How To Treat Erectile Dysfunction Without The Little Blue Pill - Transcript

Dr. George Papanicolaou: See, all the blue pill does is fix that end problem. It fixes that, let's just make sure we get the erection and we maintain it, but there's reasons why we get there. Speaker 2: Hi, everyone just wanted to let you know that this episode contains some colorful language. So if you're listening with kids, you might want to save this episode for later. Dr. Mark Hyman: Welcome The Doctor's Farmacy. I'm Dr. Mark Hyman and that's pharmacy with an F. F-A-R-M-A-C-Y, a place for conversations that matter. And if you're a guy listening to this, or you're a woman who has a guy, you better listen up, because this is about a very common problem. It's known as ED, otherwise known as erectile dysfunction, which is a very, very common problem. We're going to get into that. And today our guest is none other than Dr. George Papanicolaou. Who's one of our key physicians here at The UltraWellness Center, is an extraordinary physician, is doing great work here and we are just so excited to talk about this topic. Aren't we, George. Dr. George Papanicolaou: Thrilled. Absolutely thrilled. Dr. Mark Hyman: It's a little uncomfortable, but I guess were going to have to get into it because we're doctors and we're professionals. We can really talk about it. So, George, this is a big problem. Guys are having trouble. Women also have a lot of sexual dysfunction. We're going to maybe cover that on another podcast. Today I want to talk about male erectile dysfunction with you because it's such a big issue. The lucky accident of a failed drug experiment for a blood pressure drug led to the development of Viagra, which I talked about on a podcast with Dr. Louis Ignarro, who is the discoverer of nitric oxide, which is a little molecule that causes your blood vessels to dilate. Dr. Mark Hyman: And that's how Viagra works. It was meant to be a blood pressure pill, but it didn't work so good, but it worked better for the side effects that the guys got. And all of a sudden it was a blockbuster pill, like blockbuster, which means that people needed it. Tell us about the history of this whole story and the prevalence, how common it is and what is going on. Why are we seeing such an epidemic of this? Dr. George Papanicolaou: Well, I'll say, one of the key things was in 1998, when Viagra hit the scene, it really opened the door for men to have an opportunity to talk about what had been going on for centuries. And that was erectile dysfunction. So great. Viagra was awesome, knowing that it worked, but it opened the door for that conversation, because 10% of men under the age of 40 have erectile dysfunction. And by the time you're 70, you have a 60% chance of having erectile dysfunction. Dr. Mark Hyman: 70 or 60? Dr. George Papanicolaou: No 60% chance- Dr. Mark Hyman: By the time you're 70. Dr. George Papanicolaou: ... by the time you're 70 of having erectile dysfunction. So that's a lot of people having erectile dysfunction and people's sex lives are not over at age 50, 60, or 70. There are men that come to me wanting to have prescriptions for Viagra at age 70. And I always tell them, I'm not giving it to you unless I get a written note from your wife. Dr. Mark Hyman: That's not going to go well. Actually yesterday I was sitting in a consult with a patient who is 87 years old, who's still having sex with his wife. Dr. George Papanicolaou: I plan on it. Dr. Mark Hyman: Yeah, I'm going at least to a hundred, I don't know. Dr. George Papanicolaou: It's something that gets better as time goes on. So why stop? Dr. Mark Hyman: That's exactly right. This is a very common problem. From a traditional medicine point of view. There really wasn't much of an approach to this beforehand. We had some really coarse and crude treatments. Talk about what the traditional approach to erectile dysfunction has been other than the Viagra, Cialis and Levitra category of drugs, which now are pretty widely prescribed and do work and help people. Dr. George Papanicolaou: Yeah. Prior to Viagra, there were some fairly primitive approaches to it like vacuum pumps and revascularization, because vascular issues, endothelial dysfunction is a key part of what causes erectile dysfunction. Dr. Mark Hyman: So in English, you're basically saying that you get hardening of the arteries in your penis, which makes it not so hard. Dr. George Papanicolaou: Right. But that hardening of the arteries not only reduces blood flow, but there's this endothelial dysfunction. And it's in the endothelial cells that nitrous oxide has its effect. Dr. Mark Hyman: What are endothelial cells? Dr. George Papanicolaou: Endothelial cells are the cells that are lining the blood vessels that are inside the penis. Dr. Mark Hyman: So throughout your entire body, you've got these lining of all your blood vessels and it's a very active