#237 – Erectile dysfunction as an indicator of cardiovascular disease & early death | Dr. Merrill Matschke & Dr. Casey Means

Erectile dysfunction can be an early indicator of future cardiovascular disease, endothelial dysfunction, and early death. ED is also connected with obesity and metabolic dysfunction. So, what causes ED and can it be reversed? Dr. Merrill Matschke, a urologist with 25 years of experience in urology, shared his thoughts on ED, how it relates to insulin sensitivity, and how he’s challenging his patients to live healthier lives.

13:47 – The connection between metabolic dysfunction and erectile dysfunction

Now more than ever, metabolic dysfunction is manifesting in men through symptoms of erectile dysfunction.

More and more men are coming in now with early manifestations of metabolic dysfunction and it’s manifesting through their penis. We know that erectile dysfunction is an incredibly strong, independent risk factor for cardiovascular disease and cardiovascular events. It’s proven, it’s not a question, it’s proven. It’s more significant than the risk factor of smoking. And then you combine that with insulin resistance and it’s even more significant. So the Endocrine Society just had their meeting recently and one of the papers presented, so scary. Young kids, the children and adolescents with hyper insulinemia and insulin resistance have smaller testicles. So it’s right there. It’s right there for me to be at that proximal aspect to intervene with low hanging fruit for all men. So if I can step in and stop their bad behaviors and put them on a better path, their health span and lifespan is going to be extended.

22:08 – How ED develops

As men age, they lose smooth muscle content in their penises and collagen content goes up, which brings on ED.

There have been a lot of studies done. I don’t know how we can talk about it, they’re interesting studies. But the appropriate erectile response requires a certain ratio of smooth muscle to collagen in the penis. And as we age and we’re exposed to these chronic disease pressures, you lose smooth muscle content and collagen content goes up, and you actually get fat inside the penis right underneath that casing. And what that does is the first step to most ED is venous leak. It’s not getting enough blood into the system, it’s not getting trapped to develop the pressure head. So as that tissue scars, it doesn’t relax as well to close those veins and the amount of that tissue is smaller. And so you start to get ED. When you lose nighttime erections that natural… It’s like doing pushups in your sleep. When you’re not getting that natural exercise for that tissue exposed to the high oxygen tension there, that tissue starts to scar and you start to get ED.

34:11 – Let’s talk about oxidative stress

People need a balance of oxidative species of inflammation and inflammation species that quell that. When you have elevated oxidative stress, that will lead to damage.

Nitric oxide synthase only works well when testosterone is healthy. So that touches all of this. But when we talk about oxidative stress, we need a balance of oxidative species of inflammation and inflammation species, and species that quell that. And the problems that occur is when that gets out of balance. And when you have elevated oxidative stress and it is a generalized term, but that will lead to damage, whether it be through advanced glycation products, end products and some of these other issues, but it will cause the eventual changes that we think of when we think of vascular disease, when we think of hardening of arteries and plaque formation and thickening of the intermedia of the vessels, and then that same inflammation or oxidative stress also impacts our genetics, our DNA, it will induce things called apoptosis, which a lot of your listeners know about, but it’s program cell death, the way we kind of manage our cells and recycle cells. And then there’s a whole nother thing called senescence, but we won’t get into that. But that whole pattern when chronic inflammation starts to push that too much and whether that be in a blood vessel, then you start to see the classic changes of atherosclerosis and vascular disease and in the penis we discussed some of those, but in more, just the typical vessels, you’re going to see those changes first at the lining and they’re inflammatory factors like IL6, TNF-alpha and other things like that are the driving some of these pathways and then leading to some of the developments of connective tissue changes and vascular changes.

40:06 – The importance of testosterone levels in insulin sensitivity

The endocrine world on the mainstream is not recognizing the importance of healthy testosterone levels as it applies to insulin sensitivity.

I do not feel that the endocrine world on the mainstream is recognizing the importance of healthy testosterone levels as it applies to insulin sensitivity. So as men get heavier, obviously they start to develop deposits of fat and when you get the visceral adiposity, we all know that’s the hormonally active fat, where the IL6, the TNF-alpha and all these other inflammatory mediators these is active fat and that fat is actually acting and now those mediators act in multiple areas, it can act centrally and it can act in the testis itself. And so what we’ve learned is when you have metabolic dysfunction, hyper insulinemia and obesity, you see the increase of these cytokines and they’re acting centrally it appears at the hypothalamic level. And whether it’s working through kisspeptin, or whether it’s working through the nerves that actually are involved in the hypothalamus for the release of GnRH, you’re seeing reduced GnRH production. So you’re seeing lower gonadotropins out of the pituitary, specifically lower LH and FSH. So you’re seeing a central component, but then you’re also seeing these inflammatory mediators impacting the lighting cell within the testis. So it’s touching everything. Obesity and these inflammatory cytokines and the pathways are multiple there isn’t just one it’s happening locally in the testes and it’s happening in the control mechanism of the HBG axis as well, the hypothalamic pituitary gonadal axis. So then you T come down. And so as T is coming down, you’re just going to start to impact the efficiency of nitric oxide production. So you’re now promoting endothelial dysfunction and another thing I say to them is ED equals ED equals ED. Erectile dysfunction equals endothelial dysfunction equals early death.

46:50 – The importance of diet, exercise, and sleep

Lifestyle changes can have a major impact on ED. Try to eat more while foods, exercise more regularly, and work on better sleep hygiene.

Our diet, our exercise and sleep are the first three things I’m going to talk about. Diet, diet, diet. Nutrition, nutrition, nutrition, and diet is a four letter word to me. I talked about lifestyle changes in nutritional aspects and getting to a clean diet. Depending who I’m talking to. I’ll change the way I talk about it. But we’ve all said, “Shop at the outside of the grocery store,” we’ve all used that line, on the outside. Or if I’m talking to other people, I said, “Stop eating out of bags and boxes. Stop picking up food that has a nutrition label on it, it’s not food.” You start eating real food and start moving based on whatever their status is, what can they do? And if I need to I’ll employ the guy next door, the exercise physiologist that works across the hall from us, to try to help that guy with some barriers, to try to understand what he may be able to do to exercise if he’s got a bad back or something else. But nutrition, movement and sleep, and then anything having to do with chronic stress. I haven’t even talked about anything in terms of medicine yet. Those are the answers to how do I maintain and increase my own testosterone.

48:45 – Why is testosterone dropping?

Younger kids are now being diagnosed with formerly known “adult onset” diseases younger and younger, which means they will have compounded health complications as they age.

The endocrine society, as I just mentioned, just presented brand new information on young children and adolescents with hyper insulinemia and elevated fasting glucose already. They have smaller testicles. We are seeing this, we don’t call type two diabetes, adult onset anymore. And we know why. One of the biggest groups that’s getting it diagnosed at the highest rate are younger kids, teenagers and 20 year olds, are now being diagnosed with what used to take 40 years to occur, because they’re not moving and their diet has changed. And so we’re seeing a development and this is a big problem, because as we begin to move into metabolic dysfunction in the second decade of life, we’re going to see all these downstream problems, the top three comorbidities and mortality issues of vascular disease and neurodegenerative disorders and cancer, we’re going to see it earlier. We’re going to shortchange everyone’s health span unless we can step in. We’ve been here for what, 200,000 years in our current form and whatever we’ve been doing really, we’ve only been doing this way for the last 50 to 100 years. Modernity is killing us very quickly

59:59 – Our healthcare system needs to do better

Dr. Matschke doesn’t just see himself as a urologist, but as a doctor looking to promote a better way of life to his patients. This means there isn’t a place for him in a lot of traditional medicine.

I have to try to get the patient in whatever way I can, to hook in. I was talking to my leader about this and I said, I won’t use his name. I said, “Doctor?” I said, “This is what I do. This is why I see 20 patients, instead of 50.” I said, “I do this, I do this, I do this.” He gives me this blank stare. He’s like, “But you’re a urologist.” He goes, “So we don’t know how to compensate you. Are you primary care? Are you into chronology? Are you in fertility? Are you urology?” And I looked at him and I said, “I’m a doctor. All right. I am a men’s metabolic health doctor. And if you can’t understand that, we’ve got a bigger problem.” And so that’s when I have to be honest with myself, that I can’t come back from the well side of medicine to the sick side and fix it. I have had words said to me like, “You may not be a good fit. You don’t bill like urologists. You don’t do this.” I said, “I’m happy. I’m happy with that. I’m empowered. I now feel empowered because I know my end user is feeling better. And when I close that door, I’m not working for the entity I’m working for that person.” And so working for that person, is what makes me come back to work every day. Now, hopefully they’ll figure out a way to compensate me appropriately, but I’m not going back to that old way of just cranking the patients through because we need to do better. And there are so many other signals out there that our current delivery system is not working well.

01:07:44 – Don’t put treatment off

If you catch symptoms of ED early on, it is easier to reverse the effects and prevent other health problems from occurring.

We don’t want to wait until the guys going in with chest pain. That’s the end result of years and years of endothelial dysfunction. Some of the earliest markers of endothelial dysfunction will be some of those FMD tests that you can do, the brachial index test is a test to check the distensibility of blood vessels. You can check IL6 levels in different inflammatory mediators and some of the CIMT testing, early indicators of endothelial dysfunction. If you can step in early on those, you can stop that progression, rather than waiting in the classic, “I’m showing up in the ED with chest pain and my troponins are off the roof.” Yeah, you just step in early and we know, you see those people, the people that were active, that ate not out of boxes and bags and that had a real food diet, they were active, they had good social support. These are the people that walk into your office, you’re like, “You’re 85? You look like you’re 55. I just had a 40 year old in here that looks twice as old as you and physiologically looks twice as old as you.” The people who do it right, and have a healthy lifestyle and behavior, the machine pays you back for that.

01:14:02 – Sleep is crucial

If you have a dysfunctional sleep schedule, you’re more likely to have other health issues. Good sleep hygiene is an incredibly important facet of health.

