Dhru Purohit Show - Testosterone Masterclass: The Top Causes and Potential Consequences of Low Testosterone with Sunjya Schweig, MD

Episode Date: November 6, 2023

This episode is brought to you by ButcherBox and Pique Life.  Our modern stressful lifestyles have led to a shocking drop in testosterone levels in men. Ultra-processed foods, metabolic stress, lack of sleep and a sedentary lifestyle are all factors that have contributed to this sharp decline. Education and an understanding of the key functions of testosterone and the role it plays in preventing chronic disease can help men optimize their levels and ultimately feel better.  Today on The Dhru Purohit Podcast, Dhru sits down with Dr. Sunjya Schweig for a masterclass on testosterone. He shares the top factors that are plummeting testosterone levels, how to measure testosterone levels and options for testosterone replacement therapy. Dr. Sunjya Schweig is committed to building a cutting-edge, data-driven ecosystem to prevent and reverse chronic illness. He is board certified in family practice, integrative, and holistic medicine (ABIHM). He is also the founder and president of the California Center for Functional Medicine (CCFM), where he and his team of expert clinicians see patients all over the U.S. and provide personalized, precision medical care for a clear path to optimal health.  In this episode, Dhru and Dr. Schweig dive into (audio version / Apple Subscriber version): -The impact of Low testosterone in men (1:40 / 1:40) -Factors that lead to low testosterone (10:04 / 7:14) -Measuring low testosterone and optimal levels of total and free testosterone (23:56 / 20:55) -Strength training can increase testosterone (33:32 / 30:21) -Lower testosterone levels can increase the risk of a cardiovascular event (38:51 / 35:58)  -Testosterone levels for women (41:35 / 38:35) -Testosterone deficiency and osteoporosis (42:54 / 39:53) -Preventing cognitive decline with optimal testosterone levels (44:44 / 41:45) -Ulta-processed foods and lower testosterone levels (54:00 / 51:00) -The importance of screening for sleep apnea before getting testosterone replacement therapy (1:01:27 / 58:22)  -A nutrient-dense whole foods diet can increase testosterone (1:07:46 / 1:04:44)  -Testosterone therapy (1:13:48 / 1:10:52)  -The myth that testosterone causes prostate cancer (1:30:48 / 1:28:06 ) Also mentioned in this episode: -www.ccfmed.com -Testosterone and Cardiovascular Risk Study -Testosterone and Alzheimer's -Obesity, Intestinal Permeability, Inflammation Causing Lower Testosterone  -Sleep Deprivation Lowers Testosterone Right now, new members of ButcherBox receive New York Strip steaks for a year PLUS $20 off your first order. Go to butcherbox.com/DHRU to sign up and use code DHRU. Right now, get up to 15% off on Pique’s Sun Goddess Matcha plus a complimentary beaker and rechargeable frother on subscriptions $105 or more. Just go to piquelife.com/DhruTea to get this amazing deal. Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit megaphone.fm/adchoices

We can see pretty clearly over 100 different studies that there's an increased risk of heart disease, acrosis, cardiac events with low testosterone and testosterone deficiency, and that when you replace testosterone, that the cardiovascular risk factors and events drop. Testosterone levels are plummeting, and it's super scary. If you're a man, especially in the 40-plus category like me, you definitely want to listen to today's episode to learn why and most importantly what to do about it. Welcome to the Drew Prod podcast. Each week we explore the inner workings of the brain and body with one of the brightest minds in wellness, medicine, and mindset. This week's guest is Dr. Sanja Shwegg, and he's here to talk to

us about the top root causes that are plummeting testosterone levels and the lifestyle tips, often very straightforward that we can do today to turn it all around. Now a little bit more about Dr. Shwegg. Dr. Shwegg is the president of the California Center for Functional Medicine. where he and his team provide personalized precision medicine care to help people with chronic illness recover their health. Dr. Schweg is a graduate of the University of California, Berkeley, and completed his medical training at the University of California, Irvine, and his family medicine residency at the University of California, San Francisco. He is board certified in family practice and integrative holistic medicine.

Stay tuned for a deep dive on all things testosterone, including why it's plummeting in the first place and what to do to get it back with Dr. Sunja Swig. Low testosterone. It's a big problem. Talk about the top things that can go wrong in the male body when our testosterone gets too low, which by the way, many people are in this bracket right now. Yeah, so there's so many reasons why our hormones are critical for us.

And for the male body, testosterone is one of the most important hormones. For a variety of different benefits, health aspects, you know, across some of the things we about immediately, right? So we think about sexual health. We think about strength of erection, sexual performance. We think about libido drive for sexual performance. We think obviously about muscle mass and the ability to gain muscle, to work out, and to have your body sustained muscle easily. And we think also about, you know, some of the less known effects might be, you know, effects on mood, effects on irritability and effects on cognition, on being able to think clearly, have your brain work optimally, right? And so, and then, you know,

you know, obviously some of the other things that we don't necessarily think about as much, and if you really dive into the research, testosterone and optimal hormone balance has an incredibly important role in a huge variety of chronic illnesses. So cardiovascular health, our heart, our cholesterol, our blood pressure even, you know, the ability for, you know, our body to maintain adequate with bone mass and bone density, the ability for our body to maintain blood levels, anemia, et cetera. You know, so really interesting, a variety of different, you know, important factors, which I'm excited to dive in in more detail today.

We have a graph here, and this has been taken from the European Urology Journal. Can you explain a little bit of this graph of the decline in testosterone? And the data is very similar. We also have a link in the show notes for the Urology Times, showcase. casing a journal that was there on testosterone. Can you describe here a little bit of what you're seeing from 1999 to 2000 all the way up to 2015 and 2016 in terms of the decline of testosterone? Yeah. So what this graph shows us, it shows us three different colored bars for different age groups of men. And it shows us the testosterone, average testosterone levels for those groups

across different year spans, decades, et cetera. And what we can see is a pretty clear and pretty linear decrease of testosterone in each age group across time. And, you know, I think that if we take a step back and we look at the 30,000 foot view on this, from everything that we talk to, talk about from a functional medicine point of view, this makes sense. And it's also scary at the same time, right? Because what we're seeing is that there are many, many different factors that have a role in our optimal balance, in our optimal physiological functioning across any and all, body systems. But what we're seeing here specifically is the changes in this one hormone, this hormone testosterone, which again is vital for our health, for men and women's health.

And we're seeing that across the years. And so we can unpack this a bit and we can kind of think about, you know, what are some of those factors that might be at play. But, you know, as we're discussing prior to starting the recording, we're thinking about things like, you know, stress. We're thinking about sleep disruption or thinking about artificial light exposure. We're thinking about toxins. We're thinking there's a whole variety of different factors from an integrative and functional medicine point of view that play into this one question of our hormones, of our testosterone. So super important. You said the word scary. Let's talk about that for a second. Before we unpack the top drivers that are driving down testosterone,

not just in men, but also in women too, but in particular in men, why is this scary? What's scary about it when you look at it from the lens of a medical doctor? Yeah, so if you look at it just from the lens of testosterone, you might think, wow, that's not good. I don't want my hormones to be lower. I don't want my testosterone to be lower. We might have some men out there listening to this and say, hey, I want good testosterone. What am I going to do to make it better? But again, if you take a wider picture lens, like the testosterone really is just the symptom here. And it's a symptom of this, the fact, pretty indisputable fact, that we are living pretty far out of balance from our evolutionary history. history and what our bodies have known over hundreds, tens of thousands, hundreds of thousands of

years, right? Like what they've, what they've, you know, the information that's been fed to our physiology, to ourselves, to our genes. And over the last, you know, 30, 40, 50 years, we have dramatically changed that information that's going into our bodies and informing ourselves and our genetics. And it's happening from the, you know, pre-year-old. Reconception even, right? So, you know, when men and women are getting ready to have a baby, you know, their set point, their epigenetic set point, their inflammatory set point, what are their cytokines, where their stress levels, what's going on with their gut? All that then feeds into the epigenetic programming of the baby when it's in utero all the way up through childhood and then you add on sort of all the environmental factors. You know, so it's really, I say scary because it's really reflective of some pretty deep imbalances that we have going on. on at a global level. This episode is brought to you by Butcher Box. You know, when I made the decision to include animal foods into my diet after I'd been

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slash Drew T. That's P-I-Q-U-E-L-I-F-E-E-Pek-L-L-F-L-E-E-E-H-R-U-T-E-A. Drew, that's my first name, D-H-R-U-T-A to get this amazing deal today. By far, It seems to be when people talk about the number one thing driving lower testosterone rates for men in particular, it seems to be that obesity is the primary thing that people talk about. Would you say that's true?

I would say obesity is definitely a very, very important factor for sure. One of the top factors, maybe top three. There's a lot of mechanisms there. You know, there's, you know, basically if you have obesity, you have, have more fat cells and the fat cells are their own endocrine organs secreting estrogen. And then you have insulin resistance. You have blood sugar dysregulation. You have metabolic syndrome, pre-diabetes, diabetes. You know, diabetes, you know, diabetes, it's been called. I like that term. You know, but those, that inflammatory milieu absolutely affects our hormones and testosterone

specifically, you know, but it's not just obesity, right? It's all the factors that sort of are this ball of yarn that we try to pull apart in our functional medicine work in our practice, you know, because it's the sleep and it's the stress and it's the toxins and all these things that we're talking about today, which all play into each with each other, right? So it's all kind of this constant cross-communication happening. If you had to put a number two and a number three and sort of rank them in order, and we're going to pull all these apart, we're going to go deep into all of them. But if you had to say if there was a number two driver of low testosterone levels, because it seems to be that this decline, you know, we're in the almost 600s, at least for men in the category of 20 to 29, and even for men that are in the 30 to 40 year old age group, they're in the upper 500s close to 600.

And then there's this massive drop where 40-year-olds are closer to 400 when you start to get to 2015 and 2016. And that's obviously not even the most recent data. Who knows what's happened since the pandemic and everything else. So if you had to put a number two primary driver that was there in our sort of modern industrialized world, what would you say that would be? So if we can bury metabolic in with obesity and have that be one category. Well, I think that's what's talking about a little bit. Because sometimes people just think, well, obesity is just you're overweight, but it's so much more than that. So if you want to tease out that aspect of metabolic. Yeah.

So, you know, you can have, so with obesity, you have excess. fat you have and that becomes its own endocrine organ and then you have you know issues and imbalances that start to happen early on even pre-weight gain that start to happen with regards to blood sugar regulation right so you start getting swings of blood sugar you start getting insulin resistance you know the pancreas can't respond as well it can't produce the insulin but then the cells also become you know sort of turning off that signal because the insulin you know levels have been historically high. There's a huge feedback mechanism that happens there. But, you know, prior to that, you know, you also can have a situation where, you know, those processes are in place before the

fat is on the body, right? And so, again, it's a feedback loop. It's a vicious cycle. And so, you know, pre-weight gain or pre-significant weight gain, you can absolutely have blood sugar dysregulation, you know, over, over secretion of insulin, insulin resistance, all these factors, inflammation, you know, gut disruption, all these factors that then lead into the weight gain. Yeah, you know, you said vicious cycle. And I think that's important for people to see because especially as you get older, we know that testosterone tends to decline, especially if you're not practicing a lot of the habits that you teach your patients at your clinic. By the way, can you just mention your clinic for those individuals that are curious? Yeah, sure. I'm the founder and director

of the California Center for Functional Medicine. Amazing. So if you are not practicing these lifestyle habits, if you're not addressing low testosterone levels, testosterone will decrease over age and will lead to all these things, just going back to your list, low energy, low libido, difficulty in putting on lean muscle mass,

having a hard time focusing, and then the long-term issues that are connected to a whole host of things, but especially longevity. in the form of increased risk of cardiovascular disease. So the vicious cycle piece that I think is important to chat about is that as you get older and you're not in your sort of prime of young genetics, you know, kicking in, your low testosterone, largely driven by lifestyle, and then, of course, secondary factor being, you know, age.