lining. It does all kinds of things, including regulate the dilation and the blood flow. And lots of other things, inflammation and nitric oxide is a key regulator of that. Dr. George Papanicolaou: Very key. Dr. Mark Hyman: And that's what goes wrong. And what are the reasons why men tend to get this decreased blood flow in the penis that leads to the erectile dysfunction? Dr. George Papanicolaou: There's multiple reasons. But before we go on to that, I think probably is a good idea. Just let me just review quickly, because we're going to talk about nitrous oxide. We're going to talk about why Viagra works and other drugs like it, essentially what happens is that you have the release of nitrous oxide- Dr. Mark Hyman: nitric oxide, Dr. George Papanicolaou: Nitrous oxide. Dr. Mark Hyman: Nitrous oxide is laughing gas. Dr. George Papanicolaou: I'm just going to call it NO. Okay NO. So you release the NO and then NO has this action on the endothelial cells inside the blood vessels of the penis. It also acts on the Corpus cavernosum muscles. And so you get this simultaneous relaxation of those muscles. So blood can flow in. Those are the big muscles of the penis, so that when they're full of blood, they actually start the erection and maintain the erection. And then you have this small blood vessels, nitric oxide acts on those at the same time and causes those to constrict. So the blood that flows into the cavernous muscles then stays there as these small veins constrict, and that basically starts the erection and maintains the erection. Dr. George Papanicolaou: And what happens is you have, and that's called tumescence. Then you have detumescence, after the ejaculation, the penis relaxes. And that's when 5 phosphodiesterase breaks down the compound that was responsible for causing that relaxation and constriction. And when that compound breaks down, the small blood vessels relax, and the penis relaxes and becomes flacid. It's the 5 phosphodiesterase to gets inhibited by Viagra. So this is just a little lesson to everybody listening. That's how it works. Viagra blocks the 5 phosphodiesterase, allows this- Dr. Mark Hyman: [inaudible 00:06:42] say it increases blood flow and makes the erections stay- Dr. George Papanicolaou: Longer- Dr. Mark Hyman: ... longer. Dr. George Papanicolaou: Because you don't get the break down of this thing called cyclic GMP. So that doesn't break down, that maintains the constriction of the small blood vessels. You can actually obtain an erection and sustain an erection for longer periods of time. Dr. Mark Hyman: It's a good thing you don't have to remember all those chemical names when you're having sex, because that would not go very far. Dr. George Papanicolaou: No, it wouldn't. But that's what's going on. And so what are the things that affect that? So metabolic syndrome. When you're thinking about people with ED, see all the blue pill does is fix that end problem. It fixes that, let's just make sure we get the reaction and we maintain it, but there's reasons why we get there. We get there because of stress and its impact on that very, very sensitive neurovascular problem, that neurovascular is not a problem. The neurovascular symphony that has to occur for you to have your erection and ejaculation. Metabolic syndrome- Dr. Mark Hyman: That's prediabetes basically. Dr. George Papanicolaou: Which is prediabetes, which includes to make that diagnosis, you have to have obesity dyslipidemia, which is just abnormal cholesterol, triglycerides, HDLs, you have to have hypertension. And one of the things is insulin resistance. And so insulin resistance is connected to endothelial dysfunction. When those endothelial cells aren't working, then the NO, the nitrous oxide is not going to have an impact, and you're not going to be able to start that erection. So what do you treat? You can give the person Viagra, but since metabolic syndrome has so many of the impacts on their overall health and their health span and lifespan, it'd be better to fix that. Dr. Mark Hyman: Right. Okay. So let me translate that, because that was really good. I think here's what's going on. Basically people that are eating lots of sugar and starch and crap in their diet get prediabetes, which goes along with high triglycerides, low HDL, high blood pressure, belly fat, the whole thing. And when you have this problem, which by the way affects every other American. And if you take out the kids, it's probably more than half the adults, so we've got 75% overweight, 80% metabolically unhealthy in this country. Most of those people have some degree of insulin resistance. Dr. Mark Hyman: And what you're saying is when you have this phenomena going on in your body, it damages the ability of the lining of the arteries to function properly. So you can't get blood flow in your organs, not just in your penis, but in your heart and in your brain, which is why