I’ve been seeing so many third shift workers lately, and we know they are an at-risk class. I mean, they are now a study group because of their disruption of their sleep cycles and what it does. You listen to people like Matthew Walker and it blows you away when you start learning about sleep. And I’m like, wow, I didn’t know about that sleep issue with low T. I didn’t know how amazingly it will change your own insulin response until I got this thing, and I watched what it did in my sleep pattern, which was amazing. So I explain to them and I show them, I’ll pull out my phone and I’ll show them my own curves, and I’ll tell them what has happened to me. And I’ll explain to them that sleep is much more than just putting your head down. It is that time for your body to recycle, to maintain and to do what it needs to do to manage energy well and to manage food well. And so sleeping is crucial and it is hard. Some of these people, some men just aren’t ready yet. And that’s the other thing is you see where they’re ready, for what, and then I start to grab at those things that they’ll listen to. And then if they’re not going to, I don’t push too hard on sleep if they don’t have that option, but it is an incredibly important lever to pull.

01:19:41 – Nobody’s perfect

Allow yourself 20-30 percent of leeway when you’re trying to improve your lifestyle, because nobody’s going to do it perfectly all the time.

I look at them and I say, you can’t be perfect. I’m not perfect. None of us are perfect. Allow yourself 20% to 30% of leeway. 70% of the time, try to be tight on your diet, 20% to 30% of the time, let yourself go. That’s the durability factor that will keep you on the path. If you don’t do that, you will not stay on the path. I’ve got four young kids, they like Culver’s, they like pizza. I want to be engaged, I want to be present, so I let myself do that. But if 70% of the time you’re doing the right stuff in that other part of those compartments of lifestyle and behavior, you can do that. And that allows for a meaningful, healthy life. And so I’m very careful with guys when they come in, they’re like, “I’ve been doing this…” I’m like, that’s fine. You recognize it, you know that, just make sure… you try to keep it 70-30, 80-20, if you can. And you’ll lose some people in it, but overall you’re just trying to make incremental change in improving their health.

Dr. Merrill Matschke (00:00:07):

ED equals ED equals ED. Erectile dysfunction equals endothelial dysfunction equals early death. So I try to tie it all together. Low T is a bigger deal than I think we realize. And granted, I’m only talking about men here, but the impact that this has is staggering.

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And so I have been trying to educate the local endocrine system providers with the data out of Europe on long term testosterone replacement in type two diabetics with low T and ED. What we’re seeing is as you replace T in these men, not only are you seeing improvements in all their markers of insulin resistance and sensitivity, you’re curing a higher percentage of type two diabetics.

Dr. Merrill Matschke (00:00:58):

I’m Ben Grynol, part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health, and this is your front row seat to everything we do. This is a whole new level.

Dr. Casey Means (00:01:24):

Hello everyone. This is Dr. Casey Means, co-founder and chief medical officer of Levels. I am so excited to introduce you all to Dr. Merrill Matschke. We are going to be talking about the incredibly strong link between metabolic health and sexual function that is largely under recognized and barely makes it into the clinical practice conversation.

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Dr. Merrill Matschke is a urologist. He has over 25 years of experience in urology and specializes in male reproductive medicine and surgery. He’s leading the development of the men’s health program at Advocate Aurora Health, a large Midwestern healthcare system. He’s worked across several clinical practice models and socioeconomic environments, and is passionate about designing a real path towards health for both men and women.

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He’s also a Levels beta member. He’s introduced many of his patients to Levels, and he is just such a valued member of our Levels community. So without further ado, here’s my conversation with Dr. Matschke.

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So I can’t wait to dive into topics of men’s health, metabolic dysfunction, consumerism, and healthcare, and so much more. Dr. Matschke, welcome to a whole new level.

Dr. Merrill Matschke (00:02:38):

Well, thank you. Thank you for having me. It’s very exciting to be here with like minds and people who have the same interest.

Dr. Casey Means (00:02:44):

Yes. Let’s start with hearing a little bit more about your personal journey as a clinician. You mentioned that your mission is to be part of a new path in healthcare, a new delivery system of health. How did you come to this mission and how has your thinking as a clinician evolved over the years?

Dr. Merrill Matschke (00:03:01):

Yeah. And I’ll try to keep this brief, because I like to talk. But I am a urologist, but I specialize in what’s called andrology. And so we’re the urologists that focus on sexual dysfunction, infertility hormone disorders and the like. So I have kind of grown my practice over time from a general urology practice and then I grew my sub-specialty market.

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And as I was doing that, you just start to get exposed to the commonalities of men with ED, men with infertility, hormone disorders. And you start to immerse yourself if you’re passionate about it into what’s the common link here. And over time, I really enjoyed the first five years of my practice in general. I started to recognize this the middle five years of my practice in a kind of generalized large group practice environment. It was okay, you’re kind of hitting your stride.

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And in the last five years of this first 15 year period of my career, I really started to burn out because you start to lose that interest in those driving factors. And I just became that robot, that robot clinician, where you’re just pumping people in and pumping people out.

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I finally hit a part where I didn’t feel like I was giving a good product anymore to my patients. I was myself changing for my family and I didn’t like it. And I got to a point where I said this isn’t for me anymore. There were a couple of vignettes, little things that happened in my practice. I was constantly rated amongst a very large urology practice of about 60 or 70 providers. We were the third largest practice in the country at that time. I was constantly rated in the top by the physicians or by the patients.

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And then one day a person in my practice, one of my other partners said, “You know what? You are running behind, and you’re running behind enough that I think maybe if we’re more than 15 minutes behind, we should offer the patient like a $10 gift card or something to Starbucks.” And that was a breaking point for me because I said, “I’m giving a product they want, and they’re telling us this, our end user is telling us I’m doing a good job and I’m going to pay them for that?” I said, “I have more self respect for that.”

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So I actually took a turn. I took a turn, left kind of mainstream side of medicine, crossed the fence over to what I call the well side of medicine. And I joined a wellness and prevention concierge medical practice for a year, and it reinvigorated my interest once again in these commonality pathways or the common pathways that were going to lead to endothelial dysfunction, erectile dysfunction, infertility, and some hormone disorders. It just kind of gelled again for me, that initial passion for medicine and what led me to male reproductive medicine and surgery in the first place.

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And so I loved what I was doing. It was down in the south of the country in the Carolinas. I had an opportunity to come back and join a very large health system and be their main andrologist, their guy who’s got some male infertility background. And I loved what I was doing, but I said, “I need to see if I can do this at a bigger scale.” Because we were only getting that top level consumer, the executive type, the optimal health driver, which is great and we were seeing amazing results. You start just applying changes in behavior and lifestyle, you’re moving to the most proximal aspect of health and chronic disease. And you intervene before you’re going to deal with medicine and it works.

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And people were happy. I saw couples that were happier for all the reasons we may talk about, and just people were living better lives. And I said, you know what? We can do this on the mainstream side. There are problems on each side of this fence of medicine, but let’s bring together the good people. So I’ll go back, I’ll go back and be careful of my burnout, but I’ll return to the other side. And so I did. I came back, joined a large system here in the Midwest because they said I could go ahead and start to expand this concept of a men’s health clinic.

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So I came back and that’s really what I’m doing at this point. I’m experiencing the same friction that I met before on the mainstream side for innovation, for the ability to spend time with patients, competing in the environment now where it’s a productivity driven model.

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And unfortunately that’s it. It’s a chronic disease driven model. And I continue to change my brain. My brain has been changed to the superior physician. The superior provider is the one who prevents disease. The mediocre, inferior physician is the one that allows disease to occur and then treats it. And that’s out of ancient medical texts, but that’s the way I’m going to practice.

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In my second half of my career, that’s what I’m going to do. I want to work to find a way to develop a better product that engages, educates, and empowers men to find a better path to staying healthy first. It happened to me. All right? So I was one of these soft, fat, round kids. I always was. And I went through several periods of transformation.

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The first one was when I was doing my fellowship down in Baylor for male reproductive medicine and surgery in 2002. I checked my testosterone and I was in the 270 range. It explained a lot of things, I thought. So I went through, and you guys might not know this, but there was a program called Body for Life and the guy’s name was Bill Phillips. It was a book, it was a challenge program you’d go through for three months where you change your nutrition, gave you some exercise information.

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I did it twice. I lost 40 pounds, completely changed myself and I felt great. I came back, started my practice, got busy again and went through some issues, gained some more weight. And I went through three or four of those episodes. But finally, with the births of my first set of twins, I realized I was a little bit older. I was 44 when I had them. They’re now seven. And my back hurt, I was overweight again, I was working too hard.

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So I went through the changes of behavior, lifestyle, fixing some biochemistry, adopting some mindfulness practices, and my life changed. So I know it works. And when people see that, when the patients see that, they engage with you.

Dr. Casey Means (00:09:03):

Oh gosh, I just love hearing your story. It resonates with me so much, and so much of my personal journey as well. And I think one thing you said that I want to zero in on is that you had this shift in thinking where you started to really believe that the superior physician is the one who makes people healthy, who generates health and wellness.

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And I just want to drill into this more because I think we come from this culture in medicine where we’re indoctrinated with this idea that the most invasive interventions, the biggest things that we’re doing are the heroic things. And there’s this sort of trope of this surgeon with the bone saw doing the coronary artery bypass graph and the patient’s on ECMO and it’s like, oh my God, this person’s a savior and a hero and this deity figure.

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And I think what you and I both, having been trained as surgeons, I think, and then kind of waking up to more some of this, whoa, maybe there’s another way. I really started to feel like in my surgical training, that me going in and busting a hole in the sinus and sucking out pus wasn’t actually necessarily the heroic thing. Getting the patient healthy, reducing their inflammation, helping them actually improve their overall wellness, that was heroic, but it’s a much gentler and almost looked down upon.

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It’s like that’s nutrition, that’s this niche thing that is almost like wimpified and almost below… I’m being a little, maybe overstating a little bit, but almost below doctors to focus on, and really flipping that script and realizing there is nothing more valuable we could do for a patient than counsel them on these dietary and lifestyle factors that actually change physiology, that actually create fundamental health in their bodies, which unfortunately most surgeries can’t do. Taking something out, removing something to the body, changing anatomy, it can be helpful in many cases, but doesn’t necessarily always actually change core physiology that generates health.

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So I’m curious if that resonates with you or how that applies to urology and your surgical practice.

Dr. Merrill Matschke (00:11:10):

Well, so it absolutely does. And I don’t want to make people think that what I’m going to say here, that I have a little line that I use a lot with my patients. And it’s really from Marty Makarey, who is from…

Dr. Casey Means (00:11:21):

Yes.