As it goes down, it makes it easier for you to gain weight. And the more weight you gain, the lower your testosterone becomes. And that's the vicious cycle you're talking about. into also the other aspects of metabolic health. Exactly, yeah. And I think one thing that's important for us to point out also is that, you know, if we show this kind of a graph and we show this decline in testosterone over the years, you know, that there's part of this is just a natural process, right? You know, it is, you know, testosterone drops one to two percent every year, you know, starting in your 20s, basically. So, you know, there's a, there's a significant drop in testosterone over time. And you can

also we can talk about also you'll see increase of this binding protein called sex hormone binding glubulin which which increases gradually over time and that will bind up some of that testosterone and won't be available for your cells right so some men might think okay well it's just you know part of you know it's just kind of hopeless and I don't have anything I can do about it you know but then we show this data which shows that you know there's a pretty clear drop from external factors on our bodies. And so what we really think about, you know, when we're doing this work, when we're doing functional medicine work, we tend to throw a lot of testing of people. We tend to throw a lot of protocols, a lot of, you know, we make people work, right? It's not always easy.

We're super interested in finding how to do this more easily and how to help people and give them the support with coaching and nutrition and, you know, variety of different practitioners, et cetera, and data and wearables and all these things that help. But you do have to kind of show up you have to do some work. But what gets exciting for me is that when we start to list out all of the different factors, you know, that could be contributing to this, you know, year on year, decade on decade, drop of hormones, drop, increase of stress in our bodies. There's so much that we can be doing.

So there's so many. I just think of each one of these things like a lever that we can pull, right? There's so many different levers that if you're willing to dig in and to do a little bit of work and you want to optimize kind of how you're feeling right now. And you want to feel your best and you want to live your best life. But you also want to, you know, live your best life for 10 years from now and for 20 years for now and for 30 years from now. And you want to increase your health span, how long you live in a healthy state compared to

lifespan, right? You know, so you want to do all those things. You want to think preventively. You want to, you know, potentially set yourself up for the optimal and longest life possible. it's worth doing the work now and it's worth doing the work and digging in and figuring out what are those levers that you can pull on to make a difference. That's well said. Okay, let's keep going down a list of things that you feel that are ranked in order of whether

it's the top three, top five that are driving these low levels of testosterone that we're seeing and that we're pointing out on these graphs. So you mentioned sort of obesity and metabolic health kind of being number one. Yeah, so obviously metabolic, you know, I would put, I think sleep, sleep disruption is a huge one. I think chronic stress is a huge one. You know, I think gut disruption, chronic gut disruption is a huge one. I would probably just list those quickly, you know, and then probably environmental toxins. So would you put, so even before stress. I think sleep is bigger than stress. Sleep is number one, right? Yeah, because with sleep, I would also bundle in artificial light exposure, so increase

incidence of screen exposure over time. Right. And one thing that was interesting is that as we brought up this graph, which again was from the European, uh, European, uh, Urology. Do you want to chat about? Yeah. So we're looking at this. The biggest drop that you see on this graph is between 2003 to 2004 over to 2011 and 2012, right? When did you get your first cell phone? I probably got my first cell phone. Well, I got my first cell phone in probably 1999. Okay. So right. So just around the early 2000. So, you know, I got mine probably 2000. Okay. But it was still like not, it was, you know, it was in a smartphone. Yeah.

It was a small screen. It was a lot of light exposure. Yeah, my first smartphone was probably like early 2000s. Yeah, same. Yeah. So, you know, I'm sure that's not the only thing we're seeing, but it's pretty interesting that the biggest drop that we see, you know, in this 25-year time span or it's, you know, 17-year time span for the purpose of this

graph because we don't have the most updated data. But it's pretty interesting that the biggest drop does occur, you know, with much more widespread introduction of, you know, mobile devices. So, you know, it's one factor. You know, stress, I think increased during that time probably. And, you know, I think that toxin exposure also increased. And, you know, there's a variety of different factors. But, yeah, curious.

Yeah, very curious. Toxin exposure. So you kind of listed that as, you know, so number one, you had obesity, metabolic health. Number two, sleep, sleep disruption. Also put inside of that is screen time. And let's mention that for a second. You know, sleep, there's a whole aspect of that. Right. You did an incredible deep dive that we'll link to on the podcast last time. It was like a two and a half hour episode on sort of all things sleep. It was really fun. People still get emails about it all the time. So sleep, there's a few reasons why sleep could play into testosterone levels. Talk about some of those.

So testosterone is mainly secreted. You know, it's under, you know, central control from the brain signals from the hypothalamus down to the pituitary. and then down to the gonads and in the women ovaries and your adrenals also, right? For men, 95% of the testosterone is produced in the testicles, again, related to signals from the hypothalamus to the pituitary and then down to the testicles. The vast majority of our testosterone is secreted, you know, between probably 10 p.m. and 2 a.m. So after we go to sleep, right? and and so it's similar for cortisol right so um actually cortisol a little bit later cortisol tends to rise earlier in the morning and be at a lower stage when when we're just going to sleep

um but if you are you know for whatever reason not going to bed at that time or you've been on your screens and you have disrupted sleep and you have a drop of you know your HRV heart rate variability or an increase of your resting heart rate showing signs of physiological stress on your body or you have some alcohol. or you had a late meal or whatever the factor is, right? You know, you're stressed, your mind's going a million miles a minute. Whatever those factors are that contribute to poor sleep, you know, those will, if you don't get proper sleep or you're getting restless sleep or disrupted sleep or not enough

sleep or you go into bed too late, you will not achieve the same release of testosterone in the body. Why is this topic so important, especially for men in that sort of 40 plus category? So the topic around sleep specifically or around testosterone in general. Yeah, yeah, yeah. You know, so I think that, you know, one thing I always come back to in the work that we do and I've been, you know, in functional medicine my entire career, you know, even since I was in med school, even since I was in undergrad.

And one thing I always come back to is how incredible our bodies are, right? They can do so much. They can put up with so much crap that we throw at. them in you know from all directions right whether it's stress or sleep disruption or crappy food or air pollution or whatever it is they just kind of keep going but the ability to do that starts to kind of you know fall apart you know for lack of a better word um as we get into middle age and as we get even a little bit older right so when we're younger it's like you know we have a huge reserve and we can mostly keep going and we don't really notice it we're kind of burning the candle at both ends

but really, you know, as we get into late 30s, early 40s, certainly early, no, late 40s, early 50s, you know, that starts to mount up. I think of it almost like barnacles, like we just accumulated a bunch of barnacles and they start to add significant weight to our body and to our internal physiological equilibriums in terms of their ability to keep coming back to some degree of normal, quote unquote, right? And so after a while, and that's really the case for, I would say, most, if not all chronic illness, where functional medicine really shines and Western allopathic medicine really struggles, you know, because it's not like a quick fix. It's not like just here's a pill, here's this,

you know, surgery, here's some image, whatever. You can't, it's like a much more, more of a systems problem, right, where you really have to figure out what are all these variables, how they are all playing with each other. And if you don't do that, again, you kind of feel like you're kind of a submarine slowly submerging underwater, right? And it's, it can be subtle. You might not notice it week on week, month on month, year and year. But if you look at sort of how am I feeling, you know, now I'm in the mid-40s versus how was I feeling when I was in my mid-30s, you're like, well, like, that's a big change. Right.

And you might just want to kind of scratch your head and write it off to normal aging. But I think what we're talking about today is that it doesn't have to be. Yeah. A lot of what we see today is abnormal. Abnormal, stressed, accelerated aging. Yeah. Let's talk about measuring testosterone, right? How do you look at it?

you're trying to get a sense, you know, and what is the blood work and what are some of the associated blood work you take a look at? And give us a breakdown of some of the measurements of total testosterone, free testosterone. And if you have, what generally, you know, average numbers are considered and then what optimal numbers you like to see inside of a clinic. Yeah. Yeah. So again, labs are super important. And I'll dive into that. But it also has to be correlated with symptoms. How is somebody feeling, you know, and so, and that takes a little bit of teasing apart, especially in some men because they might not be super aware of, you know, changes over time. It's been a long, slow decline, so they don't know. And they just tend to be, like, men tend to

be, like, doers and fixers, and let's just get the job done and keep going. And they might not be as in tune, you know, stereotypically with their bodies, you know, but, you know, again, feeling down, feeling kind of blue, feeling overwhelmed, feeling irritable, you know, starting to just get grumpy and just like, er, like, you know, and all these things like, you know, starts to really catch their attention when they start to have issues with erection strength or ejaculation strength or libido just drive as wanting to have sexual intercourse, et cetera. You know, so but then, you know, in terms of labs, you know, there's a number of different labs that you can run. And one of the pitfalls, I would say, for all of our listeners out there is if you are experiencing some symptoms that you're concerned about and you go to their doctor, you go to your doctor and they run a total testosterone test.

and the level comes back and, you know, whatever the number is, let's say it's, you know, 400, you know, it's in that normal range. And they tell you, you're fine, you know, it's not, it's not a testosterone problem. You know, maybe you're just depressed or maybe you just have, you know, you're working too hard or whatever it is. Don't stop there, you know, because total testosterone is not the whole story. If you do that test and it's low, then you definitely have a low T problem. And what is low? So I would say, you know, 300 or less 300 nanograms. per deciliter or less. If you're in the 200s, some people won't put that mark around 350 even.

But if you're in the 200s in 200 range, you know, I would definitely consider that to be low. Yeah. Even by classic measures, like even by traditional allopathic medicine, that's low. And of course, by functional standards and integrative standards, that's extremely low. It's pretty nuanced, actually. Talk about it. Yeah. Even from the functional medicine point of view, because what we don't always know, so it's kind of like N

of one for each person. And we don't know, because nobody ever runs their testosterone levels when they're 18, we don't really know what that individual man had as their normal, right? So what was their baseline? Was there any comorbid issues, any chronic illness, chronic inflammation, gut disruption, etc., that was potentially lowering them from, you know, what their potential was, or at the very least, just sort of what's their set point, right? And what does their body expect as a normal testosterone level, right um but you know so we can't just say hey let's just look at replacing everybody back to you know the upper third of normal you know some doctors do that which is not totally unreasonable but some men if they're replaced to the upper third of normal will actually experience symptoms of too much testosterone right

so you always have to be guiding by how does somebody feel number one most important thing you know symptoms the patient the person in front of us is the number one most important piece of information and any lab data is secondary in any condition, helpful, but secondary, with caveats helpful. Right. So total testosterone, we talked about that, right? You know, again, if it's frankly low, you definitely have a low T issue and you should get some help. But it could also be in a relatively normal range, but you still could potentially have a problem. And so what we really want to look at there also is a long list of labs that we can talk about that are important. but particularly you want to look at the free testosterone

and that's because that's the that's you know basically and you want to look at the the sex hormone binding globular SHBG you know so total testosterone if you get that lab test it gives you a number of how much testosterone is in your system and that's going to give you bound testosterone which is mainly there's two proteins which bind in testosterone there's SHBG sex hormone binding glubulin and there's albumin when the testosterone is bound to SHBGG it's a very tight binding, and that testosterone will not be released to have activity on the cells. And that can be up to 60% of the testosterone that's measured on that total testosterone test.