insulin resistance causes heart attacks and strokes, and also dementia. So this is all connected. And in fact, the first sign of heart disease is probably- Dr. George Papanicolaou: Erectile dysfunction. Dr. Mark Hyman: ... having trouble getting an erection. Dr. George Papanicolaou: I was about to say, you're worried about your erection, but you know what, you better be worried about your heart and your brain because they're the ones that are really the target of what's going on. Dr. Mark Hyman: Absolutely. And I think people don't realize that it's not just a local problem. This is a systemic problem. Dr. George Papanicolaou: Absolutely that one of the points I really hoped we'd make today. Because as important as erections are, it's getting those root causes that impact your overall health. And then the cherry on top of the pie is great erections. Dr. Mark Hyman: Yeah. And I think most people don't realize that our whole system is connected and that's what's so different about functional medicine is that it's looking at the whole system. So most people don't think of your diet when you think about having sexual dysfunction. But that's the first thing we think about. We do think about stress, for sure that plays a role. Dr. George Papanicolaou: There's alcohol and one of the roles that alcohol plays is that when you're drinking alcohol, that itself is going to impact that endothelial dysfunction during the time of your use. And you're going to maybe that night, not have an erection. Here's what happens. You can stop drinking and say, "Okay, that will fix it." But there's something that happened. You're going to have a psychogenic response, it's called performance anxiety. And for some men, once they have a failure, it multiplies itself, they get performance anxiety, and it becomes a psychogenic problem. And there's a vast majority of men who have erectile dysfunction actually have a performance anxiety, or psychogenic cause. Dr. Mark Hyman: So basically just, if it doesn't work once you're going to be afraid it doesn't work every time and that's going to make the whole thing worse. Dr. George Papanicolaou: Yeah, yeah, Dr. Mark Hyman: Yeah. That's a hard mental thing to fix. But the fascinating thing to me is that the phenomena around seeing this as a systemic metabolic vascular issue is so important. And there's a lot of ways to address that, that we're going to get into. And of course, there's a lot of ways to also address erectile dysfunction that are up and coming that are quite new to far beyond Viagra, which we were going to talk about. I'm excited to talk about those things, but even in traditional medicine, you've got the vacuum pump, which is pre-Viagra, where you put a little ring around the base of your penis and you basically put a tube around your penis and you're basically vacuum all the blood in, which doesn't sound like fun to me. And there's implants which can work. There's there was a alprostadil, which is an injection or something that goes inside the urethra, in the penis that can help. That's a [inaudible 00:12:10] and there's revascularization, which is something I would love you to talk a little bit about. Dr. George Papanicolaou: Revascularization is essentially, you're having, as we talked about hardening of the arteries, and it's two ways that can be done, just like you have a angioplasty stents placed in the heart, the same thing can be done for the penis. And that's one possibility. Dr. Mark Hyman: So it's basically like an angioplasty for your penis. Dr. George Papanicolaou: Yeah. Dr. Mark Hyman: Wow. That's incredible. Dr. George Papanicolaou: Again, these are very interesting responses to the problem, but I would ... And we're going to go through other possibilities, as you said, we can talk about STEM cells and platelet rich plasma. I always like to go back to the idea that yeah, you can be revascularized by why get there in the first place. Dr. Mark Hyman: Exactly right. It's like you get a stent, but you got to fix your- Dr. George Papanicolaou: All of these things actually work. I mean, I've had patients of mine use the vacuum pump. I don't know how they do it. "It works, doc. I love it." I've had people get penile implants. "It works, doc. I love it." And they're pressing their testicle and they're getting their erection. And that's how, that's how the pump works. The pump is inside one testicle, and you start pressing on it and it gives you your erection. And it works. I've had men use the injections. They feel like 18 years old again, but they all have diabetes, hypertension, metabolic syndrome. And I can't get them to get to that underlying cause. So I almost sometimes want to not let them get their erections. Dr. Mark Hyman: Well, let's talk about testosterone, because there's this whole conversation about male menopause or andropause and this whole syndrome of low T or low testosterone. And