Dr. Merrill Matschke (00:11:21):

And so we are so good at playing whackamole or putting out the fires, and that’s what we do on the mainstream side. But what really matters is taking away the matches. So if I can empower that man to understand his choices and what it’s going to do to his ability to work in the bedroom that night, it’s unbelievable. And so you have to spend that time. And what you just said is so interesting because I’ve literally been told by a CMO of my current system, you don’t bill like a urologist. And I said, well, I’m a modern urologist and I’m a men’s health doctor. I’m a men’s metabolic health doctor that’s under the umbrella of urology. Welcome to the tip of the spear of traditional medicine.

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Because that’s the other thing I was going to say. I see us, those of us like you and like me and other people that I’ve kind of allied around me in my system, as traditional medicine. What we’re actually doing I think now is alternative medicine. If we go back to that traditional, we know it, food is medicine, exercise is medicine. The studies all show it. The best studies show it’s social support, exercise, and diet that gives everyone the best outcomes. We’ve all heard about, if a medicine could do what exercise does, everyone would buy it.

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And so why not do it? So yeah, it totally resonates with me. It completely resonates with me to the extent that when he said it to me, I looked at him and I said, you’re too far gone. I said, you are so blinded in your silo, your ability to understand what we really should be doing, it’s really, it’s embarrassing to some extent.

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And I’ve heard it from so many leaders in different healthcare systems that at times I can really vacillate between wanting to support it and then getting aggravated. And that is a trigger point for me that I have to manage.

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But yes, I want a path that is incentivized somehow so that we can provide this product to people. And to come back to urology and why it’s important, I see young men. You, as women, you see your gynecologist beginning with the onset of menses. Men, they leave their pediatrician, oftentimes the first doctor they’re going to see is me. They want a vasectomy, they can’t get someone pregnant, they’re having some ED issues. I basically can become that first doctor that they see after their pediatrician.

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And so more and more men are coming in now with early manifestations of metabolic dysfunction and it’s manifesting through their penis. We know that erectile dysfunction is an incredibly strong, independent risk factor for cardiovascular disease and cardiovascular events. It’s proven, it’s not a question, it’s proven. It’s more significant than the risk factor of smoking.

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And then you combine that with insulin resistance and it’s even more significant. So the Endocrine Society just had their meeting recently and one of the papers presented, so scary. Young kids, the children and adolescents with hyper insulinemia and insulin resistance have smaller testicles. So it’s right there. It’s right there for me to be at that proximal aspect to intervene with low hanging fruit for all men. So if I can step in and stop their bad behaviors and put them on a better path, their health span and lifespan is going to be extended.

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And that’s what I’m saying. I don’t know what’s important to other people, but everyone’s got something that’s going to trigger them to want to be better in terms of their health. I want to be there with an outstretched hand as that provider when that moment happens. That gentleman that you guys had on recently who talked about prostate cancer. Case in point was perfect. His issue, his trigger was his diagnosis of prostate cancer. He then said, wow, I’ve got to do something.

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I love talking about prostate cancer in this setting because in this country, maybe every 18 minutes, a man dies of prostate cancer. Every 36 seconds, a man dies of cardiovascular disease. So my statement to all these guys who come in, I say, “Do you know what the number one cause of death with a guy with prostate cancer is? Cardiovascular disease.”

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That’s where I see my purpose. I see my purpose as, I took out a lot of prostates back in the day, but I wasn’t robot trained because I’m too old. So I haven’t taken out a prostate in forever and I won’t again. But I’d step in and I’m going to say under the urology umbrella, I’m going to step into the men’s metabolic health arena and actually help more men.

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And so I want to be there when a guy has that motivating factor, whether it be a cancer diagnosis, a divorce, a chest pain event, a birth of a grandson, a grandchild. That’s where I see urology as perfectly set up to really help men.

Dr. Casey Means (00:16:13):

So you called yourself a men’s metabolic health physician, sort of under the heading of urology. I love that framework for two reasons. One, because I think it touches on this really forward thinking perspective that I think some physicians are starting to wake up to, which is that we really need to be more systems biology focused and look at the systems, and kind of see almost these sub-specialties has downstream manifestations of core pathways that are kind of going awry.

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So we’ve got the cardiologists, we’ve got the urologists, we’ve got the OBGYNs dealing with polycystic ovarian syndrome. But it’s like when you step back, what you’ve done and see, okay, well what’s the link actually connecting all of these? And our current system with 42 subspecialties, it almost blinds us to the fact that there is this common link, that there’s honestly no real doctor for… I guess internal medicine, but even in the primary care, we’re still playing the whackamole medicine. We’re not thinking about those core physiologic links.

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So I would love to hear from you. If we can start breaking down some of the mechanistic links between metabolic issues and men’s health issues, and specifically maybe touching on erectile dysfunction and then also infertility. And our audience definitely likes to get nerdy, so feel free to go into some of the science.

Dr. Merrill Matschke (00:17:43):

Sure. So ED is a great kind of system and model to look at. And it’s interesting that the development and the understanding of nitric oxide and endothelial dysfunction all came through a lab at UCLA. One of the colleagues academically that I know, Dr. Jake Rafer, was a urologist, is a urologist, excuse me there. And back in the 80s, he was in an elevator and had it open up in front of him when he was going between meetings. And he looked across the hall and he saw a heading on a lab that said vascular smooth muscle lab.

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He walked right into that lab because he just knew he needed to. He was studying a molecule that was involved with erectile dysfunction that turned out to be nitric oxide. He walked right into that guy’s lab, turned out to be Ignarro, Dr. Irnarro, the pharmacologist who got the Nobel prize for figuring out what NO was.

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And so those two put together the concept of how NO worked with the physiology of erections and boom, look what we have now. We have the PD five inhibitors, Viagra and the like. And I think that is one of the most proximal metabolic actors and messengers involved. So endothelial dysfunction and nitric oxide, oxidative stress, that’s where that intersection is, I think with men’s health, ED, and metabolic changes and cardiovascular disease.

(00:19:04):

Now, if we slow down for a second and think about that, it is actually a proximal act, probably in all three of the main issues that are chronic diseases. You’ve got cardiovascular disease, you’ve got cancer, and you’ve got neurogenerative disorders. They probably all are going to basically come down to a lot of endothelial dysfunction, chronic inflammation, and oxidative stress. And so we’re talking about that in the penis and ED. So to get an erection, I try to explain this to patients, think of the two cylinders or two biologic cylinders in the penis called corporate cavernosa, and they’re specialized blood vessels. I’m in Wisconsin now. So I say, imagine a bratwurst that you snap and you’ve got casing on the outside and meat in the middle. I said, that meat in the middle is smooth muscle tissue and that casing on the outside is kind of a tough casing called tunica.

(00:19:56):

And I said for the penis to work right, that smooth muscle in the middle of that has to be real healthy. It has to expand. It has to relax. And the way it does that is through multiple mechanisms. But there’s this thing called nitric oxide, and nitric oxide as we age goes down and it goes down in many, many other conditions. Smoking, diabetes, lots of different things. And when that happens, that tissue does not work right. I said, if it’s working right, the smooth muscles completely relax, blood flows in, and it closes off the venous drainage of the penis, these little veins that live on the underside of the casing of that bratwurst. When it all works perfectly, everything works well.

(00:20:34):

But this tissue is probably the most exquisitely sensitive tissue to low oxygen tension in the body. So it is the canary in the coal mine, it’s the check engine light. It is the thing we should be listening to. Because as you start to get problems with decreased nitric oxide production, and that can be from atherosclerosis, decreased blood flow, it can be from low T. And that’s a huge interest of mine because testosterone, when it’s low, does not allow nitric oxide synthase to work, right? It is an androgen independent enzyme, and it has been well described and proven.

(00:21:06):

And so low T, which is a huge, huge part of my practice, is a common denominator, and we’ll get to this in a minute. But all these things intersect, and when that happens, the tissues actually don’t do well. And I have to sit and explain this to men because I already said, I want to engage, educate, and empower them, and they have to understand what’s happening to their own body.

(00:21:29):

So if their T is low, if they have diabetes, if they have neuropathy from it, one of the things they’re going to start to not have happen are nighttime erections. So I use this example of nighttime erections because that is there not because back when we were here 100,000 years ago someone was going to hop on top of us while we were asleep. When we get nighttime erections, it’s actually a preventative maintenance mechanism to maintain the health of the smooth muscle tissue inside the penis. That tissue needs high oxygen exposure on a regular basis, or else it’s going to start to go through the process of apoptosis and conversion from smooth muscle to collagen.

(00:22:08):

So there have been a lot of studies done. I don’t know how we can talk about it, they’re interesting studies. But the appropriate erectile response requires a certain ratio of smooth muscle to collagen in the penis. And as we age and we’re exposed to these chronic disease pressures, you lose smooth muscle content and collagen content goes up, and you actually get fat inside the penis right underneath that casing.

(00:22:32):

And what that does is the first step to most ED is venous leak. It’s not getting enough blood into the system, it’s not getting trapped to develop the pressure head. So as that tissue scars, it doesn’t relax as well to close those veins and the amount of that tissue is smaller. And so you start to get ED. When you lose nighttime erections that natural… It’s like doing pushups in your sleep. When you’re not getting that natural exercise for that tissue exposed to the high oxygen tension there, that tissue starts to scar and you start to get ED.

Dr. Merrill Matschke (00:23:00):

There, that tissue starts to scar and you start to get ED. Now, that’s the nighttime erection lost due to low T when your T dips below about 250 or to 200 nanograms per deciliter, that’s when you start to see that. It’s also why we start to see it in men initially after a prostatectomy, because that stops for a while too, but it’s an excellent explanation to try to help people understand why that tissue needs to be exercised on a regular basis and that’s why we think we get nocturnal erections. We’ve done a lot of studies to understand different things that are happening at different points of the pathophysiology, but it really boils down to nitric oxide and oxidative stress in some of these issues. And this is a specialized vascular tissue and so nitric oxide synthase is the enzyme that makes nitric oxide and it can come out of nerves. It can be part of an endothelial cell and in the penis, both are there, both are there. And so if T is low, you’re going to have decreased drive to make nitric oxide and then that whole second messenger system that drives erection through cyclic GMP is not as efficient.

(00:24:13):

And you start to have scarring of those tissues. Those tissues, when they scar, they’ve done it three to five years before you’re going to see changes in other vessels like the coronary or the carotid vessels. That’s why it’s this early warning system and they’ve actually done studies showing the main vessel leading into the penis or vessels. They’re very small as well. That smaller diameter is going to show flow limiting issues before you’re going to see flow limited issues in the coronaries.

