Erectile dysfunction as an indicator of cardiovascular disease & early death

Dr. Merrill Matschke discusses how diet and lifestyle factors impact sexual health in men, and how fertility and related issues can be early indicators of more systemic problems.


Article highlights

  • Erectile dysfunction is an early indicator of endothelial dysfunction and cardiovascular disease risk, with lifestyle factors like diet, exercise and sleep playing a major role in prevention.
  • Testosterone is critical for nitric oxide production and healthy erections, and declining levels in men are tied to obesity, inflammation and insulin resistance.
  • Sperm counts and testosterone levels have dropped 50-60% in developed countries over 40 years, signaling the harmful impacts of modern diets and lifestyles.
  • Continuous glucose monitoring gives real-time feedback on food choices and other behaviors affecting metabolic and sexual health, providing motivation.
  • Physicians focused on empowering patients through education on lifestyle medicine represent a shift towards preventative care needed to reform our reactive, disease-focused healthcare system.

Dr. Casey Means:  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 toward health for both men and women.

He’s also a Levels beta member. He’s introduced many of his patients to Levels, and he is such a valued member of our Levels community. There is an incredibly strong link between metabolic health and sexual function that is largely underrecognized and barely makes it into the clinical practice conversation. Here, we dive into topics of men’s health, metabolic dysfunction, consumerism in healthcare, and so much more.

The Well Side of Medicine

Dr. Merrill Matschke: Thank you for having me. It’s very exciting to be here with people who have the same interest.

Dr. Casey Means: Let’s start with hearing a little bit more about your personal journey as a clinician. You mentioned that your mission is 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: I’ll try to keep this brief, because I like to talk. I am a urologist, but I specialize in what’s called andrology. We’re the urologists that focus on sexual dysfunction, infertility, hormone disorders, and the like.

I have grown my practice over time from a general urology practice, and then I grew my subspecialty market. As I was doing that, I started to get exposed to the commonalities of men with ED, infertility, and hormone disorders.

You start to immerse yourself, if you’re passionate about it, into, “What’s the common blank here?”

I really enjoyed the first five years of my practice, in general. The middle five years of my practice involved a more generalized, large group practice environment. It was okay. You’re kind of hitting your stride.

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. I just became that robot clinician where you’re pumping people in and pumping people out.

I finally hit a part where I didn’t feel like I was giving a good product anymore to my patients. I was changing for my family, and I didn’t like it. 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 patients.

Then one day one of my other partners said, “You know what? You are running behind, and you’re running behind enough that I think if we’re more than 15 minutes behind, we should offer the patient a $10 gift card or something to Starbucks.”

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.” I actually took a turn. I took a turn, left the mainstream side of medicine, crossed the fence over to what I call the well side of medicine, and joined a wellness and prevention concierge medical practice for a year. It reinvigorated my interest in the common pathways that were going to lead to endothelial dysfunction, erectile dysfunction, infertility, and 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.

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. 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 applying changes in behavior and lifestyle. You’re moving to the most proximal aspect of health and chronic disease. You intervene before you’re going to deal with medicine. And it worked. People were happy.

I saw couples that were happier for all the reasons we may talk about. People were living better lives. 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. I’ll go back and be careful of my burnout, but I’ll return to the other side.” 

I came back and 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.

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

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. That’s out of ancient medical texts, but that’s the way I’m going to practice. During the 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. I was one of these soft, fat, round kids. I always was. I went through several periods of transformation. The first one was when I was doing my fellowship in 2002, down in Baylor, for male reproductive medicine and surgery. I checked my testosterone, and I was in the 270 range. It explained a lot of things, I thought.

There was a program called Body for Life, led by Bill Phillips. It was a book and included a challenge program you’d go through for three months. It helped change your nutrition and gave you some exercise information. I did it twice. I lost 40 pounds. I completely changed myself and felt great.

The superior provider is the one who prevents disease. 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.

I came back, started my practice, got busy again, and went through some issues. I gained some more weight. I went through three or four of those episodes, but finally, with the birth 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.

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

Dr. Casey Means: I love hearing your story. It resonates with me and my personal journey as well. 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. We come from this culture in medicine where we’re indoctrinated with this idea that the most invasive interventions, the biggest things we’re doing, are the heroic things. There’s this trope of a surgeon with the bone saw, doing the coronary artery bypass graft, and the patient is on ECMO. We think, “Oh my God, this person’s a savior and a hero and this deity-like figure.”