I think part of it's gone to the extreme and there's a lot of bodybuilders who use testosterone, and I think it can be used inappropriately. But what I want you to talk about is why do we see the drop in testosterone as men age? Because I think this is really important. There are natural ways to raise testosterone and there are ways that we are living that lower testosterone. So let's get into talking about that, because if you fix testosterone, a lot of things get better. Dr. George Papanicolaou: A lot of things do get better. Erections may or may not get better. Testosterone can definitely have an impact on erectile dysfunction. It impacts the 5 phosphodiesterase we talked about earlier. And it also can have an impact on nitric oxide and that can result in improved erections. And he asked me, why do we see this drop-off in testosterone? Well, there's this natural drop off of testosterone as men age. So after the age of 30, you're losing about 1% per year. And over time, that's going to drop you pretty low, but that's not going to do it all by itself. Dr. Mark Hyman: No, I see many older guys with ranging high testosterone levels. Dr. George Papanicolaou: Absolutely. Here's the older guys that don't have raging testosterones. Those are the guys that have sleep apnea, they drink too much alcohol. They have diabetes. They haven't learned how to manage their stress. Did I mention sleep apnea? Dr. Mark Hyman: You did. Dr. George Papanicolaou: Yeah I did, but that's a very important one. And so those are things that as you age begin to impact your body's ability to make testosterone. Dr. Mark Hyman: Yeah. So I just want to emphasize something you said there, it's so important. You said diabetes, but this whole prediabetes insulin resistance thing is the biggest reason. So here's the deal, the bigger your belly, the lower your testosterone- Dr. George Papanicolaou: And the smaller your ... Dr. Mark Hyman: The more belly fat you have, the lower your testosterone is. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: And people don't understand that. And then you mentioned alcohol. And the reason alcohol is such a problem is that it increases a hormone converter called the aromatase, which is an enzyme that converts testosterone into estrogen, which is why you see guys who are drinking lots of beer and alcohol have man boobs and have big bellies and lose the hair on their chest and lose the hair on their legs. So they become more like women and they have very high estrogen levels. People are shocked to find that out. So you're basically becoming like a women, the more alcohol you drink. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: And I think those two things are really important for guys to understand, because if you are struggling with erectile dysfunction, it's a big deal for people. And they don't understand that it's directly related to what they're eating. Now, in addition to the fact that eating starch and sugar will lower your testosterone, what are the things that actually might increase it from a dietary point of view? Dr. George Papanicolaou: Mark, it goes back to one of the books you wrote, called Eat Fat, Get Thin. So now I'm going to tell you this, the name of the book can now be, the one that I'll write, will be Eat Fat, Get Hard. Dr. Mark Hyman: Oh gosh. This is getting to be a racy podcast, we've got to put explicit warnings on this one. Dr. George Papanicolaou: They shouldn't get us together, this is what happens. Yes, fat, because fat actually, we've talked about this before, has cholesterol and cholesterol is not a bad guy. Cholesterol is really important. Foundational molecule for building hormones. And one of them is testosterone. So eating good, healthy fat is going to allow you to have that precursor molecule to maintain high levels of testosterone, as long as you're doing everything else, sleeping well, managing stress and limiting your alcohol use. Dr. Mark Hyman: Hey everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Farmacy. I hope you're loving this podcast. It's one of my favorite things to do and introduce to you all the experts that I know and I love and that I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's picks. It's my weekly newsletter. And in it, I share my favorite stuff, from foods to supplements, to gadgets, to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays. Nothing else I promise. And all you have to do is go to to sign up. That's, P-I-C-K-S. And sign up for the newsletter. And I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger longer. Now back to this week's episode. Dr. Mark Hyman: Let's talk about sort of a functional medicine approach to addressing this, because at a high level, and then want to get into some cases. Because from a functional medicine perspective, we look at a lot of different things to try to identify why this person is having