(00:24:38):

It is a great model to look at and also to predict you have a problem. Now, not all ED is vascular in nature. I’m speaking specifically of vascular ED and there are other issues with regard to neurologic disease and those types as well, but then also psychogenic ED, not part of the topic of what we’re talking about here. But the health of the tissues of the penis are a great way to measure the health of endothelial function and that’s really a big part of what we’re talking about.

Dr. Casey Means (00:25:13):

Amazing explanation. Thank you. And a couple things I want to follow up on there. One, maybe a short question, you mentioned that aside from vascular issues for erectile dysfunction, there’s also psychogenic and neurologic. But one thing I was thinking about when reflecting on this, preparing for this conversation, was, is there an element of metabolic issues that actually may contribute as well to the psychogenic and neurologic part as well in the sense that are some of the neurogenic causes actually from nerve damage that are related to metabolic issues? Or is that more neurogenic issues from damage from prostate surgery and things like that?

(00:25:52):

But is there even, and then with psychogenic, I’m thinking about depression, anxiety, things like that and we see much higher rates of depression, anxiety in people with type two diabetes. Even in the nonvascular bucket, potentially, I wonder if there’s even still somewhat of an increased risk factor.

Dr. Merrill Matschke (00:26:10):

Absolutely.

Dr. Casey Means (00:26:10):

When you have metabolic issues, it just has its hands on everything.

Dr. Merrill Matschke (00:26:15):

And that’s absolutely right because the end functional unit of the erection is a smooth muscle cell. The smooth muscle cell doesn’t care why the nitric oxide is there or not and so anything that’s going to impact that. If you’ve got anything like the neuropathy of diabetes affecting nerves, absolutely that will then, because of that issue, will ultimately lead to that cascade of changes of increased apoptosis and loss of smooth muscle content in the penis and therefore ED.

(00:26:46):

You’ve got a guy who’s got just that wiring, the Type A personality that if he had a bad experience once intimately, he can’t get over it, even though his functionality is fine from a plumbing standpoint, but now he’s elevated his sympathetic tone. Now his norepinephrine is just high and that is not good. I mean, what is it norepinephrine for most of your listeners know this, but that’s part of the sympathetic discharge. That’s a fight or flight response, that is an evolutionary response to protect us. And so I say this to all my patients. I said, when we were a cave people, if you were getting chased by something, trying to eat you, and you saw a nice cave lady over there, if you stop the look at that person, you were in trouble.

(00:27:26):

The sympathetic nervous system is there to mobilize your ability to save yourself. And that means runaway or fight and getting an erection is not on that. So from an evolutionary standpoint, the sympathetic is there to turn off drive, turn off erection. So if you elevate sympathetic tone in someone with a psychogenic component to their ED, they cannot relax that smooth muscle. So the end mediators, there’s a sympathetic nervous system. They do just the opposite of what nitric oxide does, they contract. That’s how we detumesce after the event. That’s how the erection goes away.

(00:28:01):

So when you’ve elevated sympathetic tone, you are swimming upstream to try to get an erection because that smooth muscle cell remember it doesn’t care where it’s coming from. The smooth muscle cell is either going to expand and close those veins and let blood flow in or it’s going to contract. So it becomes a tug of war. And unfortunately there is no blocker for the norepinephrine and for the adrenaline kind of sympathetic discharge, because we know if you block that you’re in trouble.

(00:28:26):

So I just had a gentleman this morning in the office that exact issue and I can’t explain why, but I know what his issue is and he does too, but it’s purely psychogenic and so I recommended some mindfulness exercises and some yoga and things like that and what urologist is going to do that. And so you have to, when you’re going to take care of a man, when you’re talking about intimate and sexual dysfunction, it takes time to develop the rapport and then develop the trust. And that’s what I’m trying to explain to these people.

(00:28:54):

But when you can start to explain some of these mechanisms and explain that, dude, your A1C is 11.3. Nerves don’t work acutely there okay. When you control your sugar, you’ll have a better erection the next day, because that is true. And I said, so acutely, you’re going to be better, but you’re also going to help maintain the health of your smooth muscle cells if you get a better control there.

(00:29:16):

And so another issue there that I’ll just mention in terms of that acuity and the chronicity issue was smoking. So some of the behavioral studies that they’ve done with ED and smoking are very interesting. There was this old fashioned device called a RigiScan, it was basically a piece of tape that you’d put around the penis before you go to sleep, it would measure nocturnal erections. And there was a study probably in the ’90s that came out where they took a group of smokers and they asked one half of them to stop smoking and the other ones could keep smoking and they put the strain gauge on them. They put the RigiScan on them and had to go to sleep.

(00:29:52):

With just one day of no smoking they had much better nocturnal erections. So you can see acute improvements from these lifestyle factors that we know impact the vasoconstriction and the vasodilation and so acutely, you can see improvements but if you’re doing that chronically, that chronic depletion of highly oxygenated blood flow into the penis is having downstream effects that will make it long term and it will change everything. So when you get an erection, your oxygen tension quadruples. The PO2 goes from about 25 to 100 and not just the pressure within the penis, but the oxygen content, the PO2 quadruples as well.

(00:30:32):

So it needs that erection that blood flow in and out to maintain the health of the penis because nitric oxide synthase needs oxygen as part of the equation that helps create nitric oxide through nitric oxide synthase. So if it doesn’t have enough oxygen, it does not work totally effectively.

(00:30:54):

And, as I said before, endothelial ENAS instead of NNAS, so NNAS, nitric oxide synthase is what is going to come out of a nerve ending, endothelial nitric oxide synthase lives in endothelial cells, which line the sinusoids of these smooth muscles in the penis.

(00:31:14):

One of the triggers for the ENAS to work is literally the initial stretching that happens of the cell from the neuronal nitric oxide that’s released. So you want that stretching to occur that also triggers another enzyme system that makes nitric oxide. It’s one of the reasons why shockwave therapy works for ED, which is kind of a newer regenerative therapy, but it’s causing shear stress on that tissue that activates that nitric oxide synthase.

(00:31:44):

So when you actually get into the individual pathways, it’s fascinating, but it’s very complicated, but they all, the common nexus, the commonality is endothelial function being healthy or not, nitric oxide and oxidative stress. They all kind of come together there.

Dr. Casey Means (00:32:03):

Yeah. One thing I heard you say earlier that I think is one of the most mind blowing things I think I’ve ever heard is that metabolic issues lead to the penis transforming from healthy, smooth muscle to more collagen and fat. So basically through some of these lifestyle related decisions that we’re making, we’re converting a healthy penis to a fat scarred penis.

(00:32:27):

That is crazy to think about that the actual histology, that the cellular composition of this part of the body is changing into something different. I mean, the visual of that is quite profound. So thank you for mentioning that one, but very motivating, I would say in terms of making healthy choices.

(00:32:52):

I think the other thing I just want to drill into, because I do think it’s important and it gets a little bit technical as it’s about endothelial function, reactive oxygen, species inflammation, and nitric oxide production are some of the really key core physiology elements that are perturbed in both chronic disease, like heart disease, cancer and neurodegenerative disease. But then of course also with erectile dysfunction.

(00:33:17):

Could you give a quick primer for people listening about what endothelials function and maybe oxidative stress are? I think most people are familiar with chronic inflammation, but how these things are linked to insulin resistance and high blood sugar.

Dr. Merrill Matschke (00:33:35):

And that’s incredibly complicated and nuanced and I am not by any means an expert in these pathways, but I have a pretty good understanding and it’s interesting because just the testosterone aspect of it is a giant factor because when you start to recognize that that system that makes nitric oxide, which is basically when we say endothelial dysfunction, we typically mean that dysfunction of the lining of the blood vessel due to low nitric oxide.

(00:34:10):

So nitric oxide synthase only works well when testosterone is healthy. So that touches all of this. But when we talk about oxidative stress, we need a balance of oxidative species of inflammation and inflammation species, and species that quell that. And the problems that occur is when that gets out of balance. And when you have elevated oxidative stress and it is a generalized term, but that will lead to damage, whether it be through advanced glycation products, end products and some of these other issues, but it will cause the eventual changes that we think of when we think of vascular disease, when we think of hardening of arteries and plaque formation and thickening of the intermedia of the vessels, and then that same inflammation or oxidative stress also impacts our genetics, our DNA, it will induce things called apoptosis, which a lot of your listeners know about, but it’s program cell death, the way we kind of manage our cells and recycle cells. And then there’s a whole nother thing called senescence, but we won’t get into that.

(00:35:20):

But that whole pattern when chronic inflammation starts to push that too much and whether that be in a blood vessel, then you start to see the classic changes of atherosclerosis and vascular disease and in the penis we discussed some of those, but in more, just the typical vessels, you’re going to see those changes first at the lining and they’re inflammatory factors like IL6, TNF-alpha and other things like that are the driving some of these pathways and then leading to some of the developments of connective tissue changes and vascular changes.

(00:35:56):

And you will see it in all different areas. You see it in the brain, you see it in the brain, in Alzheimer’s patients and other kind of neurodegenerative disorders. And so why is this? It’s interesting that you bring this up because what did we just learn about Viagra in the PD5 inhibitors and what it does to the brain? 70% reduction in Alzheimer’s. We’ve known this, we’ve understood this, we’ve thought about it. We kind of wonder, is this going to happen? Boom. Now we know it happens and it’s all going through this process of inflammation at the level of the most important interface of the cellular interfaces of our different systems.

(00:36:34):

And so instead of thinking, as you and I have talked before, instead of thinking individual organ systems, when we back up and look at a bigger awareness of what’s the common thread of the entire system that we’re looking at, it’s this interface between inflammation oxidative stress and then the other mediators like nitric oxide, as it decreases some of that oxidative of stress can start to do the bad things. And I wish I had a better grasp to be able to describe all the different pathways, but it’s all very complicated.

Dr. Casey Means (00:37:08):

No, I think that’s a great overview and I think it’s a complex web. And for each of these topics that we’re talking about, endothelial dysfunction, inflammation, oxidative stress, there’s probably like 50,000 papers about this stuff and it’s really great, but just even having the high level view of how they’re interconnected and really we’re talking about the blood vessel and how we get oxygen and blood to all parts of the body. I think that basic framework that is required for essentially all aspects of health and our current diet and lifestyle is completely throwing a wrench in that system. I think that’s a key takeaway for people. Need blood flow.

