Testosterone may strengthen your heart. Research on testosterone’s relation to heart health is split. Some scientists have found that men with higher testosterone levels have an increased risk of heart disease, while recent studies have shown that men with below-normal T levels are more at risk for heart problems. The research is still on-going, but many doctors find the evidence compelling that optimal testosterone levels can help prevent cardiovascular disease.


In fact, high cortisol deals a crushing blow to testosterone in two ways. During, long-lasting stress, high amounts of cortisol release very often and have a direct negative influence on T levels. Thus, cortisol inhibits testosterone synthesis in the testes and hypothalamus. In addition, the production of cortisol is impossible without cholesterol. But testosterone synthesis also demands cholesterol. Since during stress cholesterol is first of all used for making cortisol, T levels simply plummet.


There is a large body of evidence linking the onset and/or progression of cardiovascular disease to low testosterone levels in men. It is now apparent that an increased cardiovascular risk and accelerated development of atherosclerosis occurs not only in elderly men or men with obesity or type 2 diabetes mellitus, but also in non-obese men with hypogonadism.14 Current best evidence from systematic review of randomized controlled trials suggests that testosterone use in hypogonadal men is relatively safe in terms of cardiovascular health and do not produce unfavorable elevations in blood pressure or glycemic control, and does not adversely effect lipid profiles.4,15
The study population in these TTrials included men aged 65 years or older with mean morning serum testosterone concentrations of 275 ng/dL or less and symptoms of impaired sexual function, physical function, or vitality. These trials were placebo-controlled and the testosterone treatment group received 1% testosterone gel at variable doses adjusted to maintain plasma testosterone at levels normal for young men (500-800 ng/dL).
Vitamin D3 has the ability to naturally boost testosterone levels.  Increasing serum vitamin D levels in the body can help increase testosterone production, allowing you to potentially build muscle at a faster rate. If you don’t live in an area of the world that allows for a good amount of sunlight, you could become deficient and could benefit from a vitamin D supplement.
Benefits: Ashwagandha a wonderful herb originating from India is also called the Indian Ginseng because of it’s regard as a powerful aphrodisiac. Ashwagandha roots when consumed it increases sexual powers. These sexual powers include maintaining a stronger erection, longevity, enhanced sexual feeling. It also enhances fertility by increasing sperm count and quality. Ashwaganda works by reducing prolactin and neutralizing free radicals which both leads to increased testosterone levels.

Testosterone is a steroid from the androstane class containing a keto and hydroxyl groups at the three and seventeen positions respectively. It is biosynthesized in several steps from cholesterol and is converted in the liver to inactive metabolites.[5] It exerts its action through binding to and activation of the androgen receptor.[5] In humans and most other vertebrates, testosterone is secreted primarily by the testicles of males and, to a lesser extent, the ovaries of females. On average, in adult males, levels of testosterone are about 7 to 8 times as great as in adult females.[6] As the metabolism of testosterone in males is greater, the daily production is about 20 times greater in men.[7][8] Females are also more sensitive to the hormone.[9]
I thought your article was informative if researching effects of testosterone on cardiovascular and urological findings. However, it failed to key in on the psychological effects which cause noted behavioral changes. My husband was diagnosed with mildly low testosterone level and a fatty liver. Upon convincing his NP to put him on the topical gel as a first course of treatment he has stated he feels great, no longer foggy, and energetic like never before. Please understand, he was not having any sexual dysfunction but instead decreased energy and increased fatigue. What I also noticed is that he is now acting more dominant and agressive in his behavior. He speaks with the intent that nothing he says matters to him regardless of bluntness or disrespect. He has requested a divorce after 18 years of marriage without any prior indication that this was his intentions blindsiding our entire family and friend network. He recently got a job promotion since being on testosterone therapy and has a grandiose personal about him. He has lost 22 pounds and has decreased communications and contact with loved ones. He is scheduled to return to practitioner for a refill on his gel prescription and we, his family, are hoping that he may be taken off this medication which has drastically changed the man I have known for nearly 20 years. Unfortunately because he is a pilot and travels frequently we can only hope that he has not allowed his mental alertness spill over into his physical needs and allowed for infidelity to occur as he has changed all personal passwords, eliminated me accesss to flight benefits and checking account. We no longer get his schedule and therefore only await his sporadic call/texts to let us know if his whereabouts. He has developed a despiteful attitude towards me in a matter of 3 weeks which weeks. He has been on this medication for almost one month now. Prior to the medication, all was well and happy. This medication has completely changed our lives in a negative way. Perhaps practitioner need to consider the behavioral outcomes as well especially in men in their 40’s who may also be going through a mid life crisis. Take it from my firsthand experience that it is not been considered thoroughly in his case.