erectile dysfunction and or low testosterone, which often go together. When someone comes in complaining of this, what are the kinds of things you think about and what are the testing things that you look at? Dr. George Papanicolaou: First off I want to make sure that I make the right diagnosis. I always like to emphasize the fact that when people come to my office, I'm going to get a timeline of events. I'm going to want to know everything that's happened in pretty much throughout their lifetime, how they were born, early eating habits, early traumas and stressors in their lives, disease patterns, antibiotic use, medication use, trauma. All of those things create a timeline. And once you have that timeline, you can then begin to piece together a narrative that leads you to the root cause or causes of their disease. So it can be easy for person to come in and tell me, "I have erectile dysfunction. It started like three months ago when I tried to have an erection and I didn't have one, I was with my girlfriend and ever since then I've been having a problem." Dr. George Papanicolaou: Well, oftentimes it's not as clear as the patient thinks it is. And by asking them a long history, I start to find out that maybe that wasn't the key turning point, that he was slowly building up because of other issues, maybe because of alcohol use, maybe because of a family history of dyslipidemia. And he has really high cholesterol and triglycerides and maybe early vascular disease. It's really important to make sure we get to all those and not be biased by a patient opinion or what they identify. Dr. George Papanicolaou: So I really like to emphasize when we're talking about functional medicine, we're talking about a detailed timeline, and then we're talking about using the matrix. And that matrix is, it's just basically a paradigm we use that looks at systems and not symptoms. It takes your conditions and it attaches them to your various systems. So your cardiovascular system or your immune system or your GI system where we break foods down and we assimilate and we absorb. We want to know how all those stories you're telling me how all those symptoms you've had at all of the lifestyles you have are impacting those systems because they all work together to get your body to work the way it's supposed to. Dr. Mark Hyman: You have to deal with all those things, inflammation, like you mentioned that that can affect Endothelial function. Dr. George Papanicolaou: Inflammation toxins. Toxins, mercury, lead talk about impacting endothelium mitochondrial function. I mean, those are major things. And just as a quick aside, it's not a matter of whether you have heavy metals. It's a matter of how much you have and how good you are at detoxing. So I also want to know about your exposure to toxins. So that's how I start. Dr. Mark Hyman: When someone comes in to see me, I also think very similar to you and I go through the matrix, but the things I'm really focusing in on, I'm looking at what is their diet? Are they eating an inflammatory diet because anything that causes inflammation will damage the blood vessel linings and can affect blood flow, which is processed food, fried foods, lack of protective foods that are antiinflammatory. Those are really, really important. And then I'll really dig into about looking at insulin resistance. Does this person have pre-diabetes and we look at insulin levels, we look at things that nobody really looks at traditionally. Dr. George Papanicolaou: [crosstalk 00:22:11], the insulin resistance thing. I almost, I would say eight out of 10 of my patients that come here to The UltraWellness Center, don't just get a blood sugar or hemoglobin A1C. They primarily are going to get a fasting glucose tolerance test, because it's the most sensitive way to uncover insulin resistance, because insulin resistance can be hidden. If we use the current standards that we have of fasting blood sugar of a hundred, that's not low enough. It needs to be lower. And so when you do a fasting insulin resistance test, basically a person fasts. And then after that fast, you give them 75 grams of sugar. And then you see how their body responds, how they produce insulin in response to that bolus of sugar. And if they're able to keep that blood sugar at a normal range at lower levels of insulin, we know that they have a very good carbohydrate metabolic glucose ... An efficient way of managing glucose. Dr. Mark Hyman: But you're right. But if you see someone who's able to manage their sugar and insulin, that's the key. But I've seen patients who, for example, have normal sugars- Dr. George Papanicolaou: But their insulin is high. Dr. Mark Hyman: ... but their insulin are high. And here's the take home point. When you go to your doctor, if you ask for a glucose tolerance test, good luck if you're going to get it. But if you get it, they have to measure insulin. And