In my surgical training, I really started to feel like going in and busting a hole in the sinus and sucking out pus wasn’t actually the heroic thing. Getting the patient healthy, reducing their inflammation, helping them actually improve their overall wellness—that was heroic. But it’s much gentler and almost looked down upon.

It’s like that with nutrition, which is sometimes seen as this niche thing that is almost wimpified and almost below—and maybe I’m overstating a little—what doctors tend to focus on. We need to flip that script and realize there is nothing more valuable we could do for a patient than counsel them on these dietary and lifestyle factors that actually change physiology and create fundamental health in their bodies, which, unfortunately, most surgeries can’t do. 

Taking something out, removing something from the body, and changing anatomy can be helpful in many cases but doesn’t necessarily always change the core physiology that generates health. Does that resonate with you? How does that apply to urology and your surgical practice?

Dr. Merrill Matschke: It absolutely does. I have a little line I use a lot with my patients. It’s really from Marty Makary, a surgeon at Johns Hopkins. We are so good at playing Whac-A-Mole or putting out the fires. That’s what we do on the mainstream side, but what really matters is taking away the matches. 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. You have to spend that time.

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. I see those of us, like you and like me and other people I’ve allied around me in my system, as traditional medicine.

What we are actually doing, I think now, is alternative medicine. 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 how if a medicine could do what exercise does, everyone would buy it. Why not do it?

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 and you’re siloed. Your ability to understand what we really should be doing, it’s really embarrassing to some extent.”

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. That is a trigger point for me that I have to manage. But yes, I want a path that is incentivized somehow so that we can provide this product to people.

I see young men. Women see a gynecologist beginning with the onset of menses. When men leave their pediatrician, oftentimes the first doctor they’re going to see is me. They want a vasectomy, so they can’t get someone pregnant. They’re having some ED issues. 

Food is medicine, exercise is medicine. The best studies show it’s social support, exercise, and diet that gives everyone the best outcomes. We’ve all heard how if a medicine could do what exercise does, everyone would buy it. Why not do it?

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 more significant than the risk factor of smoking.

Then you combine that with insulin resistance and it’s even more significant. The endocrine society just had a meeting recently, and one of the papers presented was so scary. Young kids, children, and adolescents with hyperinsulinemia and insulin resistance have smaller testicles.

It’s right there for me to intervene with low-hanging fruit for all men. If I can step in and stop their bad behaviors and put them on a better path, their healthspan and lifespan are going to be extended.

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. When that moment happens, I want to be there with an outstretched hand. You guys recently talked with someone about prostate cancer. His trigger was his diagnosis. He then said, “Wow, I’ve got to do something.”

I love talking about prostate cancer in this setting because in this country, one in 41 men will die of prostate cancer, according to the American Cancer Society. One in five people die from cardiovascular disease—one death every 34 seconds. My statement to all these guys who come in is, “Do you know what the number one cause of death for a guy with prostate cancer is? Cardiovascular disease.”

That’s where I see my purpose. I took out a lot of prostates back in the day, but I wasn’t robot trained because I’m too old. I haven’t taken out a prostate forever, and I won’t again. I’m going to stay under the urology umbrella. I’m going to step into the men’s metabolic health arena and actually help more men. I want to be there when a guy has that motivating factor, whether it be a cancer diagnosis, a divorce, a chest pain event, or the birth of a grandchild. That’s how I see urology as perfectly set up to really help men.

“The Canary in the Coal Mine”

Dr. Casey Means: You called yourself a men’s metabolic health physician, sort of under the heading of urology. I love that framework because it touches on this 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. We need to look at the systems and see how these sub-specialties have downstream manifestations of core pathways that are going awry.

We’ve got the cardiologist, we’ve got the urologist, we’ve got the OBGYNs dealing with polycystic ovarian syndrome (PCOS), but when you step back and look, we should think, “Okay, what’s the link connecting all of these in our current system with 42 subspecialties?”

We’re almost blind to the fact that there is this common link that there’s honestly no real doctor for. We have internal medicine, I guess, but even in primary care, we’re not thinking like this. We’re still playing the Whac-A-Mole medicine. We’re not thinking about those core physiologic links.

Let’s start breaking down some of the mechanistic links between metabolic issues and men’s health issues, specifically erectile dysfunction and infertility. Our audience definitely likes to get nerdy, so feel free to go into some of the science.

Dr. Merrill Matschke: ED is a great system and model to look at. The development and 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, is a urologist. Back in the eighties, he was in an elevator and had it open up in front of him when he was going between meetings. He looked across the hall and saw a heading on a lab that said Vascular Smooth Muscle Lab.

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

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 PDE5 inhibitors, Viagra, and the like. That is one of the most proximal metabolic actors and messengers involved.