The T Trials will serve as a prelude to lengthier and more robust trials in the future. More results from the T Trials are now coming in and overall results were mixed, with testosterone replacement associated with some benefits and some risks. More research needs to be done to figure out the balance of these potential benefits and risks as well as the precise clinical utility of testosterone treatment.

Testosterone boosters are a class of herbal supplements aimed at naturally increasing your testosterone levels. Usually, they contain micronutrients that men are commonly deficient in, such as zinc, and which have been connected in research to healthy testosterone levels. They also may contain adaptogens, which are a class of supplement that are thought to help the body adapt to stress, or ingredients which have been connected to improved sleep. Sleep restriction has been shown to reduce testosterone in healthy young men, and as Chris Lockwood, Ph.D., notes, disturbed sleep is a common symptom of low T-levels.[1]

Binge drinking on the other hand does impact Testosterone levels – especially on a short term basis. Two studies (22 & 23) show that large acute quantities of alcohol consumption in a short period led to decreases in Testosterone levels by a whooping 20-23% after 24hours! Note however this is drinking to extreme excess! Likewise, chronic alcohol abuse is known to reduce testosterone more notably (as seen in alcoholics).


Hacking your testosterone influences everything from body composition to energy levels to mood. It’s easy to eat more butter; it’s hard to visit a doctor and get tested, but that’s what I recommend: know your levels. If you’re 25, you’ll know what your target is when you’re 35. By the time you’ve noticed symptoms of low testosterone, it’s too late to get your “normal” measurements!
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I was reading in the university health news daily website that a study performed by researchers at the University of Texas M.D. Anderson Cancer Center found that men with prostate cancer who ate 3 tablespoons of milled or ground flax seeds each day had decreased prostate cancer cell proliferation compared to similar men who did not eat flax seeds. According to the American Cancer Society, men who supplement their diets with flax seed have lower PSA levels and slower growth of benign as well as cancerous prostate cells.

A man with shrinking levels of testosterone actually may lose some body hair. Testosterone replacement therapy comes with a few potential side effects, including acne and breast enlargement. Testosterone patches may cause minor skin irritation. Topical gels may be easier to use, but great care must be taken to avoid transferring testosterone to someone else though skin-to-skin contact.


We start with plastic. A lot of plastic contains bisphenol A (BPA); BPA is a weak synthetic estrogen. Like many other chemicals used in making plastics, BPA is a hormone disruptor and can block or mimic hormones and how they act in the body (34). If you think you’re safe with BPA plastic, think again. Research shows that BPA free plastic has similar estrogen-like effects on the body.
The hypogonadal-obesity-adipocytokine cycle hypothesis. Adipose tissue contains the enzyme aromatase which metabolises testosterone to oestrogen. This results in reduced testosterone levels, which increase the action of lipoprotein lipase and increase fat mass, thus increasing aromatisation of testosterone and completing the cycle. Visceral fat also promotes lower testosterone levels by reducing pituitary LH pulse amplitude via leptin and/or other factors. In vitro studies have shown that leptin also inhibits testosterone production directly at the testes. Visceral adiposity could also provide the link between testosterone and insulin resistance (Jones 2007).

I am 51 male. I have had low T for a few years now. I was using Testim for a few years, but I hated the smell and mostly feared getting thus stuff on the kids. The reason I stopped with all that nasty gel is because my T levels weren’t improving. So, why bother using anything that is not working, so I stopped. Apparently I am one of those men who do not absorb the gel very well. My T levels dropped from a low of around 200 on a 800+ scale to under 100 after I stopped using the gel.


If you do take DAA I recommend cycling it (i.e. 5 days on, 2 off, over 4 weeks then 4 weeks off). And taking it with an aromatase inhibitor (which ensures the aspartic acid doesn’t get converted to estrogen). Especially as more studies are coming out showing the increase in testosterone is limited to a week or two before it drops back to normal levels.