And there's testosterone that's bound to albumin, which is a weaker affinity. And so that can, you know, sort of come on and off the albumin and have some effects on the cells. And then there's free testosterone. The percent bound to album is frequently around 40 percent. And there's free testosterone, which really only one to two, percent of that total testosterone, right? So you can have a relatively fine total testosterone level, but you can have a low free testosterone or low bioavailable testosterone, which is the combination of free plus what's bound to album. And so then you just don't have enough testosterone around in that

case to have activity on the cells, right? So the total, again, can be deceptive. It's not one part of the story. And that's the one that most people are familiar with, but working with the right practitioner can help you go a little bit deeper. So in terms of total, because that's the one that people are familiar with, where do you like to see things? Especially, let's talk about men. And then you can even throw in women as well, too. You know, I don't know if you have any, you know, data that would be there. Of course you do, but, you know, for the purposes of this podcast to talk about or present, but where do you like to see total generally when we're talking about the optimal range, knowing that there's so many factors that are there, including if somebody's dealing with, and

infection or if their interleukin 6 is really high or other things. These are all things that can drive their testosterone down and somebody's baseline might be different than somebody else's. But based on the population data, your clinical data, for somebody in their 40s, where would you generally like to see where they're at? I personally, my preference is to at least have somebody be at the middle of the range or a little bit above. And I don't necessarily need to, especially when you're repleting testosterone. I don't necessarily need to push people to the upper end of the range unless they just feel a lot better that way. I do think it's important not to go a lot higher, because there are potentially risks to having too much testosterone around. And so what would be

the middle of the range if you just would add a number to it? You know, looking at the classic. Yeah, I would say 400 to 600 nanograms per decilator. Okay. Got it. And then what about free testosterone? drone. Where do you typically like to see that? Similarly, yeah. Yeah. So similarly, mid to upper third of the lab range is where my preference would be. And typically that lab range is like 40s. It starts at like 40s? It depends on the test. There's a couple of different tests. Yeah. So there's an analog test and there's a diffusion test. And so it kind of depends on which one you're running. Different doctors have different preferences. So you kind of have to go by the lab. And and kind of look at what's, you know, what's printed on the page in terms of the normal range

and guide yourself from there. Another one that you mentioned was free testosterone. So there's testosterone free, and I think they call it calc on a test, right? Yeah. That, what does that stand for? Yeah, so the calculated, so there's ways to directly, like you run a blood test and you send it to the lab and you get a number back that says, this is your free testosterone. Right.

And the main two ways, and it's a little bit disputed and sort of which one's, quote, better. There's analog-free testosterone and there's equilibrium dialysis free testosterone. So those are like the two main methods that are out there. Plus and minuses on both sides. You know, the book, testosterone for life, the Harvard doctor, he recommends analog as his main favorite. So those are, again, direct measurements, get the number back. The calculated free testosterone, you can calculate basically, it's not a direct measurement of the testosterone. So you could basically take your lab range for your total testosterone, your SHBG, sex hormone binding globular, and your albuin, and you put into an online calculator, and then it gives you a number for your free testosterone.

Which is a percentage often. It's a percentage, yeah. And it's a decent way of doing it. I personally do prefer to get a direct number back. You know, it's just, I think it's, you know, potentially more accurate. It's easier to use. It makes more sense to the patient in front of you, and you can use that to, if you're using the same lab over time, you can use that to track therapy too.

Yeah, and there's a few online calculators for free testosterone that people can type in and they can do it. I put my numbers into a calculator online and it came back as 1.72% right for my free testosterone percentage as sort of, you know, based on the numbers that were placed in and was calculated out. And what's that, do you know what the upper end of normal on that calculator was? I think the upper, based on percentages, no, I'll have to go back and check. Yeah, I have to go back and check. but my total testosterone, which was really interesting to me. And, you know, I've shared a little bit with my past podcast guests as a past episodes with the audience. In September of 2022, I got serious about adding, you know, lean muscle mass, just from all my great conversations with guests on this podcast, including Dr. Gabrielle Lyon.

And at the time, I was not seriously strength training. And I measured my testosterone, my total testosterone, and it came back as 507. I have some scattered sort of markers that were there previously. But that was the one that I was kind of using the sort of the reference. So I was about like 507. And just by getting more serious about weight training, which I didn't do just to improve my testosterone levels, I did for a whole host of factors. Look better, you feel better.

Look better, feel better. Longevity, better. Blood sugar. Metabolic health, better blood sugar, everything. From September 2020 to my retest, and I wasn't able to download all the reports, I got kind of cut off here. But just by looking at here on this sheet, July of June of this year, so 06, June of this year, I had.

increase my total testosterone by almost 50 points. Nice. Just through... 10%. Just through regular strength training, which of course improved my body composition as well. I lost fat. I added in muscle. And it's just another reminder that, you know, all these things that we do to improve our

aspects of our health, they have multiple ramifications on our body. And one of those being that my testosterone improved during that time as well. Yeah, that's awesome. I love that self-experimentation. And there's a pearl there too, you know, so that's exactly what we tell patients, right? So a lot of times in our medical system, the patient wants to come into the doctor, the model in the Western system is go to the doctor, kind of drop your body off like you would, a car at the mechanic and, hey, here you fix it. And let me know when it's done, right? You know, but, you know, there's so much ability to make these lifestyle changes and to positively affect your hormones, your testosterone, and a whole wide variety, a network effect of other things.

that's so, so important, you know, so we actually, and a lot of practitioners, you know, we don't actually, if a man comes to us and we, you know, they're having symptoms or labs that show concerns around testosterone or other hormones, our first endeavor, our first, you know, intervention are the lifestyle pieces because we want to do a couple of things. One, we want to prime their body so that it's, it's better able to then respond to and receive benefit from the treatments when we start them. And we also want to show them, hey, this is in your control. You know, there's a good amount of stuff that you can do, those levers that we can pull on that are going to positively push this in the right direction. And some practitioners actually

would not even prescribe testosterone replacement therapy unless a man is doing strength training, you know, because of the synergy that happens there. So it's super important. I love that you do that experiment. Yeah. And, you know, sometimes I'll talk to my friends. Not that comparison of total testosterone of me to my friends is the same thing. But I have noticed that my friends that, you know, everybody probably ate not healthy when they were younger, especially if they grew up in kind of like the 80s, the 90s, and the 2000s. That was just kind of what we were doing. A lot of processed food.

But my friends who have been working out strength training, maybe they were a high school athlete. I was, but I wasn't regularly strength training. I also have mentioned before in my podcast, I grew up primarily vegetarian. I was under-eating on protein for the vast majority of our life. My friends that weren't under-eating on protein and strength trained since they were younger and generally have a more muscular build, their total testosterone without any added testosterone inside, you know, through prescription or patches or other stuff that's there, which we'll

be talking about later on, they're in like the, you know, 700, 800s. Not that it's a comparison. Right, right. But it just shows that if you can be doing some of these things, not that testosterone is the end-all, be-all marker that's there, how much more your testosterone can stay in a better range most likely for somebody who has not dropped the ball on weight training and eating adequate amount of protein. Yeah, yeah, it's super important. Yeah. And that you can, you know, to your, to your point, how you, you prove that you can modulate that, right? Yeah, I'm excited to see what it

looks like in another five years. Yeah, hopefully I just, I mean, you know, if it doesn't go up, then hopefully it'll just hold steady. And you'll prevent this kind of, you know, loss over time that happens both from aging or decrease that. You can't, I think, I think you can completely prevent it's a natural phenomenon. But, but, you know, mitigate the environmental exposures. And, you know, so, yeah, so sedent, I mean, so I think that's one big factor also of why testosterone drops over time in men is that we tend to be more sedentary the order we get, right? We're just not out there playing sports as much. You're sitting on the couch and you're watching football, TV, whatever it is, you know, and so that's one big factor. So strength training is a huge, huge

factor of importance for so many different health reasons. And, and, of course, testosterone. Let's talk about longevity. You know, in preparation of today's episode, you put together an incredible document where you were going through all the data and references around testosterone and mechanisms and other things. And you have this whole section that you put together where you talked about cardiovascular risk. And I'd love to chat about that for a second. You know, cardiovascular risk, CVD is the main reason that we, is the main chronic disease, if I understand correctly in the United States that people die from. Is that accurate, right? Cardiovascular disease?

Absolutely. Yeah. And so, you know, people think about cancer. They think about Alzheimer's. These things are all things, autoimmune, which you've talked a lot about as well. Of course, these chronic diseases are all there and present, but cardiovascular disease, it's still sort of the quote unquote, bread and butter, so to speak, in terms of why we all end up dying. So what do we know about testosterone and its relationship?

to cardiovascular disease. Yeah, so, so there's a couple of big killers out there and heart disease, heart attack, stroke, you know, those are the big ones we worry about, but then sort of what leads to that, right? You know, cholesterol imbalances, metabolic syndrome, high blood pressure, you know, all these factors that lead in. So this is, you know, really interesting when you look at the research literature and there's not, there's some things which are still kind of like, does testosterone help, does it not help? You know, what's the role for replacement, et cetera? This is one area. that is not very controversial in a lot of ways, right? So we can see pretty clearly, you know, over 100 different studies,

that there is an increased risk of heart disease, atherosclerosis, cardiac events with low testosterone and with, you know, testosterone deficiency. And that when you replace testosterone, you know, that the cardiovascular risk factors and events drop. And what do you think is going on inside of the body? Like, what do you think the link is, what kind of mechanisms are happening that low testosterone would actually increase your risk of

a cardiovascular event? It's complex and there are many, right? So I think one of the central pathways is around inflammation. You know, so inflammatory response and testosterone, the potential benefits there. I think another really important factor is the bi-directional relationship that, you know, exists with metabolic syndrome, right? So we know that we know that if you have diabetes or insulin resistance or metabolic syndrome, that that can lower your testosterone, but it's also the other way. If you have low testosterone, you're at higher risk for those complications. So testosterone has such a central role in, you know, overall body metabolism, in strength, in muscle, you know, and the factors that then downstream lead into the cardiovascular health

are quite interesting, quite impressive. I want to pause for one second before we go into bone health, which is another thing related to longevity. Let's talk about women in testosterone. You know, sometimes people hear words like estrogen. They think, okay, that only matters to women. Testosterone. Okay, that only matters to men. I don't know if this is accurate at all,

but I once heard that testosterone is actually one of the most abundant hormones for women inside of their body as well, too. Is that accurate? Do you know anything about that? So it is definitely in lower amounts than in men, obviously. Of course, but in terms of total hormones. in a woman's body is testosterone, one of the key players that's there? It is, it is, yes, absolutely.