Endothelial dysfunction, nitric oxide, oxidative stress—that’s where that intersection is with men’s health, ED, and metabolic changes in cardiovascular disease. Now, if we slow down for a second and think about that, it is actually a proximal actor, probably in all three of the main issues, which are chronic diseases. You’ve got cardiovascular disease, cancer, and neurodegenerative disorders. They probably all are going to come down to a lot of endothelial dysfunction, chronic inflammation, and oxidative stress.

We’re talking about that in the penis, in ED. Think of the two biologic cylinders in the penis, called corporate cavernosa. They’re specialized blood vessels. I’m in Wisconsin now, so I say imagine a bratwurst that you snap. You’ve got casing on the outside and meat in the middle. That meat in the middle is smooth muscle tissue and that casing on the outside is kind of a tough casing called tunica. 

For the penis to work correctly, that smooth muscle in the middle of that has to be really healthy. It has to expand. It has to relax. The way it does that is through multiple mechanisms, but there’s a thing called nitric oxide. As we age, nitrous oxide goes down, and it goes down in many other conditions: smoking, diabetes, and lots of different things. When that happens, that tissue does not work right.

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.

But this tissue is probably the most exquisitely sensitive tissue to low oxygen tension in the body. It is the canary in the coal mine, it’s the check engine light, it is the thing we should be listening to. You start to get problems with decreased nitric oxide production, from atherosclerosis, decreased blood flow, and low T—which is a huge interest of mine because testosterone, when it’s low, does not allow nitric oxide scent to work correctly. It is an androgen-dependent enzyme, and it has been well-described and proven. Low T, which is a huge part of my practice, is a common denominator. All these things intersect. When that happens, the tissues do not do well.

I have to sit and explain this to men because I want to engage, educate, and empower them. They have to understand what’s happening to their own body. 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. 

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.

This tissue is probably the most exquisitely sensitive tissue to low oxygen tension in the body. It is the canary in the coal mine, it’s the check engine light, it is the thing we should be listening to.

The appropriate erectile response requires a certain ratio of smooth muscle to collagen in the penis. As we age and we’re exposed to these chronic disease pressures, you lose smooth muscle content. Collagen content goes up, and you actually get fat inside the penis, right underneath that casing.

That is the first step to most ED: venous leak. You’re not getting enough blood into the system. It’s not getting trapped to develop the pressure head. As that tissue scars, it doesn’t relax as well to close those veins. The amount of that tissue is smaller. You start to get ED. Nighttime erections are like doing pushups in your sleep. When you’re not getting that natural exercise for that tissue exposed to the high oxygen tension, that tissue starts to scar, and you start to get ED.

That’s the nighttime erection loss 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, but it’s an excellent explanation to try to help people understand why that tissue needs to be exercised on a regular basis. 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. This is a specialized vascular tissue.

Nitric oxide synthase is the enzyme that makes nitric oxide. I can come out of nerves. It can be part of an endothelial cell, and in the penis, both are there. 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 a cyclic GMP is not as efficient.

You start to have scarring of those tissues. When they scar, it can be three to five years before you’re going to see changes in other vessels like the coronary or the carotid. That’s why it’s this early warning system. They’ve actually done studies showing the main vessels leading into the penis are very small. That smaller diameter is going to show flow-limiting issues before you’re going to see flow-limited issues in the coronaries. It is a great model to look at, and also to predict you have a problem.

Not all ED is vascular in nature. We’re speaking specifically of vascular ED, and there are other issues with regard to neurologic diseases as well, but also psychogenic ED. 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: Amazing explanation. Thank you. You mentioned that, aside from vascular issues for erectile dysfunction, there’s also psychogenic and neurologic issues. With the psychogenic side, I’m thinking about depression, anxiety, things like that. We see much higher rates of depression and anxiety in people with type 2 diabetes. Is there a metabolic element that may contribute as well?

On the neurogenic side, are some of the causes actually from nerve damage related to metabolic issues, or is that more neurogenic issues from damage due to prostate surgery and things like that? Even in the nonvascular bucket, is there still somewhat of an increased risk? When you have metabolic issues, it just has its hands on everything.

Dr. Merrill Matschke: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. If you’ve got anything like the neuropathy of diabetes affecting nerves, that issue will ultimately lead to that cascade of changes of increased apoptosis and the loss of smooth muscle content in the penis, and therefore ED.

Let’s say you’ve got a guy who’s got a Type A personality, that if he once had a bad experience, 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 high, and that is not good. Norepinephrine is part of the sympathetic discharge. That’s a fight-or-flight response. That is an evolutionary response to protect us.