insulin is something that most doctors don't even measure and you can measure fasting insulin, because most doctors don't even measure that. If your insulin is over five, you probably have an issue. And if your triglycerides are higher HL is low, I'm looking at all that. I'm also thinking about what's going on with their testosterone levels. So I'll look at total free testosterone. I'll look at other markers. We get a really sense of what's their adrenal stress like. Do they have adrenal dysfunction? Are they chronically stressed? We can look at things like DHEA, or we can look at other saliva cortisol levels. Dr. George Papanicolaou: And all the things you're mentioning are not things that you will get through your primary care physician at Harvard Vanguard. It's just not going to happen. Dr. Mark Hyman: You don't have to pick on Harvard. Pretty much anybody, I got friends at Harvard. Dr. George Papanicolaou: Okay, I love that. Dr. Mark Hyman: But I do think you're right. And I think we're looking under the hood. Dr. George Papanicolaou: Yeah. We look under the hood and we have very specific tests that do that. Dr. Mark Hyman: Someone said regular medicine is like trying to diagnose what's wrong with your car by listening to the noises it makes. Functional medicine is basically looking under the hood. Dr. George Papanicolaou: We look under the hood and we don't guess, we test. And we happen to have really good tests at the ready. And the glucose tolerance test is a conventional test we can get in. Anybody can do that. It's just a matter of understanding the need for it. Then when we're looking at our lipid profiles, and we're not going to get into detail about this, but we don't use the conventional lipid profile, we use the NMR and we look at markers of inflammation that you might not primarily see all the time being looked at, like oxidative LDL. How LDL is oxidized because inflammatory states that you might be in. We look at CRP. Dr. Mark Hyman: It's like rancid fat in your blood. Dr. George Papanicolaou: Rancid fat in your blood. Dr. Mark Hyman: Which isn't good for your arteries. Dr. George Papanicolaou: No. So we look at other inflammatory markers and these are critical, but we do advanced testing where we do a four-point cortisol test as part of a profile that will also look at your hormones, estrogen, progesterone, and testosterone, and tell us not only what your totals are, but going back to a point you made earlier, we can actually see if you're an aromataser. If, on the tests that I look at, I can actually see the pathways in your particular physiology that are showing me testosterone being converted to estrogen. Dr. George Papanicolaou: And are you over aromatasing using and producing too much estrogen? There are some men that naturally are over aromatasers. Now, they may even come to me complaining about what, "I'm having a hard time with erections. And by the way, doc, I've always had this belly fat. And I always noticed, I have some boobs always, from when I was a kid." And then I do this test and I can show them, well, this is why. You just physiologically for genetic reasons are an over aromataser. There are things that we can do about that. And that's [crosstalk 00:26:23]- Dr. Mark Hyman: There's natural inhibitors of aromatase that block that conversion. There's even medications that do that. Like Arimidex which they use for breast cancer to prevent making estrogen in the body. So there's a lot of tricks out there for us to do. Dr. George Papanicolaou: So we do that. And so as we work on those things, obviously we're going to be helping them with erectile dysfunction, but these are not simple things to get to. And not just always a matter of the little blue pill. Dr. Mark Hyman: All right. Well, let's talk about this patient that you had and how you helped them. Because I think he was this guy named John. I don't know if that was on purpose or not that you called them John. Dr. George Papanicolaou: No, no. Dr. Mark Hyman: Is that his actual name? Dr. George Papanicolaou: I always change the names to protect the innocent. Dr. Mark Hyman: Okay good. What was wrong with John? And how did you fix his erectile dysfunction? Dr. George Papanicolaou: So John is sort of your classic case that comes to see me. 56 years old, just not feeling up to par, but is being told by this doc after his physical, "Hey, everything's fine." But he says like, "Hey, everything's not fine. My erections aren't as great as they used to be. I can have them, but they don't last as long. It's not as pleasurable. I'm not sleeping as well. I don't have the energy I had. And I just get told that it's just part of aging." Well, he's also at the age where menopause is prevalent. And so you start to think about these things. So with John, he's everything we just described. He's a little overweight, he's a very successful sales manager. Dr. George