Not as much as estrogen or progesterone, et cetera. But no, absolutely key and super important for some of the same things that we talk about with men, especially libido, sexual response, mood, irritability, cognitive function, you know, even a smaller estrogen especially, but a smaller role also in cardiovascular health for women as well. So when we have women doing, you know, perimenopausal or, you know, if they have low, low libido, we have them, you know, trying some testosterone therapy. We use much, much lower doses, but there is a significant benefit, and especially in sexual response. And so you can even,

you know, if you have a prescription for some testosterone cream, you can apply it locally on the vaginal area and even on the clitoris, and that can really enhance sexual response and orgasm. What do we know about bone health when it comes to low tea and the risk of osteoporosis? Yeah, so testosterone is critical in men and women for helping to maintain bone health and helping to prevent osteoporosis. And, you know, osteoporosis is a progressive bone disease. You know, over the course of our lifespan, we do tend to lose bone. You can protect this, obviously, from doing strength training, building, you know, early, early athletic activities, etc. But, you know, we're definitely evidence to support that men with testosterone deficiency do have an increased incidence

of osteoporosis and experience fractures as well. You know, so there's a variety of mechanisms there, you know, that gets into sort of bone physiology, but testosterone has a variety of different receptor activity on different bone cells, on bone turnover, on osteoblasts, which are sort of the cells building the bone and osteoclasts, which are the turnover cell. They sort of chew up the bone and the osteoblast spit it back out again. So, you know, and again, testosterone has some signaling there that can really be helpful. you know, as we age and as I turn, you know, turn 40, and I've been talking a lot about sort of, you know, even though that's like super young and even 50's young and 60s young, if you live a healthy lifestyle, all these numbers, you're still like, you're still so young, right? And you can age in a way where people look at you and you're like, wow, you are abnormally aging in a good way. Right. Right. So, so, but as we age, we're starting to pay attention more to, okay, our brain,

if we're not fully dialed in, it's not working the same way that it used to be. And one of the things that we open this podcast with is how low testosterone, separate from being connected to low libido and difficulty in putting on muscle mass, also impacts focus and mental cognition. So what are some of the things that you have put together and know about the relationship between testosterone and the brain? Yeah, so super important, super area of deep interest. You've had, you know, one of the amazing researchers and writers in this field, Dale Bredesen on as a podcast guest. And, you know, he talks a lot about testosterone and about hormones in general, estrogen for women, testosterone for both, you know, as being trophic for the brain,

as being sort of, you know, something, there's toxins, there's, you know, trophic things. There's something which you just need to have. You need to have it around in decent amounts throughout the lifespan in order to have optimal cognitive function, optimal brain function, and an optimal opportunity to prevent early onset cognitive decline, dementia, all the way up to Alzheimer's disease, right? But, you know, just from, you know, on the day-to-day, 40s and 50s, you know, we start to get, you know, potentially a little bit more spacey or kind of forget where we put our keys or, you know, but cognitively and on the brain, testosterone is super important

for a lot of factors, you know, spatial ability, spatial awareness, you know, things like map reading and object rotation have been shown to be affected by testosterone. And then mood is a super huge area, right? So, you know, feeling more kind of blah, feeling, you know, more tendency towards depression, you know. Not having that drive. Not having the drive, you know, sort of the vitality, the, you know, get up and go, the motivation, you know, ability to focus.

And, you know, sort of like people might think they have ADD or ADHD. but that is also potentially influenced by testosterone, right? You just have this, you know, ability to kind of put things together, to see the connections, to manipulate things cognitively and spatial in your brain, and to function optimally. And testosterone is really key. So that's really one of the most gratifying areas, I think, of working with patients with testosterone, low testosterone.

You know, they'll frequently pretty quickly see a benefit on how they feel, how their body feels, how their body responds to workouts and exercises, but then also to energy, to mood, just like, wow, I feel like I have myself back again. Like, you know, I was kind of like, you know, I had forgotten what I used to feel like and I have forgotten how good I used to feel and just kind of accepted this sort of mediocre kind of like, you know, humdrum existence that I find myself in, right? And so all those things and then the memory piece, you know, be able to recall more quickly, more clearly, you know, those are some of the areas that I find. And then, of course, the third one for, you know, replacement benefits would be the sexual benefits,

just feeling more alive, more aware, having better libido, you know, so those are really, it's one of the areas of medicine is really gratifying because you can pretty quickly, you know, with and balance, get people back to what just feels right. It just feels like, wow, you know, This is, you know, I'm kind of, hey, I'm back, you know, where was I? So. I actually want to come back to causes of low testosterone and things that either are directly or indirectly. You know, you mentioned some of the big ones that were there, obesity, metabolic health, sleep issues. We talk about, you know, processed foods being a big part of that.

Are there other environmental factors separate from toxins that play or that you feel? whether you have data or from your clinical experience, you think play a role. Like, does keeping a cell phone in our pocket as men, does that have a role in testosterone? That's a great question. I have not actually looked in depth if there's studies to show that because I do wonder about that. Front pocket versus back pocket. I also worry about women who are carrying their cell phone in their sports bra next to their breasts or tucking it into their, you know, workout, you know, you know,

tights or whatever. And so it's right next to their ovaries, you know, so I do wonder about that local effect of radiation EMF exposure as well as the bigger picture fact that we are completely bathed in Wi-Fi signal in EMF signals, you know, in a completely unprecedented way. The really interesting article just in New York Times a month or so ago showing a visualization of the Starlink satellites going up and just like sort of where we're at now. I think there's like four to five thousand or so and they're going to basically go 10 to 20x of that. And so it's just like this C of these satellites just kind of beaming us with signal. So that's a bit of an area of controversy, right? You know, there's some differing opinions on there. But I do think that

EMF exposure does play a significant role in our bodies and our ability to function. I really don't see how it can't because it's kind of a big experiment on us as a, at the side. society level. Have you seen any studies on pocket and cell phone? I have it with testosterone. I know that there are a few studies and Andrew Huberman's covered this on his podcast that we'll link to in the show notes, but there's a few studies about sperm, sperm quality and cell phones in the pocket and how just the heat alone coming from the cell phone can increase the temperature of the testicles and kill sperm. And interesting about that, as somebody who's working on family planning and you know, and wants to start a family one day is that there was a small drop when you moved your

cell phone to the back pocket, but there was still a decline in sperm quality by keeping your cell phone in your pocket. Now, I don't know how big the study was. I don't know how many studies there were, but we'll link to an episode where Dr. Andrew Heurman, who's been a past guest to this podcast, covered a few of those data. But I'm not familiar with anything with testosterone. And yes, I also, I'm untrained. I have no degree in. medicine or health or anything like that, I definitely am worried about the level of, you know, Wi-Fi, EMF, 5G, other things.

But largely I know outside of making my home a better environment for it, there's not a lot that I'm going to be able to do. And I'm so thankful that we have those things. You know, we're sitting in our studio in Los Angeles and that allows us to work and our team and everything like that. So I'm going to double down. I'm going to pay attention to the space. I'm going to continue to learn from individuals like yourself. we're staying on top of the latest signs.

But I'm going to make sure that I don't use it as an excuse to say, well, I might as well not do anything anyway because I'm bathed in all this Starlink, EMF and everything else like that. There's still so much that you can do. And it's even more of a reason to focus on the basics because those things have such a protective effect on the body. Yeah. And I know you feel the same way.

Absolutely. Absolutely. Yeah. And there's a right. Yeah, I agree with you. There's a convenience factor. and, you know, we all just live a virtual world. You know, we're still practicing a lot of telemedicine.

And, you know, so Wi-Fi internet connectivity, like, it's vital. You can't do without it. And there's a whole, you know, amazing, you know, opportunity for areas in the world that don't have reliable access and to be putting up satellites that can then provide internet access across Africa or India, or wherever those areas are. And then really amazingly, impressively help those populations live better lives, right? But, you know, within our sort of Western, you know, modernized, industrialized society, you know, simple things.

You can, you can, you know, don't have your cell phone on your bed at night for so many reasons, but especially for, you know, that potential of EMF exposure. And not just the Wi-Fi or the cellular signal to the phone. Because, you know, please, if you do have your phone next, you put it in airplane mode at night. But plugging it in and having that charger cord running, you know, definitely have. you know, an EMF footprint to it. If people want to look at this in more detail, you can purchase home EMF meters for a couple hundred bucks on Amazon.

That's some good ones. And you can just kind of walk around your house and look at where the biggest fields are, right? The biggest EMF fields. So, but yeah, get your devices out of your, of your bedroom, please, if you can. You know, you sent us a bunch of really interesting images when it came to, like, the role of testosterone and different aspects of the body. Let's bring one of those up and kind of talk about some of the, insights that you can glean from them. What about this first one about diet, fat, endotoxins, and

testosterone? Let's bring that image up on the screen. And then for those that are listening, if you could describe it and sort of what are some of the findings that you are walking away with from this image? Yeah. So this is a really cool, really cool study. And this kind of goes back to your first question a minute ago, which is what are some of the other factors that can contribute, right? So to lowering testosterone, of which is a long list. And we, we can kind of rattle them off and go in depth on a few if we want to, time allowing. But this was a study that looked at obesity and low testosterone and pointed to the fact that, you know, there's a link between inflammation and low testosterone and obesity, which we knew,

but they really point out the fact that there's this link with intestinal permeability. And so intestinal permeability, colloquially known as leaky gut, you know, basically where, you know, our intestinal cells should be, you know, have tight junctions and be nicely opposed to each other and then our body gets to decide what comes in and what doesn't. But when we have inflammation or toxins or gut disruption or sebo or mold or infections, whatever it is, you know, autoimmune, food sensitivities, et cetera, those cells will become more permeable and allow a variety of different substances to leak in now and gain exposure to the systemic circulation and a systemic immune system with a huge feedback loop of inflammation. And if you have intestinal permeability,

you're also going to have increased blood brain barrier permeability. They kind of go hand in hand because of this sort of toxin, cytokine soup that gets set up inside the body. But this study has this model that they showed, you know, where high fat, high calorie diet leading to obesity, alters the gut microbiome leads to a breakdown in the mucosal barrier. You now get exposure to what's called endotoxin or lipopolisaccharide LPS. This is bacterial toxin, which now can leak in, trigger the immune system, triggering what they call a metabolic endotoxemia.

You know, and then this toxins actually has direct effects in the Ladig cells of the testicle, where testosterone is produced, activating these interstitial macrophages, these immune cells, and then inhibiting these enzymes, these steroidogenic enzymes in the testicle, right? So more oxidative stress, decrease of these enzymes, which are used to produce testosterone,

affecting then, you know, creating basically a lower testosterone production linked to your gut balance, right? Super fascinating. And then, you know, basically these reduced levels of intrasticular testosterone, this oxidative stress that gets set up, you then see impaired spermatogenesis, reduction of sperm quality, reduction of sperm count. And then this whole feedback loop also centrally, in addition, that's local to the testicles,

with this inflammation, with this metabolic endotoxemia, they get set up from the intestinal permeability, you can have direct, you know, down regulation at the level of the hypothalamus and the pituitary on that central signal of lutenizing hormone, follicle-stimulating hormone, to then produce testosterone. So it's multifactorial. You know, so really interesting, right? You know, the gut, as we believe, is really the center of the universe when it comes to health. And it's just pretty fascinating to see this kind of a really kind of linear connection being made related to our hormones and our testosterone.

Yeah, really just showcases how important our total lifestyle is. And when we get super far away from it, we're not talking about, you know, some saturated fat in the diet. that's coming from largely cleaner sources and whole foods, even if that means animal products. They're talking about a high fat, high calorie diet. Again, to me, that's ultra-processed foods and that impact that it plays in the gut and that to think that our gut health has a direct link with our testosterone. And through the explosion of ultra-processed foods that we've had over the years, it's another reason why you're not surprised.

You're definitely shocked. but you're not surprised to see that there's been this major drop in testosterone levels. Yeah, it's one big factor. And I think also just, you know, one thing I love seeing in articles like this is that they pull out this idea and they show this connection between, you know, intestinal permeability and then the downstream effects on the hormones. And they're really just talking in this one article about obesity and ultra high fat processed foods, et cetera.