(00:37:51):

Actually, I was talking to a orthopedic surgeon who’s very much aligned with a lot of the things we’re talking about and very metabolically focused and one thing he said that I thought was fascinating was that rotator cuff injuries, which are super on the rise and most people are not making a link between metabolic issues and something like a rotator cuff injury, but muscle to be strong and to not tear needs proper blood flow, it needs good metabolism. And so he talked about how rotator cuff injuries are erectile dysfunction of the shoulder and it totally makes sense if you’re getting this microvascular issues to this tissue, it’s going to become weak. It’s going to be changed into different type of tissue that’s weaker, and you’re going to be more prone to tears.

(00:38:38):

So eating for good vascular health can actually even potentially help things like prevention of a sports injury, which we just think like, oh, we’re getting older and we played tennis and now we screwed up our shoulder, but how could you have built more biologic resilience by optimizing your blood flow to prevent something like that from happening or just lowering the risk. But I just love the erectile dysfunction of the shoulder just cracked me up.

(00:39:06):

So another physiology thing I’d love to hear your thoughts on is how metabolic issues lead to low testosterone because I know there’s some stuff around fat aromatizing testosterone to estrogen, but I would love to just hear what’s the landscape of how men should be thinking about how their weight and other issues like cholesterol could actually be affecting their testosterone, which then feeds into both erectile dysfunction and sperm production, which gets into the fertility stuff.

Dr. Merrill Matschke (00:39:35):

Low T, as an andrologist I see the health of the man through the two outputs of the testis, which is sperm and also testosterone. So the exocrine output in the endocrine output and both of them are dropping at faster rates than ever. Sperm counts going down 50 to 60% in the last 40 years, testosterone also going down, not quite as significantly, but certainly going down and that is not to make it the whole thing, but it is unrecognized and I do not feel that the endocrine world on the mainstream is recognizing the importance of healthy testosterone levels as it applies to insulin sensitivity.

(00:40:16):

So as men get heavier, obviously they start to develop deposits of fat and when you get the visceral adiposity, we all know that’s the hormonally active fat, where the IL6, the TNF-alpha and all these other inflammatory mediators these is active fat and that fat is actually acting and now those mediators act in multiple areas, it can act centrally and it can act in the testis itself. And so what we’ve learned is when you have metabolic dysfunction, hyper insulinemia and obesity, you see the increase of these cytokines and they’re acting centrally it appears at the hypothalamic level.

(00:40:59):

And whether it’s working through kisspeptin, or whether it’s working through the nerves that actually are involved in the hypothalamus for the release of GnRH, you’re seeing reduced GnRH production. So you’re seeing lower gonadotropins out of the pituitary, specifically lower LH and FSH. So you’re seeing a central component, but then you’re also seeing these inflammatory mediators impacting the lighting cell within the testis. So it’s touching everything. Obesity and these inflammatory cytokines and the pathways are multiple there isn’t just one it’s happening locally in the testes and it’s happening in the control mechanism of the HBG axis as well, the hypothalamic pituitary gonadal axis.

(00:41:41):

So then you T come down. And so as T is coming down, you’re just going to start to impact the efficiency of nitric oxide production. So you’re now promoting endothelial dysfunction and another thing I say to them is ED equals ED equals ED. Erectile dysfunction equals endothelial dysfunction equals early death. So I try to tie it all together. I use that right after I’ve used a fire and the matches line, but my point is low T is a bigger deal than I think we realize it and granted, I’m only talking about men here. I do have some experience in taking care of women, but really I’ve been focused on men for the last five years or so, but the impact that this has is staggering.

(00:42:31):

And so I have been trying to educate the local endocrine system providers with the data out of Europe on long term testosterone replacement in type two diabetics with low T and ED. But what we’re seeing is as you replace T in these men, not only are you seeing improvements in all their markers of insulin resistance and sensitivity, you’re curing a higher percentage of type two diabetics. So a study came out about two years ago and it was a long term, real world experience clinic based study, but this is what we need to pay attention to. We don’t live in vitro. We live in vivo. And so too many studies right now I talk about in being in vitro, they don’t take into the real world experience.

(00:43:18):

This was an 11 year study. They looked at hundreds of men that they’ve been following and it was a group of men with diabetes and low T. Half of them said I’ll take T the other said I don’t want it. Now they’ve been following these men for 11 years. All of them getting T. This is fascinating that 11 years the paper, they just presented 34% of them no longer diabetic. All of them have otherwise improved measures of A1C, fasting plasma glucose, and fasting insulin.

(00:43:52):

In the group that elected not to take testosterone none of them, none of them are cured, but none of them are better. They’re all worse. And the only difference is they were both given the standard treatment for type two diabetes. This was in Europe. The only difference is that group got a testosterone undecoylium and they got it to normalize their T and they did it because of what we know is probably happening at the level of the nitric oxide, of the nitric oxide synthase, and also the ability to maintain more lean muscle mass. And then you lose that visceral adiposity. So you lose that drive of those inflammatory cytokines.

(00:44:33):

And it’s not just one thing. There’s the psychogenic aspect of replacing testosterone, because that guy now has more energy. You give him more energy he wants to go to the gym. He doesn’t want to go sit home in his man cave in Wisconsin and fill up his couch. He wants to go do something. And so I get so upset when some of these people lock onto one thing. Well, yeah, you know testosterone causes prostate cancer. I said, first you’re wrong, go read. Secondarily, you just blocked that guy that was getting better that I put on T.

(00:45:01):

Now you scared him with misinformation. I said, go back and read and see we now know testosterone does not cause prostate cancer. So one of the things I get passionate about is when some other providers kind of gum up the works to actually start to get people back to healthy lifestyles and behaviors with their old training that they haven’t kept current on because they’re buried under the RV wheel of seeing 40 patients a day.

(00:45:28):

And it’s just so unfortunate that you really start helping people and then they get derailed, but it’s part of the torch I carry now and we all do because we have to deal with the knowledge that we’ve acquired kind of through functional concepts and integrative medicine that is really the traditional medicine that we should be offering as a first path. And so I kind of got off the topic there, but testosterone and it being low is primarily in people who are obese and with type two diabetics, you’re going to see it both from a central mechanism.

Dr. Merrill Matschke (00:46:00):

People who are obese and with type two diabetics, you’re going to see it both from a central mechanism, as well as a primary mechanism in the testis.

Dr. Casey Means (00:46:12):

You were mentioning that both sperm count is precipitously declining and also it looks like testosterone may also be declining, sort of at large. What are the main lifestyle and dietary factors that are leading to that? And is there anything that people can do naturally to increase their testosterone as well? I realize it’s a bit of a chicken in the egg situation, because sometimes people’s T is low and then they’re not motivated to maybe work out or do those things. But if they do, are there things that people can do to raise their testosterone naturally?

Dr. Merrill Matschke (00:46:45):

Absolutely. To that, our diet, our exercise and sleep are the first three things I’m going to talk about. Diet, diet, diet. Nutrition, nutrition, nutrition, and diet is a four letter word to me. I talked about lifestyle changes in nutritional aspects and getting to a clean diet. Depending who I’m talking to. I’ll change the way I talk about it. But we’ve all said, “Shop at the outside of the grocery store,” we’ve all used that line, on the outside. Or if I’m talking to other people, I said, “Stop eating out of bags and boxes. Stop picking up food that has a nutrition label on it, it’s not food.” You start eating real food and start moving based on whatever their status is, what can they do? And if I need to I’ll employ the guy next door, the exercise physiologist that works across the hall from us, to try to help that guy with some barriers, to try to understand what he may be able to do to exercise if he’s got a bad back or something else.

(00:47:43):

But nutrition, movement and sleep, and then anything having to do with chronic stress. I haven’t even talked about anything in terms of medicine yet. Those are the answers to how do I maintain and increase my own testosterone. If I could just get people to do that, that’s our problem today. I want the pill. I want the pill that’s going to make me better. And that’s what you hear from so many people because that’s kind of the way our system has developed. We want something now, we want it free and we want it to work perfectly. And some of this is hard work, so you have to wait for that motivating thing to happen for a guy to want to engage in that. But once he wants to, we’ve got all the knowledge and ability to help him help himself to begin with.

(00:48:39):

Now you were asking about testosterone and why is it dropping? The endocrine society, as I just mentioned, just presented brand new information on young children and adolescents with hyper insulinemia and elevated fasting glucose already. They have smaller testicles. We are seeing this, we don’t call type two diabetes, adult onset anymore. And we know why. One of the biggest groups that’s getting it diagnosed at the highest rate are younger kids, teenagers and 20 year olds, are now being diagnosed with what used to take 40 years to occur, because they’re not moving and their diet has changed. And so we’re seeing a development and this is a big problem, because as we begin to move into metabolic dysfunction in the second decade of life, we’re going to see all these downstream problems, the top three comorbidities and mortality issues of vascular disease and neurodegenerative disorders and cancer, we’re going to see it earlier.

(00:49:44):

We’re going to shortchange everyone’s health span unless we can step in. We’ve been here for what, 200,000 years in our current form and whatever we’ve been doing really, we’ve only been doing this way for the last 50 to 100 years. Modernity is killing us very quickly and sometimes I’ll shift not to a conspiracy theory kind of mode. But I said, if you really look at what’s happening to testosterone, but more specifically to sperm counts, which we’ll get to in a minute, this is a big problem. We’re seeing sperm counts go down anywhere to 50 to 60% in 40 years, and remember that’s only in developed countries. What is that saying to our ability to propagate our species? And so you have to be careful because you can lose some people into woo-woo land if you start talking about that too much. However, there’s a real message there and it’s not one study.

(00:50:34):

Those studies have been starting to pour out since the late ’80s and early ’90 and they all reproduce the same message, we’re doing something wrong. And so if you think about it in the most biologic way, mother nature will speak through what we’re doing and she is right now. Testosterone is definitely dropping per decade. A 30 year old now, has a testosterone that’s lower than a 30 year old of 20 or 30 years ago. This is some recent data that came out of the University of Miami, their urology program. They followed young men and they’ve been seeing this obvious downward trend for each decade. As we’ve moved on, testosterone levels are dropping. And I’m sure, the biggest thing that we’re attributing that to is obesity.