Papanicolaou: He now has a very high end job with an international corporation. Doing international sales training. Spends a lot of time socializing. And that means that he drinks a bit too much. So we got some extra belly fat or drinking too much. And he's under an enormous amount of stress. He wants to retire early. He's very focused on his retirement and making his bonuses that he can save tons of money. And he's very proud of that. And the offices are talking, so what's the treatment for him? Well, of course he says his main focus really was the erections. And he said- Dr. Mark Hyman: He didn't care even that he was about to have diabetes. Dr. George Papanicolaou: Mark, I'm not making this up. Dr. Mark Hyman: I believe you, that's what guys care about. Dr. George Papanicolaou: When you see it over and over again. So it was just really a matter of just saying, look, let's work on your lifestyle before we condemn you to a lifetime of paying for a little blue pill. So you want to overall feel better and have erections, let's start working on it. The first thing, I got all the testing done I did a fasting glucose tolerance test. And of course he had insulin levels way above 40 at an hour and two hours, which is really very significant for insulin resistance. He was actually just on the board of being declared totally pre-diabetic. His blood, his hemoglobin A1C was 5.6. So 5.8 is considered pre-diabetic. But I told him for all intensive purposes, you're pre-diabetic. Why do I do that? Because when they hear the word insulin resistance, they don't know what that is, but when they hear the word diabetes, they know what that is and that's bad. Dr. George Papanicolaou: So I purposely say that. I say, pre-diabetic all of a sudden I have leverage. Well, how do I fix that doc? Let's work on your diet. So we work on his diet. First thing we do is I put them on, following what you've written about so wonderfully over the years is basically a cardio metabolic diet. We detox them. We take out sugars, processed foods, gluten, dairy, alcohol, soy, basically put them on a whole food, vegetable based clean diet, minus those things. Just that alone in the first six weeks definitely leads to, I feel better. I'm losing weight, I'm sleeping better. The second thing I tend to go after is stress, particularly in a man like that. So I tell them, by the time you come back to me in six weeks, I want you to establish a good stress management program. Dr. George Papanicolaou: I'll get even more specific and say, I want you meditating. I want you meditating at least once a day. I'm a huge believer in the power of meditation to alter every part of your physiology and improve it for life and actually slow the aging process in many parts of our body, most particularly the brain. So I really emphasize meditation and stress. That's what I do with John. So John was a lifestyle change with nutrition first followed by meditation. And then what else did I do with him? Oh yeah. So I added in some things early on. So fish oil, his vitamin D was really low. Vitamin D was like 17. Vitamin D is a very important precursor to all hormonal function. So we got his vitamin D up. We got his fish oils to reduce inflammation as he lost his weight. I gave him an adrenal adaptogen to help modulate his cortisol, because cortisol- Dr. Mark Hyman: Like Ginseng, you mean? Dr. George Papanicolaou: Yup, yup, Ginseng. There was some Rhodiola and Ginseng. And Ginseng actually, and Rhodiola can have an impact on erectile function. So I was able to give him that. And after about nine months he lost weight. His testosterone was low. It was in the low 400s. We talked about testosterone replacement, but I really pushed him on let's get diet, let's get stress, let's get sleep. We did those things and he felt better. And by the time we were done in nine months with that particular process, his hemoglobin A1C had gone down to 5.1. Dr. Mark Hyman: His blood sugar was way better. Dr. George Papanicolaou: His Blood sugar was way better. He had dropped 23 pounds. He was sleeping better. He started meditating and his erections were a lot better. They weren't perfect, but they were, he said, "Doc, they are tremendously better." Dr. Mark Hyman: That's so great. Such a great story. And I think there are also other things that are out there that people are using. And I think, when do you decide you want to give someone testosterone? Because that's a reasonable thing to do as guys age. I think there's some controversy about it, but it can definitely help increase desire, libido, function, pleasure, orgasm. So, when would you decide to give someone testosterone? Dr. George Papanicolaou: And in his particular case, his testosterone wasn't ... it came up it was 450. And like I said, nine months, he was better, but things weren't perfect. So, we did at that point talk about testosterone and that's when