But, you know, what you and I know and what functional medicine practitioners know is that there's so many other triggers for intestinal permeability that are activating this same pathway. What are some examples? So any kind, you know, microbiome imbalances in general, that can be also be any hidden infections. We're very aggressive in our practice about doing comprehensive stool testing. We actually frequently send two separate labs at once to different companies to look for hidden infections that we can treat. And that would be like a parasitical infection, for example.

Yeah. So parasites, you know, common ones that will find. you know, Jardia, cryptosporidium, blastocystis hominus, which is a little bit of nuance there. Some mainstream GI docs would say that that's more of a commensal pathogen and maybe not necessarily a, you know, triggering inflammatory pathogen that you have to eradicate, but it's strain-dependent, and we don't really have a great ability to test which strain it is. So we do tend to like to try to eradicate that, especially if people have symptoms. So it has been shown to be connected to fatigue and to joint pain and to, you know,

you know, gut symptoms in general, bloating gas, et cetera. So, yeah, so, you know, there are a couple examples. CBO, small intestinal bacterial overgrowth, very, very common. We test everybody for this at the start gate in our practice. We also have CFO, small intestinal fungal overgrowth. You can have environmental mold exposure, which is irritating your mucous membranes and causing a variety of different mucous membrane symptoms, including intestinal permeability. You know, toxins, heavy metals, antibiotics.

environmental pollution, exposures, you know, the list goes on, stress, sleep disruption, those all contribute to intestinal permeability. So, you know, the gut being super central and all the factors then that lead in are really important to address. Super important. Again, it's complicated, right? So I hope we're not losing people out there, meaning like, wow, I really want to address this. I think it might be a problem. But like, whoa, I don't know if I can do all that. You know, so I would say, you know, knowledge is power. right so just kind of realize that again there's all these things that we can work on that are working against us if we don't pay attention to them because they're just present in our lives

in our environment but try not to get overwhelmed you know find the right people and the right team to work with and then get the support that you need because making lifestyle change is not easy and so working with a really comprehensive care team which is what we've really been brainstorming and trying to build and using any angles in there just to like get people the support that they need when they need it. So it doesn't feel too overwhelming. So they can be successful, you know, week on week, month, month, year on year about locking those changes in so they can live their best life. Yeah. That's what we want for everyone. I want to come back to this idea that when it comes to testosterone, there's more awareness than ever, you know, social media, other things,

and just this massive decline. And for a lot of people, the car analogy that you had was perfect. have so many friends that are not so super health oriented. Even friends that are like executives at other companies or founders that are like, oh yeah, I need to go get testosterone replacement therapy. And there's so many nuances that are there. And I'd love to just chat about that for a second because you're talking about all the complications that kind of come in. You brought up one nuance before we started recording,

which is you're talking about how something like fixing your sleep and sleep, apnea actually plays a role into whether or not you or somebody else might consider for a patient, whether or not getting replacement therapy would be a good idea or not. So could you talk about that? Yeah. So it's again, you know, in functional medicine in this work that we do and that we you and I both live in this space, you know, it's very, it's a network effect. It's a systems effect. The body is constantly communicating across different systems and, and there's this interplay, this is bi-directional information flow, right? And so we know that, you know, having low testosterone can lead to, you know, we see this image here, you know, it can lead to disrupted sleep. It can

lead to more arousal. It can lead to less deep sleep. It can lead to decreased sleep efficiency, you know, sleep fragmentation, right? And so- More arousal, less arousal. Thank you. Less sexual arousal, but more nighttime sleep disruption. Just general arousal, not in a sexual context. Yeah, exactly. Yeah, yeah, yeah. So you're more likely to wake up at night and then have trouble falling back to sleep or just be restless or be moving around a lot in your bed. If you use a wearable at all, you can see that. You know, so you'll see a lot of movement and a lot of microarousals, not sexual. We're not talking about sexual. So thank you. It's a very good

clarification on that one. And so, that is very, there's a lot of overlap there with sleep apnea, right? And so, you know, and so it can kind of push you over the edge of potentially, you know, having that condition or that diagnosis and there's, you know, a lot of effects that can lead into that, you know, from having low testosterone, right? But in addition, then having obstructive sleep apnea has all those factors and more inflammation and hormone disruption can then also directly lower your testosterone, you know, so it can be this negative feedback loop that happens.

And if you're not dealing with both, you know, the potential for the optimal outcome for, you know, managing that condition for you is lower, right? It's also very important, you know, if you're going to start testosterone therapy that you screen people for sleep apnea, because starting testosterone therapy, I think we have an image for this as well,

from this study out of the World Journal of Men's Health, you know, there's a variety of factors where, if you give somebody testosterone and they had sleep apnea, but you didn't know it, you could potentially worsen the sleep apnea. You could have them have them have more symptoms. You know, and there's a variety of physiological reasons for that. You know, with starting testosterone, you can have decreased contraction of your airway dilator muscles. You can have, therefore, increase upper airway collapsibility, decrease ventral airway response, increased metabolic requirements leading to more

oxygen consumption and therefore using up more oxygen, which could exacerbate sleep apnea, right? So, you know, you want to screen people the easiest way to do it. And I would like everybody who's listening to this. When they're done, we can link in the show notes, hopefully, you know, go out and just go online and find this questionnaire called the stop bang questionnaire. And it's just like a pretty easy to do. It just take you a couple minutes and it will give you basically your risk factor potentially for sleep apnea. So, you know, if you, you know, if you if you screen medium or high on that, you should absolutely be evaluated, right? There's so many reasons that sleep apnea is potentially dangerous for you from,

you know, hormone level we're talking about, but also metabolic, inflammation, high blood pressure, you know, just cardiovascular risk, you know, huge, huge downstream negative effects of having sleep apnea. But again, if we're going to start testosterone, we want to make sure we know, you know, so we'll screen them with a stop bang, so a variety of different questionnaires, but then also do either a home sleep test. There's a couple that we like a lot, either a watch form factor device or a ring, not the OR ring. This would be a device called the sleep image, which has a real-time SPO2 monitor for your oxygen levels and it measures your heart rate and your heart rate variability based on your pulse and your movement through gyroscopes, etc. So you can get a really nice snapshot of what your sleep looks like and how fragmented it is and your oxygen levels relative.

So the nice thing about these devices, they'll map your oxygen level on one graph against your heart rate. And so if you see, you know, a lot of times if someone has problems getting enough oxygen at night, right? So, you know, a lot of people will call this sleep disordered breathing. We like to flip that around and call it breathing disordered sleep because how you breathe during the day, you know, all through the day and especially at night, absolutely affects your sleep and your sleep quality. But if you drop your oxygen level in the night, you will see a compensatory sympathetic stress nervous system response with a spike of your heart rate.

And so you can see this really nice kind of contiguous graph where you'll see those matching up. And that can be a really nice way to diagnose. So your heart has to work harder to get the oxygen that it needs, essentially because somebody might have an obstruction or something's going on. They might be snoring. Partly that, for sure.

Yeah, you're getting hypoxic, your oxygen levels are dropping, your heart has to pump faster. But it's actually worse than that. It's more complex, meaning your body kind of sees that drop in oxygen and it goes, oh, no, no, no, this is bad. And so you get this huge flood of stress hormones. So you're getting this constant spike of your cortisol during the night when it shouldn't be, you know, when it should be much more balanced. And that's basically just this constant drain on your adrenal cortisol production, which then leads to adrenal fatigue or adrenal burnout or, you know, adrenal. Those are in terms we don't love as much, but basically adrenal dysregulation. So drop out

of your cortisol response, right? And then a huge downstream negative effect from there. Wow. So we've been talking a lot about what goes wrong with the body when testosterone levels are low and especially chronically low. What do we know about how to bring them up and what plays a role? So let's talk about the first aspect, which is diet, right? And in diet, there's a few different categories. The first category we've sort of touched on, which is just generally moving away from ultra-processed foods, calories, excess calories from ultra-processed foods. For some people, especially too, even a high-fat diet, even if it's not ultra-processed, if their gut is really messed up, potentially looking at that, maybe getting a stool test done, working

with a doctor, because even a high-fat ketogenic diet for some people could be creating a lot of endotoxemia. Yeah. I was one of those individuals when I did keto pretty hardcore for about a seven-month period of time. I, for the first time in my, after being in my 20s, when I stopped having acne, which was largely from dairy, I started having acne and breakouts and little pimples that would come over my body.

And it was working with a microbiologist who's a friend of mine, I've been on this episode before, is like, I think you're having an endotoxemia reaction to a high saturated fat diet, you should move towards if you're going to do keto. This is many years ago, like 2016, 17, 18. He said you should move to a more cleaner keto. You could still eat higher fat, but in particular the saturated fat your body may not be doing really well with at the levels that you're having. And some of your fat choices at that point. Where did you switch to? I was doing a lot of grass-fed beef at that time. And I was moving away from that towards more mono unsaturated fats, olive oils, avocado oils, things like that, leaner cuts of protein

that were there. And I stopped adding in sort of ridiculous amounts of MCT in my diet. And that seemed to do the trick. Nice. Right. I'm not on a ketogenic diet right now. I don't fear fat and I don't demonize any sort of macro nutrient groups that are there. I have a much more balanced approach now.

through the whole process and the learning lessons that were there. But yeah, diet, after we've gone away from excess calories, ultra-processed foods, dialing in the right sort of diet for you in particular, are the things that we know about dietary choices that can help us increase testosterone levels? Yeah, so a couple of just sort of big picture tenets on this is that you want to have the optimal information coming into your body that your body across all different systems can use for its different functions, right? You know, so really nutrient density is a really important concept, you know, sort of eating food closest to its actual natural state and as much of a

nutrient dense way as possible. So, you know, minimizing grains and pastas and, you know, cake, cookies, crackers, et cetera, even if they're, you know, or especially actually if they're gluten-free because the gluten-free alternatives are frequently less healthy except for the gluten factor than their counterparts because they have all sorts of sugar and additives and, you know, bindings, et cetera. So nutrient density and then eating a wide variety of fruits and vegetables. You know, so we call this eat the rainbow. You know, so when you eat fruits and vegetables of different colors, you're getting this huge amount of different antioxidants and phytonutrients and phytochemicals, which, you know, our bodies, again,

have evolved with and understand and need in order to build hormones in order to, you know, optimize the adrenal function in order to optimize the enzyme function for processing all these hormones and for getting them into their active states in order to decrease inflammation, right? Another really critical tenets that we've touched on is glycemic balance, right? eating for, you know, metabolic balance and to lower insulin resistance, you know, so, you know, avoiding a lot of sweets and sugars. And if you're going to have something that's sweeter matching it with some fat or protein, that then slows how quickly that, you know, moves into your body, you know, really basic concepts, but really, really surprisingly important,

right? And then on top of that, making sure that you're getting, you know, foods that give you the nutrients that you need, right? So things like zinc and magnesium and B vitamins and folic, acid and vitamin D and we can go into any of those in a little more detail if we want. But, you know, those are the key things, some of the key things that you need to have optimal hormone balance along with most other systems, right? So those are some of the basics. And then I would definitely obviously add, you know, the intestinal permeability piece and the gut inflammation and the microbiome. I love the episode you did with Dr. Will Bolshevitz on fiber, right? So soluble and insoluble fiber, the effects that that has on our beneficial gut bacteria,

on our butrate producing short-chain fatty acid producing bacteria, how that's anti-inflammatory in the gut, but also throughout the whole body. All these things have a key effect. And so lots of different levers. When you are working with a patient and let's say they've gotten a lot of these basics covered, but their testosterone is still generally low and it's matching with a lot of the symptoms that they're telling you. Like they don't have strong sexual appetite or libido. They feel like they have a harder time putting on muscle at the gym compared to when they were a decade ago.