Once your elevate testosterone levels, you will also sharpen your focus, enhance sports performance, and enjoy enormous competitive spirit. You will also soon notice that the lack of motivation is no longer your problem. Being highly motivated and aggressive due to the action of testosterone boosters, you will experience better muscle gain. Whether you are a novice or a professional sportsman, you will quickly reach your sports goals.
“She” being the key word. I had to quit a female doc because even though my level was down to 200, she thought I just needed more vitamin D! When I tried that and came back a few weeks later and told her there was no change in how I felt she refused to order another blood test, and after that wouldn’t even see me. I would never trust a female doctor with testosterone replacement therapy, as they all seem to have the same shit attitude from what my friends have told me, they treat it like it’s not a real thing even though you better bow down and kiss their asses when it comes to breast cancer and menopause.
We required all of our testosterone boosters to have magnesium, but gave preference to magnesium aspartate, citrate, lactate, and chloride. These forms have been found to be more easily absorbed than magnesium oxide and sulfate. (On the other hand, it didn’t count if the supplement had magnesium stearate, which is used to make pills not stick together.)

ZMA (unnecessary). So when I researched how to increase testosterone, a supplement called ZMA kept popping up. It’s a blend of zinc, magnesium, and vitamin B6. The purported benefits of ZMA include better and deeper sleep which indirectly is supposed to increase testosterone. Zinc and magnesium are necessary minerals in testosterone production, so a mega-dose should be useful, right? Well, no. I bought some and took it during the duration of experiment. I should have done some more research before I made the purchase. While one study in 1998 showed increased strength among athletes taking ZMA, two recent studies (study 1, study 2) have shown that it has absolutely no effect on total or free testosterone levels. Crap. My advice, unless you have a zinc and magnesium deficiency, no need to waste your money on this.
More recently, a study from 2015 noted that consuming 600mg daily of standardized fenugreek extract for eight weeks increased free testosterone levels compared to placebo. The test group also experience an increase the the number of repetitions the could perform in the leg press before reaching failure. And, to top it off, subjects receiving the fenugreek supplement dropped body fat without losing strength.
NHT works to reach a targeted level of hormones in your body, restoring your body’s natural ability to keep healthy and fit. Hormones are beneficial at any age, but most commonly we administer the therapy to people in their 40’s, when your body naturally begins to slow production of certain hormones. Supplementing these declining hormones can keep your body fit and active for much longer. Bio-identical hormones are made from plants and are identical to the hormones naturally produced by your own body. We never use synthetic hormones, which have been shown to increase your risk of heart disease and diabetes.
The doctor regularly measured my levels to be sure they were within the normal range for a male my age. In other words, I wasn’t taking ‘roids to get big; I was getting control of hormones that were not functioning well. This is how you should look at testosterone therapy – it is a gentle nudge to help you be in normal ranges, not a big push to get you huuu-yge. If you’re like me, you want “normal ranges” of a 27-year-old, not of a 60-year-old. It’s my plan to keep my testosterone where it is now (around 700) no matter what it takes. Right now, the Bulletproof Diet and the other biohacks I’ve written about do that! I’m 43.
“I can't tell you how good the product is! I'm in the best shape of my life. I used to take blood pressure medication and I don't even take that anymore. It's changed every aspect of my life. I was a 40 waist and I'm down to a 36. I'm 54 years old, and people tell me I look better than I ever have, and I look like I'm in my early 40s! And I'm telling you it's the Andro. This product is so much better than even the advertisements! From taking Andro400 I immediately notice a burst of energy . . . and my skin color, my sexual advancements, my energy, plus the weight loss, the toning of the body, and the increase strength and endurance . . . it's like night and day where I was then and where I am now, and Andro400 has made the difference. And my wife also takes it, 1 pill every other day, and she has experienced an amazing transformation in her body alone, with her hair, her complexion, and as well as in the gym. It's an outstanding product. My customers, my friends, my family, everybody is noticing the difference!”
Cognitive abilities differ between males and females and these differences are present from childhood. In broad terms, girls have stronger verbal skills than boys who tend to have stronger skills related to spatial ability (Linn and Petersen 1985). It is thought that the actions of sex hormones have a role in these differences. Reviewing different cognitive strengths of male versus female humans is not within the scope of this article but the idea that cognition could be altered by testosterone deserves attention.