I use it. When somebody has done everything they can to really improve their lifestyle, manage the metabolic syndrome, manage their insulin resistance, manage their hypertension, manage their stress and their testosterone's just aren't budging. That's what I use it. And so I did, I put John on testosterone. Dr. Mark Hyman: And you can do a topically. You can do injections. There's pellets. There's a lot of ways to do it, that a doctor can prescribe and you have to monitor it and you also have to make sure you take the right supplements with it, to regulate some of the things that happen around estrogen. So it's going to be a really effective treatment, but what's interesting is you can increase your testosterone significantly by fixing your diet by adding more fats and decreasing the sugar and carbs and reducing stress, alcohol. But also exercise is a very interesting thing that happens to the body. When you exercise, you also can boost testosterone, but there's very specific exercises that can do that. Can you talk a little bit about that? Dr. George Papanicolaou: So the specific exercises that will do that, number one, aerobic activity, number two, high intensity interval training will definitely improve your testosterone levels. Those are the two that I recommend the most for patients, a combination, and weightlifting. Dr. Mark Hyman: Why do you recommend weightlifting? Dr. George Papanicolaou: Okay. For multiple number of reasons, muscle mass actually helps improve carbohydrate metabolism. Muscle is actually very important to you in the aging process. You need muscle to be able to move and function, so very important. And that's why ... Those are the main reasons why I prescribe exercise and particularly weightlifting. But the other side of that is that I prescribed testosterone to help men when they're working out to actually make the muscle gains, because oftentimes they're working out, they're not making muscle gains. So testosterone can help them and benefit the muscle gain, which then helps them in dealing with their insulin resistance and their metabolic syndrome and to age more appropriately. Dr. Mark Hyman: Absolutely. I think that's right. I think the testosterone can help for people, but it also by just weightlifting and using heavier weights, you can literally build your own testosterone along with increased fat. Now there's a few other things I just want to mention for people listening. And I think are up and coming treatments, and they're still needing more research and investigation. But people are using STEM cell injections or exosome injections, peptides, platelet rich plasma. So these are the things that actually are out there that are being used in varying degrees of effectiveness. One of the treatments that I've found really fascinating is shockwave therapy. This is an ultrasound shockwave therapy, which is applied on the penis with a little ultrasound device. They use a little lidocaine to anesthetize the penis because it's a little uncomfortable, but it usually takes about 15, 20 minutes. Dr. Mark Hyman: It's done over a period of weeks. And what it does is it helps to break down some of the stiffness of the arteries that are causing the decreased blood flow. So it can really increase the blood flow and vascularization. And it's been well looked at by research. So I think that's another interesting avenue, but I think for men listening and women who are married to men, this is a solvable problem and it's an embarrassing problem. There's a stigma about it. People feel anxious talking about it, but often it's a medical issue that can be sorted and solved. And sometimes you need to think a little bit out of the box and it's just not as simple as just taking Viagra or Cialis. There's a lot more to it. And I think that's really the approach we take here at The UltraWellness Center is a comprehensive approach that looks at all the factors in someone's life that may be impacting their sex drive, their sexual function and their ability to actually enjoy life well on into their 80s and 90s. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: I think it was important. I was very inspired yesterday talking to that patient who's 87 and he was still having sex with his wife. And we're just talking about how to make it a little bit better. But that is possible if you pay attention to the quality of your health and deal with your lifestyle. So George, thank you so much for being part of The Doctor’s Farmacy House Call podcast. If you all been listening to this and you love the podcast, share with your friends and family, maybe not yet mother, but certainly leave a comment. We'd love to know how you've managed through this difficult problem. If you've struggled with it or your partner has. Subscribe wherever you get your podcast and we'll see you next time on The Doctor’s Farmacy. Dr. George Papanicolaou: Thanks Mark.