They may not feel that drive. Drive is actually the biggest one that I've seen when my peer group, especially my friends that are older than me, are starting to question and wonder if they need to start doing some sort of intervention when it comes to testosterone. that tends to be one of the biggest ones, that and probably like sexual libido. Yeah. When do you, and let's say they're focused on the basics, their sleep is doubt in, their diet is

generally the things that you've mentioned, right? When do you start to consider whether or not or how do you consider if they should be adding in some sort of testosterone replacement therapy? Yeah. So it's very individual. It's very, you know, end of one for each person. depends on their level of motivation, their resources, you know, both in terms of time and brain function and energy and, you know, financial and, you know, how long can they, what's their runway,

you know, how distressing is this? Or are they okay, kind of going for the slower, but more, you know, in-depth wins? So you mentioned diet, you mentioned sleep. You know, we want to optimize exercise also, make sure that's, you know, optimal strength training, not, you know, not overdoing cardio, which can be a drain on testosterone, not over-training. you know, mindfulness, stress reduction, all those pieces. So we try to get all those lined up. And, and, you know, if we can do that and then retest and even start them on some testosterone support supplements or work on their adrenal gland functioning after we've tested that with special

tests. And then kind of C does do the levels naturally rise? Because you showed that, right? 10% rise of testosterone just doing that one piece of more strength training, right? You know, so it's actually kind of impressive what you can achieve. But, you know, if they're up for that, great. And if they say, you know what, I'm willing to do all that and I want any quicker results because I'm underwater here and, you know, things are not working and maybe struggles at home and

marriage, relationship with the kids, with job, et cetera. You know, so at that point, you know, depending on the labs, depending on the symptoms, we might jump in sooner. So it's very, it's a kind of individual thing with each person where we work with them. I like to kind of use any condition and especially, you know, this testosterone is kind of like a gateway diagnosis, if you will, meaning like, hey, we have your attention now. You know, you're here. You're talking to us. You want help.

You recognize as a problem. Yes, let's work on that problem. But that's also kind of like sneak in like sort of Trojan horse like some of this other work that will really help you to, you know, you know, really extend your health span, your longevity potentially. Right. And so kind of tailor it to their unique concern at the moment, but also try to build those habits. So they're just much better set up for the rest of their lives. you know but again we have to respond to their immediate needs as well so it's a little bit of a dance because generally would you say that you know it's not like everything is perfect and then just your

testosterone is off. Correct. Chances are there's something else. Yes. That's going on the body that has to be paid attention to. Always. Yeah. And it also depends on the levels on the lab, right?

So if they're really struggling and their levels are super low, we'll go quicker, we'll move quicker because we know that, you know, yes, we can do all those lifestyle pieces and really it'll help but you only see sort of a certain percentage of improvement that might not get them over that, you know, sort of symptom line where now they're really starting to feel it, right? Because you want people to feel better. You want to feel better kind of quickly so they're engaged and they, and it's a win for them. And generally would you say that, you know, for a male in their 50s, they might respond better to some of these lifestyle interventions, generally than somebody

who might be in their later 60s or 70s, where their body may not have, you know, they could do the same lifestyle interventions, but just again, through aging, they may not respond as well in terms of an increase. Is that generally? I would say generally, yes. Yeah, but again, individually. Yeah, individual one-on-one. But it also flips the other way, too, like some of the younger people who are struggling

actually, you know, can respond, you know, either not respond well to the lifestyle or responds super well to the lifestyle you know i think some of the the when you're younger there's definitely a lot of other comorbid conditions that can be occurring that can be contributing to low testosterone some of the obvious ones obviously we've talked about like sleep and light exposure and stress and kind of over overworking etc um you know but you know sedentary lifestyle you know poor diet you know none of movement you know all these pieces uh can have a surprising benefit too so it's uh you know we definitely see those helping in older folks too right It's just kind of really different.

If it was you and you're showing up in 15 years, but you're like, I've been so savvy with all lifestyle pieces, then yes, I think that's going to be potentially less of an incremental boost. But if it's someone who's like, has not really looked at these things and is, you know,

overweight or pre-diabetic and you put them on a 30-day nutrition reset and you get them sleeping and get them doing some mindfulness, it's pretty actually impressive of like the turnaround you can, you can create from lifestyle. You know, we show that with some of our work with first responders and firefighters. you know, we put them through a four to six month long program where it just really locked in, you know, first month was nutrition and, and, you know, diet reset, second one once was asleep.

And then third month was recognition and command of stress and then metabolic health and then toxins. And, you know, we put a bunch of wearables on them and did labs pre-imposed and did dexascans pre-imposed to look at body composition. And we're able to show a really interesting shift in the physiological markers, right? So HRV improved dramatically, resting heart rate dropped dramatically, and then redistribution of body composition. Not even like, so a good amount of weight loss, but that wasn't the whole story. It was definitely like a redistribution from fat to muscle too. That's incredible.

Let's talk a little bit about replacement therapy. What are the options that people have available to them? You know, there's been some innovations in this space over the last little while. There's more awareness that's there. So what typically would be the way? that you would once you've decided to work with somebody. They've done the basics. They are incorporating straight training. There's still a delta between where they want to be, where you want them to be, and most importantly, how they feel. How do you think about prescription interventions? What's on the

table? And then in terms of approach and dosing, how do you like to think about that? Yeah. So there's like five or six or so main options, right? Definitely by far, I think the top two are either an injection form or a topical form, a cream or a gel. There's also patches. There's pellets that can be put in that can, you know, last for several months. There's, you know, a sort of bucle, you know, inside your cheek treatment. There's even some pills. We don't really, we don't really use the pills at all. It's concerns around toxicity. And most of the time we're just focusing on either an injection or a gel. And there's pros and cons on each side. You know, the injections, the conventional recommendation was to sort of give a shot every two weeks. That's, you know, very pretty antiquated

because, you know, you have this really long sort of, you know, drop of the testosterone level then. You get sort of a sharp rise. It comes up within the first few days and then it starts to drop. And then you really have this long tail on the back end of that where you're not getting physiological testosterone levels. So probably more commonly will be once a week that some practitioners will do. We like to actually give the shots twice a week, if possible. And so you kind of take a total dose and you divide it up into that more frequent administration. We definitely prefer, you know, a testosterone cypionate form. This has about an eight-day half-life. And so, you know, if you give that twice a week, you can get into a really nice steady state on dosing and keep them at a kind of nice,

you know, nice release level there. Probably, you know, it depends on labs and response also, but probably then it would be about 40 to 60 milligrams per shot. And, you know, usually it comes as a 200 milligrams per ML. So then you kind of get like a little insulin syringe and pull up a small amount and measure it pretty precisely that way. You can really dial it in quite well. You know, and then you you check the labs. You follow it and you make sure that you're not overshooting, you're not undershooting, you track symptoms, you measure SHBG, you measure things like PSA, prostate specific antigen. You kind of track a hemoglobin hematocrat to make sure you're not pushing into, you know, too much like an erythricytosis, like a too high of a level. Based on response

then, based on symptoms, and then based on labs, you can dial it in that way. You know, a lot of men really need to kind of get their levels up to the mid or upper range and keep them there for a month or even a little bit longer before the benefits really start to kick in. And, you know, but, you know, so otherwise we'll frequently use a topical, a cream or a gel. You can get this compounded, a compounding pharmacy. You can kind of have it at any dose strength you want that way. Or there's also some commercial preparations that you can get, you know. And so gels and creams work quite well.

A lot of men like them because they don't want to be doing injections. You know, testosterone injection is a little bit of a thicker liquid. it's in some oil, so it has sort of like a time release factor to it. But because of that, you have to use a little bit of a larger sized needle. It's not ridiculous, but, you know, it's still giving yourself a shot at home and there's variable acceptance or interest in doing that. Typically in the like the belly area, like the fat or the sides, buttock or outer thigh is my preference, yeah. And you like to rotate when you're doing it twice a week, you like to rotate sites too,

so you don't saturate the receptors in any one site. So a couple questions on that, you know, that I got from my audience, you know, in preparation of today's conversation. So there are people that are out there that sort of pride themselves on doing things naturally and, you know, they want to do food first approach and they want to focus on that. And sometimes it's hard for them to wrap their head around the fact that, well, on one side, they don't feel good and they've been focused on a lot of the basics. And maybe they've even met with a practitioner or they have a feeling based on hearing other people's story that, you know what, it might be time for some sort of. of additional prescription intervention. Maybe, maybe not. That's why working with a great practitioner, you know, can help you dial in. But there's just general concern that, oh, well, isn't this a reliance on something external, like a drug, a pharmaceutical or something like that? What do you feel

about that? And what do you tell patients who sort of come in with that concern? Yeah. So by all means, if you want to, you know, try all the natural things you can and see if that works. And there's also a a bunch of different supplements that have potential support for hormones, testosterone. But again, if you kind of reach the end of line and you're like really thinking, hmm, I'd like to or should I or but you're concerned around again, yeah, sort of taking over for the body or doing something that's not natural. You know, let's just talk again about how we started this podcast. Like what's happening to our bodies is not natural, right? And we're kind of up against a little bit of a wall with regards to the stressors that we're putting on ourselves and and the effects that has on our entire physiology

and especially our hormones, right? And so I don't think it's natural to be at such a low level of testosterone as a population. And then especially if you start to stack symptoms related to that and you start to have those symptoms at a younger and younger age. Because we know there's just tons of research out there like we've talked about today to support that sure, you could kind of go the quote natural way and not replace it. But then you're at higher risk of so many different. adverse health outcomes from brain health to heart health to bone health to mood and cognition and

depression so if you have any of those things um you know that's you know going to be a major impediment to living a fulfilling and you know long life right so you know it's definitely a balance of how much we choose to intervene um to the point of that question though i would also say you know we're we try to be very middle ground with this because there's some doctors, you know, I've been to some conferences and there's some medicals, you know, in the functional integrated medicine space, you'll go to these conferences and a lot of doctors are doing this education for hormone health. And they're very, very aggressive with like dosing and levels and labs. And they're kind of pushing, you know, sort of this more anti-aging,

you know, aggressive sort of replacement protocols, which I don't know if that's totally natural, right and they're maybe doing it because they say hey well we can you know we can do this and why not you feel like what you did when you're 18 um that's not my philosophy right i want people to age gracefully and to age healthily and to respect the natural processes that we all have as part of the arc of being alive on this planet um but also to do it optimally and to balance that and to prevent chronic disease and again to have that opportunity to have a long health span that mostly matches your lifespan right and so in that setting i think judicious replacement of testosterone um and other hormones you know two levels which are physiological and we're not overshooting and we're tracking carefully

you know i do think it makes sense you mentioned supplements that could play a role um can you talk about some of them and then to what degree that these supplements can be uh impact and where there might still be questions, but they could be still generally supportive for other aspects of health. Yeah. Yeah. So there's kind of like a couple of categories here. There's like your general bucket of your sort of support stack that, you know, it would be good to be on in general. And especially if you're worried about hormone health. You know, those are a lot of things, you know, for around mitochondrial support. You know, this is some of the very important early steps for testosterone synthesis pathways. But mitochondria are important for everything.