(00:51:22):

To answer the question, what do we think the link is? We think it’s obesity and probably through those obesity gens that we were just talking about at the hypothalamic level, as well as endogenously right there in the testis. We’re having major issues there and it’s not just lifestyle. We’re now seeing probably the epigenetic impacts of their parents. This is why it’s so complicated. The methylation patterns we’re seeing are different based on was one of their parents, insulin resistant, type two diabetic? That will then increase the risk that they’re offspring also has smaller testes and lower testosterone. It’s all intertwined. It’s really fascinating and you can go dark quickly, but to keep it simple, we just start doing the right things and you’ve right the ship. Our bodies are pretty amazing. I went through it myself. You do the right things, the body rights the ship.

(00:52:19):

It doesn’t happen right away. And that’s why I go back to that study from Europe about the 11 year experience with testosterone replacement. Here in the United States, when I talked to my local endocrinologist, they said, “No, no, this paper said that that didn’t happen.” I said, “That paper was following patients for six months on T.” You’ve got to follow them for many years because of not just the acute effects, but some of these chronic effects that we’ve talked about, that I talked about in the penis. The maintenance of the health of that smooth muscle tissue, when you have elevated T levels will maintain the preventative mechanisms of that smooth muscle tissue. If T is low, that preventative maintenance is gone and it’s going to be the same thing, a preventative maintenance in a vessel in a brain or the vessel in the heart, in that patient. If they have low T, you’re going to see progression of their problem. And so that is kind of the testosterone side. We’re clearly seeing a decrease in the endocrine output of the testis.

(00:53:16):

Now, on the other side, when we talk about the sperm count decline, it is real and it is multifactorial. The person that was the lead author on that, one of the authors on that paper that came out in 2017 in human reproduction update, that clearly showed amongst over 40,000 men is meta analysis. They looked at men from westernized and non westernized countries, so basically developed and undeveloped countries. It was only in the developed countries, where they saw the decline in the semen parameters. In the more tribal communities in Africa and Asia, they didn’t see any declines. Now, the quality and the amount of data was not quite as robust, but it was still there. Only in developed countries like ours, do we see this decrease in the semen parameters and they’re precipitous and it’s corresponding to the generalized decrease in infertility we’re seeing, about 1% per year.

(00:54:12):

The couples that are seeking ART, which is assisted reproductive technologies, whether it be inseminations or IVF, is going up 5 to 10% per year, and we’re not really responding to this. And I was so disappointed when this last paper came out in 2017, it got about one second in all the main media outlets. And then the glossy journal, GQ, came up with an article on it. And in there was one of the fathers, one of what we consider the one of the fathers of andrology, one of the big fellowship guys, I won’t use his name, but he has a line in there saying, “Well, yeah, they are going down, but it doesn’t matter. We have ART, so we’ll always be able to get people pregnant.” See, that’s what I mean, why we playing whack-a-mole? Why are we putting out the fire? Why not take away the match?

(00:55:04):

It’s such an opportunity to impact someone early when they come in with that infertility, that low T, that ED and we can improve their lifespan and their health span, but we just don’t do it. The reasons we’re seeing some low sperm counts and the reason we’re seeing some of this is multifactorial, but, it is going to be tied to our obesity and metabolic health epidemic, number one. Number two is absolutely going to be sleep related issues and stress and the nutritional aspect, which I should say with number one, the quality of our food, the endocrine disrupting chemicals, which way back when someone started talking about that, a lot of people just kind of wrote them off, but we now know it’s real. The phytoestrogens, the xenoestrogens. We are seeing real changes related to estrogenization, whether it be anogenital differences and distance changes.

(00:56:05):

Things that have been conserved for millennia are now changing and are pointing to changes in our hormonal milieu in utero and during life. And so these are very big issues with these endocrine disrupting chemicals, whether you’re talking about insecticides, pesticides, estrogen that’s getting into a water system from other issues or estrogen mimics. Plastics that end up in your water bottle, when you crack open that top, they’ve done the studies on the microplastics. Those are estrogen mimics. Now I think in the past, we probably wouldn’t have been susceptible to some of those, but we’ve destroyed our gut such as that tiny lining between the outside world and our immune system is now literally paper thin. And so our immune system, isn’t supposed to be seeing these things and then it sees stuff it’s not supposed to. And it’s confused because they’re mimics, they look like estrogen and now we’re activating our immune system in ways that’s leading to other immune disorders, whether it be the skin diseases we’re seeing the other GI, we haven’t touched on gut issues, but it all ties together.

(00:57:10):

It all ties together. And the impact on sperm production from our diet and what we put in, is very telling, that we need to make some changes. Because yes, it’s nice we have ART. I have four kids from IVF. Great, I love it, its amazing. Thank you. But, we should recognize that this is a signal and then I use one more, I like to try to engage people. And this is another thing I will say. Remember that horrible story of that building in Florida, that pancaked on itself in Surfside. That homeowner’s association for years, blew off their preventative maintenance. They didn’t want to do the difficult thing. They didn’t want to spend the money to take care of their building. They saw the cracks. And then within the cracks, they saw that there was these rebar that were rusting and then doing more things on the inside, almost like the lack of nitric oxide. And what happened?

(00:58:10):

Eventually, a horrible thing happened to that building that pancaked. And so, I tried to explain this to my leaders. I said, “We really should elevate this concept of prevention because there’s some signals here, that we’re blowing off.” And one of the biggest ones I think, is the semen analysis data, that has been reproduced so many times and some evidence based medicine, kind of aficionados, kind of normalize and say, “Well, this study showed this, so I don’t know if this is real or not.” Back up and look at the big picture.

Dr. Casey Means (00:58:43):

I could just listen to you talk all day. I just think everything you said is so important. And so just the big picture. You touched on microbiome, endocrine distributing chemicals, leaky gut, chronic inflammation, sperm counts. It’s amazing and then what’s happening to our youth, which I think cannot be overstated.

Dr. Merrill Matschke (00:59:05):

Let me just come back, because when I was fighting for myself with my local leaders, to explain why I was of value, to explain why they were getting written responses from my patients, that said, “He’s the only doctor that I’m staying here for.” Now, I’m not doing this to pat myself on the back. I’m here to show that the value is here and the end user is asking for it. And they’re handfuls of doctors like me. When they say, “Whoa, I’m going to listen to this guy,” because you engage them in this conversation and you empower them so that they now say, “This is my responsibility. This is my responsibility.” And we have offloaded that responsibility in this world of Medicare and payers. Well, insurance doesn’t pay for this, so it must not matter. You know how that is. It drives me crazy.

(00:59:58):

And so I have to try to get the patient in whatever way I can, to hook in. I was talking to my leader about this and I said, I won’t use his name. I said, “Doctor?” I said, “This is what I do. This is why I see 20 patients, instead of 50.” I said, “I do this, I do this, I do this.” He gives me this blank stare. He’s like, “But you’re a urologist.” He goes, “So we don’t know how to compensate you. Are you primary care? Are you into chronology? Are you in fertility? Are you urology?” And I looked at him and I said, ” I’m a doctor. All right. I am a men’s metabolic health doctor. And if you can’t understand that, we’ve got a bigger problem.” And so that’s when I have to be honest with myself, that I can’t come back from the well side of medicine to the sick side and fix it.

(01:00:49):

I have had words said to me like, “You may not be a good fit. You don’t bill like urologists. You don’t do this.” I said, “I’m happy. I’m happy with that. I’m empowered. I now feel empowered because I know my end user is feeling better. And when I close that door, I’m not working for the entity I’m working for that person.” And so working for that person, is what makes me come back to work every day. Now, hopefully they’ll figure out a way to compensate me appropriately, but I’m not going back to that old way of just cranking the patients through because we need to do better. And there are so many other signals out there that our current delivery system is not working well.

Dr. Casey Means (01:01:31):

I truly just got shivers when you said that line, “I am a doctor,” because we have gotten so far off course, I think as a medical culture. And through the lens of billing, what you’re doing could look like a failure in some way, you’re still billing a lot, but it’s crazy that the success criteria is not based on how well the patient’s doing. It’s based on the RVUs and the billing. And it’s like, “Where did we go so off course?” And I also want to highlight for people when you said 20 verse 50 patients, that is per day. Per day. This is a machine and that person who’s doing the 50 patients a day, no matter what is happening with those outcomes, is going to be celebrated. Obviously if its terrible patient care, it’s a problem. But generally speaking, that person is going to be the star of a department. And it’s like, “What are we doing?”

Dr. Merrill Matschke (01:02:34):

When the measuring stick is only volume, that’s the culture. And so I tried to introduce that word during the last couple of conversations I had. The culture here is not one of promoting health, it is a promoting illness. And I said, “We’ve got to change that.” And they said, “Well, no, no, it’s our structure that does that.” I said, “You can use those words interchangeably.” I said, “But culture is by what you do, not what you say. And so when you sit here and you reimburse someone and you compensate them based on volume, that’s what you’re incentivizing.” And so, that’s not really what we’re here to talk about today. But the problem is, to do metabolic health well, takes time. One guy said, “You just have a TRT clinic.” I said, “Yeah, but do you know what TRT is?”

(01:03:18):

I said, “It’s time, rapport and trust. You spend the time, you get the rapport, now you’ve got the trust of that guy. He’ll do whatever you tell him and he’ll do it because he looks at you and he’s inspired by your story. And number two, you start giving him a product. You give him a DEXA scan. You give him a fasting insulin number that he hasn’t looked at before. You give him his CRP. You do things that the other doctors haven’t done and you make a change. You bring him back and you’re like, ‘Look what you did.’” You almost gamify it, but guys want that. When you give them a different product and it resonates with them, they now are empowered to advocate for themselves. And so, there’s so many opportunities in urology to do that well, especially in andrology. And so the people with my kind of mind are usually the guys who did an andrology fellowship, because we get exposed to hypogonadism, and then that opens up the whole world of metabolic health.

Dr. Casey Means (01:04:10):

Question for you, may not be able to give an exact number for this, but I’m just curious. What is your hunch as someone who’s really a leading kind of world expert in this, of how much of the burden of… Let me rephrase this. How much of the erectile dysfunction cases that we’re seeing in the US do you think are either preventable or reversible, if we fully dialed in our diet and lifestyle and improved metabolic health?