If your need is greater though, there are other legal options to consider. DHEA is a precursor steroid hormone that is only available on prescription in the UK, but if taken under close supervision it can have dramatic effects. It must be taken under supervision though because too high a dose can cause mood changes and aggression — roid rage, in other words — as well as all the other unwanted by-products of too much testosterone.
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These berries are known to improve your overall stamina and mood. But that’s not all, they also keep temperatures in the scrotum at the optimum level. The scrotum contains the testes which produce sperm. Higher temperatures tend to hamper the sperm production and decrease the volume that is released in a man’s ejaculate. They also promote sperm production by improving blood circulation and protecting against free radical damage.
A: Androderm comes in the form of a transdermal patch and is used for testosterone replacement therapy in patients who have insufficient levels of testosterone. Testosterone is a hormone produced in the body that plays a key role in many physiological processes in men. In some men, however, the body does not produce enough of the hormone, resulting in a variety of symptoms including decreased libido, erectile dysfunction, muscle loss, anemia and depression, among others. Androderm helps treat these symptoms and raise low testosterone levels by delivering therapeutic amounts of the hormone, which are absorbed through the skin. According to the prescribing information for Androderm, depression was a reported side effect of the medication. Other common side effects of Androderm include itching and redness at the application site, prostate abnormalities, headache, and burning or hardening of the skin at the application site. Less common side effects of Androderm include reduced libido (sex drive), fatigue, high blood pressure, anxiety, confusion, increased appetite, and body pain. For more specific information, consult with your doctor for guidance based on your health status and current medications, particularly before taking any action. Your physician can determine if your dosage of the medication needs to be adjusted or if an alternative medication should be considered. Lori Poulin, PharmD
Important future developments will include selective androgen receptor modulators (SARMs). These drugs will be able to produce isolated effects of testosterone at androgen receptors. They are likely to become useful clinical drugs, but their initial worth may lie in facilitating research into the relative importance of testosterone’s action at the androgen receptor compared to at other sites or after conversion to other hormones. Testosterone will remain the treatment of choice for late onset hypogonadism for some time to come.
Hi my names Graham. I’ve suffered with Gyno for most of my adult life. Even when I’ve lost a ton of weight , those two unhelpful bags of fat are still there. To save me 4 to 6 grand on liposuction or surgery, will an estrogen blocker and testosterone booster help. I’ve also heard of a cream called andractim that can help , but they are expensive. Any advice would be great . Thanks.
Since then, multiple studies have found no link between high testosterone levels and increasing your chances of developing prostate cancer. However — and this is a BIG however — if you already have prostate cancer, increased levels of testosterone may exacerbate the problem. It’s best to wait until after you treat your prostate cancer before you begin any T-boosting regimens. Tread carefully and talk with your doctor.
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Hacking your testosterone influences everything from body composition to energy levels to mood. It’s easy to eat more butter; it’s hard to visit a doctor and get tested, but that’s what I recommend: know your levels. If you’re 25, you’ll know what your target is when you’re 35. By the time you’ve noticed symptoms of low testosterone, it’s too late to get your “normal” measurements!
You may be interested in boosting your testosterone levels if your doctor says you have low levels, or hypogonadism, or need testosterone replacement therapy for other conditions. If you have normal testosterone levels, increasing your testosterone levels may not give any additional benefits. The increased benefits mentioned below have only been researched in people with low testosterone levels.
Before assessing the evidence of testosterone’s action in the aging male it is important to note certain methodological considerations which are common to the interpretation of any clinical trial of testosterone replacement. Many interventional trials of the effects of testosterone on human health and disease have been conducted. There is considerable heterogenicity in terms of study design and these differences have a potential to significantly affect the results seen in various studies. Gonadal status at baseline and the testosterone level produced by testosterone treatment in the study are of particular importance because the effects of altering testosterone from subphysiological to physiological levels may be different from those of altering physiological levels to supraphysiological. Another important factor is the length of treatment. Randomised controlled trials of testosterone have ranged from one to thirty-six months in duration (Isidori et al 2005) although some uncontrolled studies have lasted up to 42 months. Many effects of testosterone are thought to fully develop in the first few months of treatment but effects on bone, for example, have been shown to continue over two years or more (Snyder et al 2000; Wang, Cunningham et al 2004).

