Right hand and left foot and vice versa.
Slowly extend and raise the arm until they are parallel to the floor.
Lower the arms in the same manner.
If the shoulders are healthy and strong enough, try adding dumbbells or kettlebells to increase the resistance.

References

Calatayud, Joaquín et al. “Tolerability and Muscle Activity of Core Muscle Exercises in Chronic Low-back Pain.” International journal of environmental research and public health vol. 16,19 3509. 20 Sep. 2019, doi:10.3390/ijerph16193509

World Health Organization. (2013) “Low back pain.” www.who.int/medicines/areas/priority_medicines/Ch6_24LBP.pdf

Youdas, James W et al. “Magnitudes of muscle activation of spine stabilizers in healthy adults during prone on elbow planking exercises with and without a fitness ball.” Physiotherapy Theory and practice vol. 34,3 (2018): 212-222. doi:10.1080/09593985.2017.1377792

The Latest Guidelines For Male Hormones | Part 2

Dr. Alex Jimenez

Table of Contents

Introduction

The body’s entire system is controlled by hormones. Hormones are what make the body regulate temperature and control the organ system so it can function properly. When there is an imbalance of hormones the body can develop chronic problems causing pain to individuals and disrupting their everyday activities. Many of our patients over the last decade have asked complex and intuitive questions about hormone replacement therapies. Part one explains what happens when there is low testosterone in a male body. By referring patients to qualified and skilled providers who specialized in hormone wellness services. To that end, and when appropriate, we advise our patients to refer to our associated medical providers based on their examination. We find that education is the key to asking valuable questions to our providers. Dr. Alex Jimenez DC provides this information as an educational service only. Disclaimer

What Is Hormone Replacement Therapy?

In older males, hormone replacement therapy can help replenish testosterone levels in the male body. When the hormones are off-balance, HRT can help reduce levels of androgen that the male body produces. With HRT it can help prolong prostate cancer progress and even lower the adrenal glands from overproducing unnecessary hormones that the body does not need.

What Constitutes “Stress”?

There are many factors that can cause body stress. There are two types of stress levels acute stress and chronic stress. Acute stress is caused by simple things like studying for an exam or running late to work. Chronic stress is caused by situations that can negatively affect a person’s health. Some examples include:

“Fight or flight” responses
– fear, anxiety, worry
Depression, feelings of defeat or
helplessness
Pain syndromes
Infection, inflammation
Hypoglycemia
Inadequate sleep
Disrupted light cycles
Toxic exposure

New Guidelines Presented at the American Academy of Anti-Aging.

Download

Let’s Talk About Toxins…

There are some toxins that can affect the human body and can cause prolonged effects that can lead to chronic pain.

Pesticides
Food additives and preservatives
Electromagnetic radiation
Heavy metals
Phthalates
Bisphenol A
And many more…

Toxins – Phthalates

Phthalates are a group of chemicals that are used to make plastics more durable. However, these toxins can cause male hormones to be off-balanced.

Esters of phthalic acid and are mainly used as plasticizers
As of 2004, 800 million pounds produced
Introduced in the 1920bs
– 1856: castor oil
– 1870: camphor
– Enteric coatings
Current uses:
– Enteric Coatings
– Viscosity control agents
– Binders
– Lubricant

Phthalates can be found in hundreds of everyday products that we use in our day-to-day lives. These include:

Personal care items
– Make-up, shampoo, moisturizer, liquid soap, hair spray, cologne
Detergents
Cleaning materials
Modeling clay
Fishing lures
Paints
Children’s toys
Food packaging

Bisphenol A

Bisphenol A or BPA has been primarily used to make certain resins and plastics for everyday items and has been used in commerce for the past 50 years. Some of the common products that BPA has produces include:

Polycarbonate bottles (clear, flexible plastic)
Baby bottles
Water bottles
Dental sealants
Sports equipment
Eyeglasses
CD’s and DVD’s
Toiletries

When males are exposed to BPA, it can cause male infertility and erectile difficulty to the body and even lower testosterone levels causing the body to go haywire.

Increased Risk From TD on Cardiovascular Events & Mortality

With testosterone has many important effects on the body including the cardiovascular system. When there is a decrease in testosterone that happens in men after they turn 40 has been associated with an increase in all-cause mortality and cardiovascular risk.

A meta-analysis that investigated 16,184 community-based participants with a mean
follow-up of 9.7 years found that low T levels were associated with an increased risk of Overall and CV-related mortality with an HR for CV mortality of 1.35 (95% CI, 1.13-1.62; P<.001). (Araujo, 2011)
Meta-analysis of 70 studies showed a clear association between low T and CV disease Of those, 10 longitudinal studies demonstrated that overall mortality and CV mortality were highest in those with low T levels. Whether low T and increased mortality are simply covariates or a causal the relationship remains to be proven” (Corona, 2011)

Laughlin Rancho Bernardo Study

The prospective study of 794 men aged 50-91 with Testosterone at baseline and followed through mortality.
• Average 11.8 years f/u (but up to 20)
• Total and Bioavail Testosterone inversely related to the risk of death
in-depth of DM metabolic syndrome, CVD but attenuated for
adjustment by CRP ad IL-6
• Lowest vs highest quartiles of Testosterone conferred 40%
increased risk of overall mortality and 38% higher
risk of cardiovascular mortality

Khaw et al EPIC-Norfolk Study

“In men, endogenous testosterone concentrations are inversely related to mortality due to cardiovascular disease and all causes”

N = 11,606 men (no cancer or CVD)
– 825 men died matched with 1489 living men in the control group
– Nested case-control looked at endogenous Testosterone at baseline
Men have to have a follow-up 7 years

Testosterone Deficiency

A wealth of modern data accumulated over the past 2 decades has generally revealed that a low serum testosterone level is associated with increased risks of atherosclerosis, CV risk factors, and mortality. Testosterone therapy has beneficial effects on multiple risks factors and risk biomarkers related to these clinical conditions. Notably, TD has been projected to be involved in the development of approximately 1.3 million new cases of CV disease, 1.1 million new cases of diabetes, and over 600,000
osteoporosis-related fracture.