right for so many other processes right you know but just to go down the list quickly you know things like um ar lipoic acid vitamin c selenium your b complexes magnesium manganese copper coquitin um glutathione support you know micronutrients especially in minerals so zinc is a critical um you know a supplement or or you can source it through foods you know there's a variety of different excellent food sources of of zinc um that are that's really really critical for for testosterone production and many of us are low in zinc, right? So zinc and for testosterone synthesis then making the testosterone itself things like zinc and magnesium vitamin D again your B complexes come in there vitamins A, C, E so your antioxidants right? Again helping within the testicle itself to protect against

oxidative stress so that you can you have optimal testosterone production. You know and so then from there, there's sort of, sort of, you know, a variety of different botanical medicines, nutrient supplements, you know, which do have some research literature and some historical usage to support hormones. Things like maca, you know, branch chain amino acids. You know, you talked about that. Super helpful. You know, betane is a really interesting one. Btane probably works around methylation and production, you know, sort of recirculating, recycling, you know, methionine and also production of creatine. And there's definitely some very interesting evidence out there that, you know, betane up to five grams a day can really help to increase

testosterone, improve muscle mass. So you can get this like trimethyl glycine is a great source of that. What about creatine itself? Yeah, absolutely. You know, I do prefer the betane because I think it's farther back on the metabolic pathway and your body can kind of decide what it wants to do with it better. Also, betane is linked up frequently in supplements with, as a betane HCL, hydrochloric acid, which can have some benefits on, on your gut, on, you know, digestion, inflammation, intestinal permeability. So lots of benefits there. When somebody has their diet dialed in, when they're getting their workout dialed in, and let's say they're getting that minimum dose of the 150 minutes a week, the strength training,

and maybe like one hit workout. What have you generally seen about how much of a bump you can get from some of these supplements that you've recommended? Like what should be expectation levels around it when it comes to testosterone? Yeah, I think so it's again very end of one because it really depends on the individual operator and how they're dialing in all the different pieces.

But let's just say it's someone like you and it's pretty optimal and they're doing a great job. and, you know, they're doing their strength training. And, you know, I would say it's probably on the order of seven to eight, seven to ten percent. Okay. So that's a pretty decent bump. Yeah. Especially because, you know, again, it varies a little bit with sort of how depleted they were

or, you know, if they were low in zinc or, you know, frankly low or relatively, you know, what those numbers look like, vitamin D, Lose pieces. But, yeah, it can be decent. One of the other categories when it comes to testosterone that you feel, that people come in and there's maybe either misconceptions around it or a lack of understanding around it or there's just that information that you have from having treated so many patients over the years that it's something that people just don't get about how vital it is or how to access it or how to support it. Is there something that comes up for you?

Well, some of the misconceptions out there, I think, are one big one is around prostate health. you know so there was some early um a lot of early discussion around potential risk of prostate cancer and um and bph benign prostate hypertrophy and um you know if you go on testosterone supplementation that that might um trigger or cause either of those conditions um and what we know is that you know we now know this pretty well um is what we call this saturation effect so testosterone replacement does not cause prostate cancer. That's pretty clearly shown now. But you can actually see some, if the person's testosterone levels are very low,

usually like low 200s or so, the prostate itself is not saturated with testosterone. And if you do start testosterone therapy, you might actually see some growth of the prostate or some increase of the lower urinary tract symptoms. And so that could be concerning, obviously, right? And so if someone comes in their testosterone levels are super low, you know, we warn them about that and we let them know this is a possibility. I want you to keep track your symptoms.

We're going to track your PSA. We definitely absolutely get a baseline PSA as part of our screening labs. And then we'll follow that up and track that and make sure there's not a sequential rise, which would be concerning. But if someone's testosterone level is in the 300s or above, we actually don't see a lot of effect on the prostate. And so that's still, but there's still a lot of holdover on that of men coming in saying, hey, I think I might need this.

I think I might want this, but I really don't want to do it because I don't want to get prostate cancer, et cetera. So there's some education there. And we talked a lot about the benefits on cognition and brain and neuroplasticity and all those pieces. But the research is also a little bit mixed there in terms of what the actual net effect on sort of day-to-day cognitive function is and how people, what the outcomes are. And I think it's just because there's just a lot of complexity of dosing and sort of how

high they're, you know, what levels they're targeting and what the outcome were there, we definitely see a benefit in our populations of that cognitive boost that happens, but there's still being elicited in the research of what that actually looks like. Before we get into a case study that you have of somebody that you worked with, another question that I had regarding prescription testosterone, supplemental testosterone that people would add in. Once you go on it, is the goal to get people off, to stay on it, And even if you wanted to get off, let's say if you raise your testosterone significantly, could you get off?

So how do you think about that and what education do you provide to people that you work with? Yeah. So I think in general, most people will usually get on it and decide to stay on it relatively long term. Because at that point in time, if they've gotten on it and they need a prescription intervention, chances are they kind of have needed that for a while and their body will continue to need that. Right. Absolutely, yeah. And they'll then usually reap the benefits of being on it and they'll feel good and they'll not want to lose that. Right. And so then it becomes, you know, they're motivated to keep going. You know, so but we do sometimes have people for whatever reason, you know, that they need to get off of it, which you absolutely can do. You know, we ideally like to taper people, you know, because there is some, especially if you've been doing injections or creams or sort of an exogenous replacement. there definitely is some down regulation of the central systems in the body, right,

from the hypothalamus to the pituitary to the testes, etc., where the body says, hey, it looks like everything's good and we have enough testosterone, and so we don't need to produce that much, right? And so, you know, in general, that can come back online. You know, sometimes the local production of the testosterone in the testicle itself, which amounts to about 5% of total testosterone production. That one is variable on how much it comes back. And so that's an important point also with younger men who are still desiring fertility.

There's a lot of factors there. You can get, you know, changes in local testosterone in the testicles, which can affect sperm production and fertility. So, you know, if we don't like to put men who still desire fertility on either a testosterone injection or a gel, but assuming that's, you're, non-concern. So, yeah, slow taper. Sometimes you can, you know, get that back. And then again, really dialing in the lifestyle factors.

You have a case study that you have for us. I think it's a 46-year-old man that you worked with in your clinic. Do you want to talk about that? Sure. Yeah, so it's a great case. You know, kind of just goes through a lot, brings to life a lot of what we've been talking about. You know, this is a man named Jonathan. You know, he had been experiencing fatigue and low libido and difficulty maintaining an erection.

He was feeling frustrated about his inability to gain muscle in the gym. He had some extra weight around his belly and, you know, a little bit of borderline high blood pressure, right? And so, you know, kind of a typical 46-year-old guy, had a full-time career, which he really enjoyed. He was loving it. But it was really stressful. It was really competitive. So you need to kind of maintain that drive. Three kids at home, school-age kids, wife also worked full-time.

And they're also, you know, caring for his mom, his elderly mom who had dementia. So just kind of like all burners firing, right? So, you know, and, you know, we basically did everything that we talked about today, right? So he came in, we did a bunch of intake forms as a couple of questionnaires. You know, one of them is called Adam, A-D-A-M, you know, energy deficiency in the aging male. And you can get a score on that and sort of see like what's your potential, your likelihood possibility. He scored pretty high on that, especially for a couple of key questions on there, which are really key us into this being a concern. We did a bunch of testing on his gut.

we tested for Cibo, nutrient deficiencies, his adrenal hormone function, his testosterone, PSA, all those hormones as well. You know, and so basically, you know, we came back to him and said, hey, you know, this is real. There's definitely concerns that we have. You know, his labs showed increased markers of inflammation. He has a number of different nutrient deficiencies. He did show, you know, blood sugar imbalances, sort of this metabolic derangement that we've talked a lot about today. he had an imbalance GI system. He had SIBO, small intestinal bacterial overgrowth, right? And his testosterone levels were frankly low.

You know, his total testosterone was 215 milligrams per decilator. You know, so, and it's important also to mention that we do like to measure testosterone in the morning in a fasting state. Right. So that's when we get the most accurate measurements. And so, you know, we would, again, really like to see him at the mid-level or higher, you know, ideally above 500 on that. And so, you know, basically, you know, kind of dialed in, you know, we actually sent him links to the Will Bolshevist episode with fiber.

We got, you know, eating more fiber, having regular bowel movements. We had him hydrating. I showed him here your sort of hydration boot camp, you know, episode that you did, you know, and worked first on his gut. And, you know, got his bowel movements happening, better treated his sebo, got him on some nutrient support, you know, talked about his sleep, optimized that. He worked really closely with our health coach. We actually did run that sleep image study that we talked about today. We had him use a wearable to track his sleep. So we kind of get some data on that. And then just put him through

some basic sleep hacks, you know, that are really effective and really key. You know, he was also sort of a hyper-cardio exerciser, you know, training for long-distance runs. And so, you know, we had him do keep doing some cardio for the health benefits but also pushed him and encourage him more into strength training weight training all these pieces right so full spectrum right all these different pieces and i don't know if you mention it but when he first came in his testosterone if you could mention the number yes 215 yeah so low yeah yeah very low yeah which is eye-opening to him too right i mean it's it's so it's so fun on our side to do this work and to have somebody like him come in and you know he's just like go, go, go, like doesn't really basically have time to think about how he's feeling,

but he's starting to get this sense like, gosh, it's just not, you know, it's just, I feel heavy. Like, I just feel energetically heavy and I'm just feel slow. And it's like I feel like I'm kind of waiting through, you know, quicksand, just slipping back all the time, you know, and so then we get, you know, him in, we do this deep dye. We start building these lifestyle habits with him. We show him data across all these different, you know, areas. And that's like kind of my favorite visit with people, right? The first visit is great because in general people have had trouble usually finding someone who do a deep dive and really think about this with their health issues with complexity and nuance.

But then when we come back and we say, look at all these things that are contributing to what you're experiencing and it's real. So you kind of see this like weight lift and his shoulders drop a little bit. And he's like, okay. People feel validated. I knew there was something going on. And so not only that, but that we now have things we can do about it. right so it's really it's really gratifying work um so you know again lifestyle pieces got them all dialed there he worked with our health coach and our nutritionist um we got him on a bunch of supplements

and adaptogenic herbs for his adrenals we put him on some um you know testosterone precursor hormones like dhia and pregnenalone um you know and we worked with him like just with that over about four to six months you know and he actually saw some really interesting gains you know his testosterone with all of that went up by 200 nanograms per decilator Wow. Right. And so now we're in the low 400s. He lost about 10 pounds of weight.

His energy was better. His libido was improving. It wasn't kind of back to what he would like or where he felt like, you know, he could be. He had some increased muscle, you know, mass gain. And he was generally feeling pretty happy, right? And as were we and appreciating that he did a lot of that hard work, right? And so then we reevaluate. We got some, you know, reset the labs, new baselines.

And then we did start a testosterone prescription. But again, we were able to do it at a relatively lower dose because it wasn't the only tool that we were using, right? And so we were able to kind of use it as sort of like an extra spice, a little, you know, extra, you know, on top. And with that, it kind of took him over the edge of sort of, you know, really feeling like he was, he got his mojo back. You know, he was back feeling very vital, feeling, you know, able to make decisions more quickly, able to juggle all the things that he was juggling, you know. And so, so, yeah, that was really fun. That's great. Do you know where he ended up after, you know, that last sort of boost? Yeah, so he's about in the 600s in terms of testosterone level, you mean?

Yeah, so he's kind of holding in the mid-600 range, and to him that feels great. Yeah, and most importantly, he feels good. Feels great. That's awesome. It's amazing how, again, it's not just that this conversation about testosterone, but we're using that as sort of the opening for so many other aspects. Yeah. As you mentioned, his body composition improved, you know, his mood improved. all these areas improved in sort of in his life.