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One more thing that I have experienced from getting injected T is that my testicles have shrunk and they have shrunk quite a good amount. I would say that my testicles are about half the size they were just 4 months ago. This is a result that many men get when they get T injections. I have a buddy who also gets injections and his testicles have shrunk a good amount as well. It’s not a bid deal overall as I am 51yrs old and things like that are not bother. However, I do miss feeling/having larger testicles when I catch a glimpse in the mirror or “adjust” my private parts and I can feel less there. 🙂
When you’re under stress (be it from lack of sleep, workplace stress, emotional stress, stress from a bad diet, overtraining etc.), your body releases cortisol. Cortisol blunts the effects of testosterone (47), which makes sense from an evolutionary point of view – if we were stressed as cavemen chances are it was a life or death situation – not running late to a meeting - in this state (i.e. running from a lion) the body wouldn’t care if you couldn’t get it up, there was more to worry about!
An added testosterone benefit of my high fat and balanced protein and carb diet was that it probably helped me lose some body fat (I went from 18% to 12% body fat). Studies show that high fat diets actually contribute to increased body fat loss. And as we discussed earlier, as you lose body fat, your T production ramps up. Virtuous cycle for the win!

BCAA peptides are the building blocks of muscle.  Your body cannot make BCAA’s.  You have to eat them.  One easy way of course is food and things like whey protein powder.  That is why whey protein works so well because it contains BCAA’s at high levels.  Advanced BCAA is 50% BCAA in peptide form!!  Peptides are digested faster and more efficiently than whole foods and normal protein powders.  This means more muscle building and recovery support!!