Dr. Merrill Matschke (01:04:42):

I’ll spitball that. But if you look at the organic vascular causes and obviously we talked a little bit about in the past, on the psychogenic impact, but if you remove the spinal cord injuries and those other kind of neurologic injuries, I believe that of the vascular causes, probably 70 to 80%, you could significantly prevent and improve. Now the question of prevention, rehabilitation improvement, is a loaded question because how bad is it, and how long has it been going on? That’s the whole kind of concept of restorative and regenerative therapies for ED, whether it be right now, shockwave is a big one, but there’s this growing interest in platelet rich plasma and stem cell use. And there’s signals there that in the right patient that can work, but it’s still in the investigational phase. Shockwave, you can recover and rebuild smooth muscle content in a rat penis, they’ve shown.

(01:05:45):

Shockwave turns on some of these pathways to heal through vascular, neurologic and stem cell recruitment pathways. We can prevent some and recover some functionality of that vascular smooth muscle tissue. But I think if you step in early with the appropriate changes, as we all know what they are, of metabolic improvement, you can change and stop the loss of healthy, smooth muscle content, within the corpora cavernosa and maintain that function.

(01:06:19):

Now age alone will march that on. And so you’re not going to be able to stop it all. But I do believe, probably three quarters of this, we could really have a major impact on. And we haven’t even talked about the levels kind of product and CGM and what that does. But part of this is engaging a man right there, so he understands what his choices are doing. And so, if I’m going to get him to really think about what is he eating and how is that affecting his erections? How is it affecting his insulin as in sugar? When we start to empower them with that kind of information, it’s fascinating. It’s fascinating how that’s another big part of prevention of the sequela of metabolic disease. It’s an amazing opportunity to build content around and build a path of education and empowerment.

Dr. Casey Means (01:07:19):

That’s amazing. Those are big numbers, 70 to 80%, three quarters, could potentially be significantly reduced, especially if we’re talking about early, and we’re really just trying to reverse the blood vessel issues before maybe the penis has actually really changed in terms of its architecture from the long term damage. That is so empowering and-

Dr. Merrill Matschke (01:07:41):

Well, because you think about it. We don’t want to wait until the guys going in with chest pain. That’s the end result of years and years of endothelial dysfunction. Some of the earliest markers of endothelial dysfunction will be some of those FMD tests that you can do, the brachial index test is a test to check the distensibility of blood vessels. You can check IL6 levels in different inflammatory mediators and some of the CIMT testing, early indicators of endothelial dysfunction. If you can step in early on those, you can stop that progression, rather than waiting in the classic, “I’m showing up in the ED with chest pain and my troponins are off the roof.”

(01:08:25):

Yeah, you just step in early and we know, you see those people, the people that were active, that ate not out of boxes and bags and that had a real food diet, they were active, they had good social support. These are the people that walk into your office, you’re like, “You’re 85? You look like you’re 55. I just had a 40 year old in here that looks twice as old as you and physiologically looks twice as old as you.” The people who do it right, and have a healthy lifestyle and behavior, the machine pays you back for that.

Dr. Casey Means (01:08:56):

Yes. I’d like to get that, that’s where I actually want to drill in next, because I think we’ve talked a lot about physiology here and…

Dr. Casey Means (01:09:00):

[inaudible 01:09:00] because I think we’ve talked a lot about physiology here and the epidemiology of this stuff, but I’d love to leave people with some practical takeaways. And one stat I was just going to mention, I was looking at a paper I think was out of Harvard that showed that people who were obese had an 80% higher likelihood chance of having semen that had no sperm in it. So essentially zero sperm. I didn’t realize that was a thing that you could actually have semen that had no sperm in it.

Dr. Merrill Matschke (01:09:33):

I saw two azoospermics today.

Dr. Casey Means (01:09:36):

And this is largely all the things we’re talking about, but low testosterone probably, and [inaudible 01:09:41]-

Dr. Merrill Matschke (01:09:41):

Well, so there are some people who have a genetic issue. The guy I saw today was a triathlete, and so he may actually have some overexercise oxidative stress-related. And then there’s another gentleman that has a Y chromosome microdeletion. So there are true genetic mishaps that lead to that. But the bigger impact is the obesity, heat, oxidative stress, and what that’s doing on the spermatogenic potential in the testis. And so it is a big deal.

Dr. Casey Means (01:10:12):

Amazing. I just don’t think most people are aware of that, that you can be having semen come out, but it’s actually just not… there’s no sperm in it. And that’s amazing to me and that it actually could be in some way related to our diet or our weight. So I’d love to hear basically, what is the Dr. Matschke general dietary lifestyle plan to help men essentially improve their sexual function, and improve their fertility? And maybe we can go through just… you talked a little bit about diet here with don’t eat things out of boxes and bags, don’t eat things with labels, eat real food and me going into… we recap diet, but then also talk about generally movement, sleep, stress and endocrine disruptors, and just… what should someone be thinking about if they’re hearing this and feeling really inspired of where they should go next?

Dr. Merrill Matschke (01:11:05):

And so when I see a gentleman that’s clearly got evidence of metabolic dysfunction and obesity, I don’t want to overwhelm him with the initial kind of discussion of what to do with nutrition, because if we go through everything we can talk about, including fasting concepts and these types of things, it can overwhelm them. So I try to look at what is their diet, where are some of your problem spots and start working on some of those things first. But I absolutely talk to them about avoiding the obvious added sugars, the obvious processed carbohydrates. I’m in a part of the country where I see a lot of guys who are third shift workers. They’re manufacturing warehouse people. They are truck drivers. They are in a situation where their choices are limited, so it’s very hard. So you start to work within that, look for the healthier proteins that you can find, look for the healthier carbohydrates that you can find, and those issues.

(01:12:09):

I don’t start talking to them as much about order of food and timing of food initially. I try to deliver that in a segmental way so as to not overwhelm them. But then you might have someone walking in who’s already pretty tight on all of that, so then I start digging in on more specifics about when are you eating, are you eating late at night, you should be eating that really heavier maybe carbohydrate-type meal earlier in the day not later in the day. So I will tailor my nutritional discussion to them based on their background and their knowledge base as you try to educate them so that I don’t lose them. It is a high touch process. If you’re going to give this product and do it well, you’ve got to continue to touch this guy, whether it be through a health coach, myself or otherwise.

(01:12:58):

And so, I will obviously try to get them, the biggest thing is reduce the bad carbs and reduce the sugar. That’s where I will hit first. And then I will rapidly move to some fasting concepts, because they want to see changes in a hurry. Guys want to see something happen. It’s the same thing that I will quickly get their testosterone up, because that helps them. Not only does it literally help them get rid of fat and maintain muscle and they like that and they feel better, but it’s going to further engage them in the process because they’re going to see changes and it’s going to help them, and then it’s going to increase the retention and compliance. And so, I will do that and then I’ll introduce some fasting concepts. However, they may be able to do that.

Dr. Casey Means (01:13:44):

Amazing. So fasting, a very powerful tool for seeing rapid results and getting people motivated. How do you talk to men about things like the importance of sleep and stress and what kind of response do you get when you bring in some of those concepts as well?

Dr. Merrill Matschke (01:14:00):

And so the interesting thing is I’ve been seeing so many third shift workers lately, and we know they are an at-risk class. I mean, they are now a study group because of their disruption of their sleep cycles and what it does. You listen to people like Matthew Walker and it blows you away when you start learning about sleep. And I’m like, wow, I didn’t know about that sleep issue with low T. I didn’t know how amazingly it will change your own insulin response until I got this thing, and I watched what it did in my sleep pattern, which was amazing. So I explain to them and I show them, I’ll pull out my phone and I’ll show them my own curves, and I’ll tell them what has happened to me. And I’ll explain to them that sleep is much more than just putting your head down. It is that time for your body to recycle, to maintain and to do what it needs to do to manage energy well and to manage food well. And so sleeping is crucial and it is hard.

(01:14:59):

Some of these people, some men just aren’t ready yet. And that’s the other thing is you see where they’re ready, for what, and then I start to grab at those things that they’ll listen to. And then if they’re not going to, I don’t push too hard on sleep if they don’t have that option, but it is an incredibly important lever to pull. And so, you have to understand what their sleep hygiene is like, are they on the device late at night? Are they drinking? Are they having a lot of alcohol at night? This is Wisconsin, so that’s a big issue. Those caffeine, the obvious things we talk about, I talked about those lifestyle factors that are going to impede the ability to get to sleep and stay asleep. But then I just get them to learn that it’s a priority. It has to be a priority if they’re going to take this seriously, just like the nutrition is a priority.

(01:15:50):

And now the stress aspect of it, as it impacted me massively, I do explain to them, I show them my app on my phone for… Wake up is the one that I just got. But I also have Oak and I have Calm on there. And I said, these are different techniques and different things that you can try. And I said, I’m talking to some of these guys that are warehouse workers and otherwise, but I said, this is important. I said, we are now a 24/7 brain that was never built to be that way. Our brain was supposed to be turned off and we don’t do it. And so we don’t do it because kids, and just like you, are getting up in the middle of the night to check their phone, and it is impacting our brain’s ability to put itself away and rest. And we know what it’s doing, from a chronic stress standpoint, to children, because the studies have been done about device use and that chronic interruption of sleep.

(01:16:42):

And I said so stress and whatever you can do to improve stress and quiet the brain is so important. You get some uptake on it and not others, but that’s it. You have to slowly move this thing. And then what’s happening to me is as I do have positive impacts on men, I’m getting a huge amount of word of mouth. So it’s not physicians that are sending a lot of these men across the transom of my building, it’s my other patients. So word of mouth and the consumerism and the end user demand is showing itself. Even in a place like Racine and Kenosha, Wisconsin, you’ve got people who are saying in the gym, “You’re changing, what’s happening?” “Oh, I’m seeing this guy now. Go over and talk with him.” So it happens every day. But you’ve got to find a product and a way to connect with the people, because each guy is different. What matters to him is what’s going to matter to me, and that’s why I look at him. What do you want to get better at? This guy, it might be a cognitive issue. This guy, it might be his erections. This guy, it might be man, in the past, every time I work out and I clean up my diet, I lose some weight, it’s not happening anymore; what’s wrong? And then I’ll drill down on the biochemistry and find out they’ve got low T usually and address that.

(01:17:56):

And I’ve heard this from so many people, the N of one is very important. When you’re taking care of someone that is… everyone’s unique. There’s no cookie-cutter approach to doing this to a man or a woman. Yes, there are general concepts that apply, but you have got to find a way to engage and educate that man that he will listen to. And so everyone’s got to be dealt with individually, because we’re all different. And women are a whole lot different.