And it just shows you what's possible when you focus in on something and you pay a little bit of attention. And again, you work with the right team. You get some labs done so that you actually know what's going on inside your body. And then you take action. It's not something that somebody else can solve for you. You know, you can have your testosterone levels brought up to normal, even optimal from just prescription alone. But if you don't put in the work that's there, you're going to have challenges on other sides of things later on. Sure, you might have high total testosterone, but you could have

other issues that impact your longevity. Right. Yeah, absolutely. And what really gets me passionate about this stuff too is like, you know, here's this guy, this 46-year-old guy who came in and, you know, sat down in front of us and we're able to start working together. And over the course of six to nine months, we're really able to shift his experience of his own body, of his own life. That's awesome. Love that. That's a win for him and for us, right? Everyone's feeling good. But what really gets me is like just this big picture thing, right? Like if he never had landed in front of us or he didn't hear about functional medicine or he didn't understand like there is something I want to dig deeper on here.

I want to there's something that's not quite right. You know, if he just settled for the status quo, you know, his, I believe, right, I believe, you know, that his life in 15 years, in 20 years, hopefully he lives that long, 30 years even, would look very, very different. than it has the potential to look, right? And so it's kind of like this fork in the road and, you know, where, you know, it's partly about the immediate wins, but it's really much more about this sort of opportunity

to live your optimal life and to try, you know, in a really creative and, you know, very structured and very scientific and evidence-based way, try to roll back some of the negative effects that are just pushing down on us all the time, the environmental exposures and the toxins and stressors

and all the things that we all deal with, right? So it's kind of like, you know, I feel like, and I'll ask you if you agree with this, but I almost feel like we don't really have a choice anymore, right? There's so much coming at us that, you know, we have to get more proactive. And, you know, I mean, I guess the choice if you don't is you just settle for, you know,

you're just going to be one of those numbers of people with chronic disease, those numbers which are dramatically rising every month and year, you know, and you're just going to kind of settle for being sick, right? So, but you don't have to. Yeah, you're really asking, like, are you just trying to make it through the day, which, okay, you might be alive. That could be survival. Or are you trying to thrive? And when you thrive, all the goals and dreams in your life that you want to put love and attention on, they get better. And you can actually accomplish them. Let's do a little bit of a recap. You know, we've been going for about an hour in almost 40, 50 minutes. Let's do a recap so we can kind of put all these pieces together. And if there's anything that we missed, you know, feel free to, you know, interject and we can give you space to be able to cover it. So there's both the short-term and long-term reasons why we want to pay attention to low testosterone levels. Can you share some of those short-term and long-term reasons again before we go to the next one? Yeah, so short-term, you know, that you can feel your optimal potential.

You can have better focus. You can have better energy, better vitality. You can maintain, you know, body composition that feels good. You know, sleep optimally, you know, so many different things. factors. And some of the long term. Yes. So preventing long-term negative outcomes like heart attack, like stroke, like atherosclerosis, you know, like lipid abnormalities, blood pressure abnormalities, you know, basically being able to potentially roll back some, maybe not all, but some of the cardiovascular risks, which are tied to testosterone. We talked a lot about cognitive, about your

optimal brain function, about your ability to think clearly and have the best possible spatial awareness and memory and potentially help to maintain that trophic level of testosterone, of hormone, which is part of what's going to help us prevent dementia or cognitive decline or even Alzheimer's disease, right? Things like bone health. You know, so there's many. And it's normal. It's normal as we age, right, especially for men, that your testosterone will decline. What we're talking about in general is this specific abnormal decline when you look at these cohorts of people, even not that long ago, back to this graph that we shared over here from the European Urology Journal.

Even in the 2000s, we saw that the average testosterone levels of every cohort, 15 to 19, 20 to 29, 30 to 30 to basically 40 years old, all of those have significantly dropped. since, you know, the data they have there of 2015 to 2016. So something is going on. And in particular, you have highlighted some of the main root causes that you feel that are contributing to that, that if you could recap those. Yeah. So stress, sleep disruption, artificial light exposure, gut disruption, intestinal permeability, exposure to toxins, you know, in our water, in plastics, you know, heavy metals, you know, mercury lead, you know, et cetera, you know, arsenic, cadmium, you know, air pollution, you know, all these factors play a key role. And just to go back to what you just said before about the levels, absolutely, you know, having your testosterone decrease

overtime is part of natural aging and it's physiological, right? And is associated with negative health ramifications. And so even in that group, taking away any of those concerns that we have, there are potential benefits to supporting testosterone to a balanced level. But then you stack on top of that, you know, all of this sort of, you know, newer, you know, stressors and triggers that are pushing on our bodies over the last 20, 30, 40 years. And yes, we're now pushed into an even more severe drop and decline and potential negative outcomes on our hormones as well as many, if not most other health issues. And as part of the recap, you know, it doesn't have to be this way. It does not have to be this way. Even if you find yourself in a older age group, 40, 50, 60, 70, it doesn't have to be

this way. You can make some serious gains in your increase in testosterone, which obviously benefits your entire life. And some of those things that are lifestyle tools that are available to us are, if you could recap them. Yeah, absolutely. So eating a healthy diet, getting optimal nutrition, nutrient-dense foods, as clean as you possibly can, organic whenever possible. I just saw a really great seminar by Mark Houston talking about integrative and functional medicine for cardiology, for lipids, for blood pressure, for, you know, CHF, cardiovascular disease, plaque formation. You know, he says he will not eat anything that's not organic. You know, so maybe not, we don't all have that luxury in terms of availability and cost also, but as much as possible,

You know, look at the environmental working group, look at the, you know, the dirty dozen and the clean 15, which foods, the dirty dozen are ones that you really should only eat organic, et cetera, choosing the healthiest animal proteins, you know, you know, et cetera, et cetera. There's many, many opportunities there. So nutrition, number one, you know, balanced sleep, balancing your stress and movement exercise. And within the stress category, you know, mindfulness, breathing, breath work, you know, chigong, Tai Chi, you know, restorative work as well. So, yeah, those are all beautiful things. And with a little bit of a, you know, extra focus on, especially adding in if you're under muscle, that lean muscle mass to improve body composition,

to make sure you eat a diet that supports that component and to not only see the testosterone go up, but to feel, you know, stronger in your body, which has a whole bunch of, you know, of, that's the most important thing, just feeling that you get. Yeah, you feel better. And then if you have the basics covered and you still need some interventions, you can look at the tools that are there like supplemental, supplemental dietary supplements, herbal medicines, you know, nutrients that help with conversion and production of testosterone, make sure your zinc levels are good, make sure your vitamin D levels are good, you know, magnesium, et cetera. And then yes, absolutely, you know, in the balance and judicious way, working with somebody who can help you to optimize your testosterone using

what feels like the right prescription method for you can be really helpful for a lot of people. Amazing. Well, this has been fantastic. Anything else you feel in your incredible preparation for today's episode, anything else or final words that you want to leave the audience with when it comes to this topic of testosterone? Yeah, I mean, we touched on it during the podcast, but I just want to highlight it again, which is that, you know, you know, you always do such a good, you know, amazing deep dive with your guests and, you know, we go through so much information, you know, and so I, I want to, I think it's valuable and I think it's really critical to put that information out there for people, but I don't want people to get overwhelmed. You know, I'm notorious for wanting to do everything

all at once and it can be kind of overwhelming, right? It's just a lot. It's a lot of work. It's a lot of lifestyle stuff. It's a lot of things to take. It's a lot of things to buy, testing to do, et cetera, et cetera. So, you know, if you're curious about this and you, but on the other hand, you're feeling like that just feels like too much. Just do one thing at a time. You know, just do one small change, you know, look up, you know, the previous hydration episode and just start drinking more water in the morning, see how you feel. You know, just try being off your screens at eight o'clock for a couple of weeks. Don't even commit to forever. You know, that might feel too overwhelming. Just do it for a week. Do it for two weeks. See what you notice. If you're using any

kind of a wearable device, look at that data. Just kind of see what those incremental changes do. And you guys are a step by step back into this, right? It doesn't have to be a sprint, right? You know, hopefully you will live for a long time to come. And if you make small changes, you know, over time, you will see the benefits of it. And so it doesn't have to be, you know, it doesn't have to be everything all at once, right? That's actually, if you try to do it that way, you're really likely to fail, right? Because it's going to, it's going to feel overwhelming. It's not your natural rhythm. It's not your natural habit. And so you'll, you'll, you'll, give up, right? It's a New Year's resolution. Right. So go slow, make it sustainable, work with a team

who knows how to do this, who believes in you, get a health coach, find some community and friends who are also curious about this, and that way you really have some success in building it into your life. Amazing. Speaking of team, if people want to reach out to you and your team and want to work with you, you guys obviously do telemedicine in a bunch of different states that are there, where do they go? and how do they get in touch with you? Yeah, so we're the California Center for Functional Medicine, and our website is CCFMED.com. For anyone listening out there under our programs tab,

we actually do have a webinar and a Q&A that we put up. Also, there's an e-book up there on men's health and testosterone, which is free. So you're welcome to log in and grab that. And we also have a service called the Functional Medicine Checkup, which is a low-cost $500, $500, $200,000. two-visit sequence where we do a deep dive on blood test labs and kind of get you started on the path of this work. So if it feels, again, too overwhelming, it's just a really easy, quick way to

start. But again, we're just passionate about trying to change people's lives one by one and trying to change the impact that chronic illness has on our society and on our healthcare system. So, yeah, reach out if we can be of any help. That's awesome. They'll get the basic snapshot of what's available to them with a little bit of guidance as well, right? Some basic lifestyle things, things that most of them, most people can do just from the comfort of their own home. Without a lot of cost intervention to sort of start heading in the right direction. Absolutely. Yeah. Yeah. All those labs, you know, zinc, copper, vitamin D, deep dive on lipids, looking at the particle number and the sub markers, you know, that show us sort of the lipid

ecosystem, you know, so yeah, there's a lot of really interesting information that can come out of that. Amazing. We'll link to that in the show notes at ccfmED.com. Correct. Where you can find out more about the California Center for Functional Medicine and all your great work and your team's work. Dr. Sanja, this has been fantastic. Thank you for the breakdown and the little masterclass that you took us through on testosterone. I learned a bunch and I hope the audience did too.

So I always appreciate you coming on the show and sharing your knowledge with us. Yeah, Drew, it's been great to be here. I really appreciate the opportunity. It's just fun to sit down and chat with you and go through the time. deep dive on this really, really important topic. Hi, everyone, Drew here. Two quick things. Number one, thank you so much for listening to this podcast.

If you haven't already, subscribe, just hit the subscribe button on your favorite podcast app. And by the way, if you love this episode, it would mean the world to me. And it's the number one thing that you can do to support this podcast is share it with a friend, share with a friend who would benefit from listening. Number two, before I go, I just had to tell you about something that I've been working on that I'm super excited about. It's my weekly newsletter. And it's called Try This.

Every Friday, yes, every Friday, 52 weeks a year, I send out an easy-to-digest protocol of simple steps that you or anyone you love can follow to optimize your own health. We cover everything from nutrition to mindset to metabolic health, sleep, community, longevity, and so much more. If you want to get on this email list, which is, by the way, free and get my weekly step-by-step protocols for whole-body health and optimization, click the link in the show notes that's called Try This or just go to Drew Perot.com.

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