The TTrials were funded by the National Institutes of Health, and consist of 7 integrated, placebo-controlled, randomized clinical trials evaluating the short-term efficacy of testosterone treatment in older men with low circulating levels of the hormone. The benefits of testosterone were evaluated in 7 clinically relevant medical concerns and at least preliminary evidence of efficacy in sexual function, physical function, vitality, cognition, anemia, bone health, and cardiovascular health.
Bikinis, models, nuts … Is there anything Brazilian that’s not sexy? Selenium is a trace mineral found in Brazil nuts that plays an important role in hormone health. You only need a tiny bit for healthy sperm, but a tiny deficiency can be catastrophic for reproductive health. In one study, men who had lower testosterone and were infertile also had significantly lower selenium levels than the fertile group. Supplementing with the mineral improved chances of successful conception by 56 percent. And a second study that included 69 infertile men with low levels of the mineral, found selenium supplementation could significantly improve sub-par sperm motility associated with testosterone deficiency. Moreover, 11 percent of the men successfully impregnated their partners during the trial!
In 2002, the federally sponsored Women’s Health Initiative (WHI) stopped its hormone replacement therapy (HRT) trial (estrogen plus progestin), which included more than 16,000 women, three years early because those taking the pills had an increased risk of developing breast cancer and blood clots, and an increased risk of suffering a stroke or heart attack than those taking a placebo. The findings ran counter to the long-held belief that HRT could preserve health — and trim heart-disease risk in women.
Another benefit of the increased muscle mass was that I got stronger. My bench press, squat, and deadlift all enjoyed significant gains during my experiment. It’s great to be able to bench press 225 pounds again for 5 sets of 5 like I used to in high school, and I’m on track to beat my maxes on the bench and squat that my 18-year-old self set over 12 years ago.
Another point I’d like to make for people worried about a link between high testosterone and prostate cancer is that it just doesn’t make sense. Prostate cancer becomes more prevalent in men as they age, and that’s also when their testosterone levels decline. We almost never see it in men in their peak testosterone years, in their 20s for instance. We know from autopsy studies that 8% of men in their 20s already have tiny prostate cancers, so if testosterone really made prostate cancer grow so rapidly — we used to talk about it like it was pouring gasoline on a fire — we should see some appreciable rate of prostate cancer in men in their 20s. We don’t. So, I’m no longer worried that giving testosterone to men will make their hidden cancer grow, because I’m convinced that it doesn’t happen.
During the month before my experiment, I was definitely sleep deprived. Some nights I was only getting 4 to 5 hours. Testosterone killer! During my experiment I tried to get 8 to 9 hours of sleep at night as consistently as possible. I had to go to bed earlier, but I was only cutting into time that I would have been using to mindlessly surf the net anyway.
Men who take Testosterone report a surge in their sex drive and frequency of sex. They are better able to work out, build muscle mass and strength. The fat around their belly melts away as they lose weight and trim their waists. Men who enroll in a comprehensive Testosterone Replacement program which includes diet, nutrition and exercise - feel better, sleep better and look better. They have their edge back along with a restored enthusiasm for daily living, pursuing relationships and living life.
Low testosterone levels may contribute to decreased sex drive, erectile dysfunction, fragile bones, and other health issues. Having low testosterone levels may also indicate an underlying medical condition. See your doctor if you suspect you have low testosterone. A simple blood test is all it takes to check if your testosterone falls within the normal range.
It seems like today it’s a badge of honor to train every day until exhaustion. The ethos is to push yourself harder and harder every day. If that’s your philosophy towards exercise, you might be sabotaging your testosterone levels (as well as your 20 Mile March). Studies have shown that overtraining can reduce testosterone levels significantly. Yes, it’s important to exercise hard, but it’s even more important to give your body rest so it can recuperate from the damage you inflicted upon it.
Testosterone is observed in most vertebrates. Testosterone and the classical nuclear androgen receptor first appeared in gnathostomes (jawed vertebrates).[193] Agnathans (jawless vertebrates) such as lampreys do not produce testosterone but instead use androstenedione as a male sex hormone.[194] Fish make a slightly different form called 11-ketotestosterone.[195] Its counterpart in insects is ecdysone.[196] The presence of these ubiquitous steroids in a wide range of animals suggest that sex hormones have an ancient evolutionary history.[197]
This one is another herb that is known to increase semen volume. It has been found that men who consume this herb in the form of a supplement can expect higher sperm count per milliliter of semen, higher semen volume per ejaculation and also better sperm motility. It is also known to have a positive effect on the sex drive and arousal of both men and women.
“Before taking Andro400, my husband weighed 290 lbs. He's a diabetic and his blood pressure was through the roof. I purchased Andro based on the reviews, and he's lost 60 - 70 lbs! ​It's enhanced him health-wise in a lot of aspects too. He used to be depressed because of his weight. The fact that he was losing weight like crazy gave him a lot of relief. He's not depressed now, he's really happy. He's more loving. And it's so exciting for me as a wife to see him happier -- it made me happier​! ​ So I'm really grateful. Andro400 gave him a lot of ​energy ​ too because of the testosterone boost.​ The 3 main things everybody's noticing are: no more​ depression, a lot more energy and ​the huge weight loss. He went from size 42 to 38, so it's like, oh my God it's WORKING!! Trust me, we've tried a lot of other things that didn't work. And that's why I'm so excited because it's actually, literally changing our lives!”
The body’s endocrine system consists of glands that manufacture hormones. The hypothalamus, located in the brain, tells the pituitary gland how much testosterone the body needs. The pituitary gland then sends the message to the testicles. Most testosterone is produced in the testicles, but small amounts come from the adrenal glands, which are located just above the kidneys. In women, the adrenal glands and ovaries produce small amounts of testosterone.
The testosterone booster pills are effective from 4 to 8 hours. To maintain testosterone levels high during the whole day, you need a multiple daily dosing regimen. 2-times daily dosing still not always can improve hormone production to the greatest extent. 3-4-times daily dosing is the best solution to make your body normalize testosterone synthesis and prevent it from decreasing before you take another pill. Don’t forget that the regularity of daily supplement intake is crucial if you really aspire to give a boost to hormone production.
Before assessing the evidence of testosterone’s action in the aging male it is important to note certain methodological considerations which are common to the interpretation of any clinical trial of testosterone replacement. Many interventional trials of the effects of testosterone on human health and disease have been conducted. There is considerable heterogenicity in terms of study design and these differences have a potential to significantly affect the results seen in various studies. Gonadal status at baseline and the testosterone level produced by testosterone treatment in the study are of particular importance because the effects of altering testosterone from subphysiological to physiological levels may be different from those of altering physiological levels to supraphysiological. Another important factor is the length of treatment. Randomised controlled trials of testosterone have ranged from one to thirty-six months in duration (Isidori et al 2005) although some uncontrolled studies have lasted up to 42 months. Many effects of testosterone are thought to fully develop in the first few months of treatment but effects on bone, for example, have been shown to continue over two years or more (Snyder et al 2000; Wang, Cunningham et al 2004).
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