Dr. Casey Means (01:18:30):

That I think is so important; it’s not cookie-cutter. And I think something that I found when I switched from ENT to more functional medicine and I was spending literally two hours with every patient in the initial visit was really figuring out, like you said, what are the particular barriers in that patient’s life to making successful behavior change, and what’s the lowest hanging fruit for that patient of where we can get some rapid improvement. And then like you said, not overwhelming with 10 different things, every pillar of lifestyle and diet, but figuring out what are the highest leverage areas to start with that are going to both be effective, adopted, and then let it evolve, build trust through all that.

(01:19:11):

It’s really an incredible dance when you have the time to spend to dig into this stuff. And I found that if a recommendation, when it’s up against huge barriers in the patient’s life, it’s just not going to be effective. And then there’s, of course, discouragement. And so, I think the way you framed it is beautiful. There are general concepts that are important, like don’t eat packaged foods, don’t eat processed foods, get sleep, but really intersecting that with the patient’s realities so that you’re going to be successful.

Dr. Merrill Matschke (01:19:39):

Well, and that’s another thing is as I look at them and I say, you can’t be perfect. I’m not perfect. None of us are perfect. Allow yourself 20% to 30% of leeway. 70% of the time, try to be tight on your diet, 20% to 30% of the time, let yourself go. That’s the durability factor that will keep you on the path. If you don’t do that, you will not stay on the path.

(01:20:03):

I’ve got four young kids, they like Culver’s, they like pizza. I want to be engaged, I want to be present, so I let myself do that. But if 70% of the time you’re doing the right stuff in that other part of those compartments of lifestyle and behavior, you can do that. And that allows for a meaningful, healthy life. And so I’m very careful with guys when they come in, they’re like, “I’ve been doing this…” I’m like, that’s fine. You recognize it, you know that, just make sure… you try to keep it 70-30, 80-20, if you can. And you’ll lose some people in it, but overall you’re just trying to make incremental change in improving their health.

Dr. Casey Means (01:20:46):

So final couple questions here. I would love to hear, I know you’ve recommended Levels some of your patients and you’ve obviously used it yourself. How has that played into some of your successful patient outcomes? If you have any particular stories of patients who have done well and been successful using CGM as part of their metabolic health journey, would love to hear any.

Dr. Merrill Matschke (01:21:06):

Yeah, the couple stories I’m thinking about are all things that we’ve heard before. But mostly the guys are blown away at what bread will do to them, or other kinds of things that they didn’t really realize had a lot of added sugar in it. But the carbohydrate stories, the Mountain Dew, the energy drink stories and these types of things… we all know it, because we’re preaching to the choir here.,But when you see that response on that curve, you’re like, wow. It just sets in and holds you accountable for what you just did. And so those are been very important to me.

(01:21:48):

I saw a gentleman probably about two weeks ago and he said, “I haven’t felt this good ever.” And he has a CGM and he’s been using it for about two months. And he said, “It’s unbelievable what I’ve done to my numbers.” He goes, “In fact, I have to get rid of my insulin now.” And so it’s just so nice to hear that, and the factors of getting him on… and I see this all the time, not to go back to T, but I put these guys on T and I throw them on daily tadalafil. And so many of these guys, their A1C just lowers out very quickly, and there are studies showing daily tadalafil lowers A1C.

Dr. Casey Means (01:22:29):

And what is tadalafil?

Dr. Merrill Matschke (01:22:30):

Cialis.

Dr. Casey Means (01:22:31):

Oh, Cialis, okay.

Dr. Merrill Matschke (01:22:31):

Cialis. And so that’s working by probably dumping more glucose into the skeletal muscle because it’s opening up those blood vessels, just like the ortho guy talked about, okay?

Dr. Casey Means (01:22:40):

Yeah.

Dr. Merrill Matschke (01:22:41):

And that shows you again, the systemic aspect of something that I got interested because of the penis, but now it’s acting everywhere. And so when you’ve got a guy like this gentleman who started paying attention, and he said it to me and I hadn’t even brought it up yet, he goes, “And you know what?” He goes, “I’m sleeping better, and when I sleep better, I’ve also noticed that this tracing comes down lower.” And so that then plays to me when I put this thing on, I was really amazed at a couple of things.

(01:23:11):

The first thing I noticed was yogurt. So I love yogurt in the morning and I’ll usually go with Siggi’s or something like that that has lower sugar, but even some of the flavored ones have added sugar in them. And I almost always now go with a full fat plain yogurt. I’m very regimented. And one day I got to work and I realized I didn’t eat my yogurt. So I went out to the little Starbucks thing in the front and I got one of their Danone ones, and I looked and I got the one that got the least amount of sugar in it. But that spike, that excursion took me to about 180. Now I came right back down. So I’m a weird guy. When I first checked myself before I got healthy, my A1C was 6.3. Now my A1C lives 5.1 to 5.3, but now my fasting insulin lives between two and three. So my spikes go up fast and they come right back down. And so that for me, the added sugar in the yogurt differential little test I did kind of really was interesting.

(01:24:10):

And bread for me, I no longer go to Potbelly, not because it’s just Potbelly, but I used to go there for lunch. I couldn’t believe just what bread, even if I got the one where they scoop out the inside of the bread, I now avoid bread as much as I can. And sleep was the other factor for me, sleep. I put it at about seven to seven hours and 15 minutes. If I’m below that, I wake up and my numbers stay a little bit higher. If I’m below that my baseline is lower. So those are big. Now stress, we all know what stress does to cortisol, and that does to your insulin level. Whenever I’ve had a stressful meeting and I’ve got this thing on, I see the response. So it really plays right into the physiology that we know out of the textbooks and out of all the pathways that we look at, and then when you see it for real, it really brings it home.

(01:25:02):

And so this technology in the hands of a guy who chooses to try to understand it, it’s life changing, because he can learn all these things that we know about, and then to watch him learn it, and then take him to those more nuanced things about eat your fiber first, stay away from the carbohydrate first, eat the salad first. That so it’s not just what you eat, it’s not just when you eat it, it’s also the order with what you eat it.

(01:25:33):

You go back to what we were saying before about nutrition, I choose when to start to introduce some of this stuff, but it’s fun to play with it, especially you’ve got the right guy, who’s interested in it. And sometimes, we all kind of make assumptions based on people when they walk in. Sometimes the guys I think are going to want to have nothing to do with it, they love it. So it’s a great tool. And then to build the content around it, that kind of funnels into metabolic health, that is really the creation of a path that answers a lot of the… it really fills in the cracks and the absences in our current healthcare system. But it’s not happening in the offices of most healthcare systems.

Dr. Casey Means (01:26:15):

But hopefully conversations like this will be part of changing that, because we’ve got to get in the water, we’ve got to get in the ears and share your incredible message with people. So I think we’ll wrap up on that note, because that was just very uplifting and positive. And I really do feel like I could chat with you for hours more. Thank you. Is there any stuff we missed that you feel like is really important, or any last minute words of wisdom to share with people? You’ve shared a lot, but just want to make sure.

Dr. Merrill Matschke (01:26:48):

Yeah, it’s just to engage with patients, you have to offer them something new. You have to somehow capture their interest, so you have to get to them at a vulnerable time. And so I think the important thing for men is trying to… and this phrase, it’s overused, but you have to meet them where they’re at. You have to be ready to get to them when they need the help. And then you have to educate them on their problem and how it ties into what’s actually happening in their body. And then it’s simple. What we’re talking about sounds complicated, but it’s just simple changes that go back to healthy behaviors. And if we can do it, it is a self-fulfilling prophecy. So it is low hanging fruit. It improves people’s lifespan, and it’s something that sadly is not happening within our mainstream medicine today.

(01:27:52):

And one thing I do want to mention, and we didn’t do it either earlier, and I don’t know if you want to include this, but it is so important to recognize what our current healthcare system is doing. Are you aware of the Commonwealth Fund study?

Dr. Casey Means (01:28:09):

I don’t think so.

Dr. Merrill Matschke (01:28:09):

So the Commonwealth Fund is a large corporation that has evaluated healthcare systems on a yearly basis, and they use four primary metrics: infant mortality, maternal mortality, lifespan after 60, and preventable mortality and morbidity. And they look at high income countries. So there are 11 systems they look at, 11 countries on this planet. We are dead last. We have always been dead last. And not are we just dead last, we are so far low that they had to drop out the data from the United States from a lot of their data analytics because it’s skewed it. And we spend twice as much as the next country above us.

(01:28:51):

So I get frustrated with some of our leaders when they talk about how good of a system we have, when they are creating their own metrics to measure themself against. So if you’re going to create your yard stick, it’s going to make you look good, right? So these are standard metrics that you just apply. They’re population health metrics and I already mentioned them. But we are the last. In things like infant mortality and maternal mortality, it’s scary. But all you have to do is go take a look at what’s happening to our population in terms of obesity and metabolic health. And I just wish more people knew about that so that they would start to challenge our healthcare system a little bit more. We need to change and it needs to be more health-forward.

(01:29:39):

The last thing I will say is, I do this with all my guys when they’re kind of questioning me, I say, go back to your old family photos, go look at your black and white family photos and see how much obesity is there in the history in your family. You don’t see it in the black and white photos. Now go look at your family outings now. I said, our bodies have been here for 200,000 years plus, and in the last 50 to 100 years, we’re feeding and treating them differently, and we haven’t been able to adapt, and our bodies are showing us that. We’re overfeeding with the wrong kind of energy, and our bodies are rebelling. And so I try to present that in a positive way and sometimes, you can go into darker areas. But we have so much opportunity ourselves to recapture responsibility for our own health, and that’s where it starts.

(01:30:31):

And I love now when patients challenge me, when they bring in a book or they say, “What do you think about this?” Because I can tell them if it’s valid, I can tell them if it’s misinformation, I can try to help them. But responsibility has to be shifted back to the individual, and you have to do it in such a way that it’s obtainable to them. And that’s why I came out of the well side back to the mainstream side because my goal is to find that path that allows us to push health and wellness first and have a health-forward path. And I think we can do it, and it’s going to come through entities like Levels and other… there are other systems out there, Virta Health and some of these other places that are showing you can do this. And when you improve the metrics, they’re starting to get the payers to pay attention too. And so I am hopeful that when you empower people, we’re going to be able to turn this ship more towards health.