Testosterone and Sarcopenia

When testosterone levels start to lower in a male body it can correlate with the pathophysiology of sarcopenia. Sarcopenia is defined as skeletal muscle mass and strength loss due to age and low testosterone can contribute to decreasing sex hormones and changes to body composition.

“Given the likelihood that age-related sarcopenia contributes importantly to frailty, and the importance of osteoporotic fractures as a cause of morbidity and mortality in elderly men, testosterone replacement is a potentially useful strategy for reducing age-associated disabilities in some aged men.”
– Three months of Testosterone enanthate injections increased lean body
mass in men over 60 yr of age.
– Testosterone treatment improved hamstring and quadriceps muscle
strength after 4 weeks in healthy older men
– Testosterone replacement for 2 yr produced again in the bilateral grip
strength in elderly hypogonadal men.

Testosterone and Erectile Dysfunction

The body produces androgen for the male body to function properly. When there are low levels of testosterone and high levels of androgen it can cause erectile dysfunction.

“Visceral obesity, a component of metabolic syndrome, adversely affects endothelial function and testosterone levels, contributing to hypogonadism and erectile dysfunction. “
Clinical screening for the risk of erectile dysfunction in obese
patients should include:
– Waist circumference
– Testosterone levels
– Body mass index
– Physical inactivity
Study of Testosterone levels and ED in 802 men showed moderate and
severe ED assoc w/ lower T levels
– lower serum testosterone levels were strongly associated (p < 0.001) with severe
(OR 0.78; 95% CI: 0.62-0.86), and moderate ED (OR 0.85; 95% CI: 0.72-0.97)

Conclusion

All in all, hormones play a major role in the body. Hormones are what keep the body functioning properly and make sure the organs are doing their job. When unwanted pathogens start affecting the body, it can cause the hormones to be off-balance and cause major chronic problems that cause pain and illnesses that no one wants.

Disclaimer

Everyday Movements

Dr. Alex Jimenez

Charming elegant woman receiving professional treatment in spa wellness center — Cropped head back view portrait of unrecognized female in black sportswear standing in medical office while male massage therapist examining her back and spine

Posture is how we hold our bodies while standing, sitting, or lying down. A healthy posture is the correct alignment of the body supported by the right amount of muscle tension. Our everyday movements and activities affect the body’s alignment. A postural imbalance can impact the body’s health in various ways. It can cause:

General soreness
Back pain
Muscular pain
Fatigue
Digestive problems
Poor self-esteem

Unhealthy posture can increase the risk of spinal dysfunction, joint degeneration, stress joints, and muscles, resulting in permanent damage if left untreated. The best way to prevent postural imbalances is to be aware of the causes utilize proper ergonomic and movement strategies that can help avoid these problems. As the everyday bad habits, behaviors, and activities are understood, it is much easier to prevent and correct them.

Table of Contents

Everyday Posture Is Important

Specific muscles maintain the body’s posture, so we don’t have to think about it and constantly adjust. Muscle groups, including the hamstrings and large back muscles, are essential in maintaining healthy positions. When the muscles function correctly, the postural muscles prevent gravity from pushing the body forward. Postural muscles also maintain balance when moving. A healthy posture reduces strain on the supporting muscles and ligaments during everyday movement and weight-bearing activities. Engaging in healthy posture helps:

Keep the bones and joints in correct alignment so that the muscles function correctly.
Decrease the abnormal wearing of joints resulting in degenerative arthritis and joint pain.
Reduce the stress on the ligaments holding the spinal joints together, preventing injury.
Allow muscles to work more efficiently.
The body exert less energy.
Prevent muscle fatigue and muscle pain.
Prevent muscle strain and overuse disorders.

Unhealthy Posture

Unhealthy posture results when the body sits or stands with the spine in an abnormal position. When an individual practices unhealthy posture over a long period, it progressively leads to muscles and ligaments becoming elongated and weak, while others become short and tight. This creates a physical imbalance that leads to postural abnormalities like:

Rounded shoulders
Forward head posture
Thoracic kyphosis or hunched back
Lumbar lordosis
Swayback
Limited mobility
Increases the risk of injury

Causes

Habits

Individuals can begin to develop unhealthy habits that negatively impact their posture, like walking with their head looking towards the ground. This shifts the body out of alignment.

Sitting For Too Long

Spending too much time sitting even with the correct posture will impact the spine and muscles. It weakens the muscles, ligaments, and abdominals.

Weight

Carrying extra weight can force the spine into an awkward position. This is true for individuals with pot bellies, as it pulls the lower back forward, increasing the risk of lumbar lordosis.

Unhealthy Diet

If the spine does not have access to the vitamins and nutrients it needs, it can struggle to maintain its strength and flexibility. It is also more difficult for the body to repair damage to the spine’s muscles and ligaments.

Clothing and Footwear

Clothing and footwear can impact posture.
High heels, poor-fitting shoes, saggy jeans, large belts, heavy jackets, and other items can force the spine into an unnatural position.
These are fine to wear for short periods but avoid wearing them day in and day out.