I say this to all my patients. When we were cave people, if you were getting chased by something trying to eat you and you saw a nice cave lady over there, if you stopped to look at that person, you were in trouble. The sympathetic nervous system is there to mobilize your ability to save yourself. That means run away or fight, and getting an erection is not a part of that. From an evolutionary standpoint, the sympathetic is there to turn off drive and turn off erection.

If you elevate the sympathetic tone in someone with a psychogenic component to their ED, they cannot relax that smooth muscle. As a sympathetic nervous system, the end mediators do just the opposite of what nitric oxide does. They contract. That’s how we recover after the event; that’s how the erection goes away.

When you’ve elevated sympathetic tone, you are swimming upstream to try to get an erection because those smooth muscle cells don’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. It becomes a tug-of-war.

Unfortunately, there is no blocker for the norepinephrine. And for the adrenaline sympathetic discharge, if you block that, you’re in trouble.

I just saw a gentleman this morning in the office, with that exact issue. I can’t explain why, but I know what his issue is, and he does too, but it’s purely psychogenic. I recommended some mindfulness exercises and some yoga and things like that. What urologist is going to do that? 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 to develop trust. That’s what I’m trying to explain to these people.

But you can start to explain some of these mechanisms and explain that, when your A1C is 11.3, nerves don’t work acutely there. You can explain how, when you control your sugar, you’ll have a better erection the next day. I say, “You’re going to be better, but you’re also going to help maintain the health of your smooth muscle cells if you get better control there.”

Another issue was smoking. Some of the behavioral studies 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, and it would measure nocturnal erections.

There was a study in the ’90s where they took a group of smokers and they asked to stop smoking for 24 hours. They put the RigiScan on them before they went to sleep. With just one day of no smoking, they had much better nocturnal erections.

You can see acute improvements from these lifestyle factors that we know impact the vasoconstriction and vasodilation. Chronic depletion of highly oxygenated blood flow into the penis is having downstream effects that will change everything.

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

Neuronal nitric oxide synthase (nNOS) is what is going to come out of a nerve ending. Endothelial nitric oxide synthase (eNOS) lives in endothelial cells, which line the small blood channels, called sinusoids, of these smooth muscles in the penis.

One of the triggers for the eNOS to work is the initial stretching of the cell from the neuronal nitric oxide that’s released. You want that stretching to also trigger another enzyme system that makes nitric oxide. It’s one of the reasons why shockwave therapy works for ED, which is a newer regenerative therapy, but it’s causing sheer stress on that tissue that activates that nitric oxide synthase.

When you actually get into the individual pathways, it’s fascinating, but it’s very complicated. The commonality is endothelial function being healthy or not, nitric oxide, and oxidative stress. They all come together there.

Inflammation, Stress, and Hormones

Dr. Casey Means: You said earlier that metabolic issues lead to the penis transforming from healthy, smooth muscle to more collagen and fat. Basically, through some of these lifestyle-related decisions we’re making, we’re converting a healthy penis to a fat, scarred penis. That is crazy to think about—that the cellular composition of this part of the body is changing into something different. The visual of that is quite profound. Thank you for mentioning that one. It’s motivating, I would say, in terms of making healthy choices.

Endothelial function, reactive oxygen species, inflammation, and nitric oxide production are some of the key physiology elements that are perturbed in both chronic diseases—like heart disease, cancer, and neurodegenerative disease—but then also with erectile dysfunction. 

Could you give a quick primer on what endothelial dysfunction and oxidative stress are? How are these things linked to insulin resistance and high blood sugar?

Dr. Merrill Matschke: 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. The testosterone aspect is a giant factor. When we say endothelial dysfunction, we typically are referring to dysfunction of the lining of the blood flow of the blood vessel due to low nitric oxide. 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 species that quell that. The problems that occur are when that gets out of balance. When you have elevated oxidative stress—and it is a generalized term, but it will lead to damage whether through advanced glycation products, end products, or some of these other issues—it will cause the eventual changes we think of when we think of vascular disease, hardening of arteries, plaque formation, and thickening of the intimate media of the vessels.

That same inflammation or oxidative stress also impacts our genetics, our DNA. It will induce something called apoptosis, which a lot of your listeners know about: programmed cell death. It’s the way we manage and recycle cells. 

When chronic inflammation starts to push that too much, you start to see the classic changes of atherosclerosis and vascular disease. We discussed some of these changes that occur in the penis, but in the typical vessels you’re going to first see those changes at the lining. Inflammatory factors like IL-6, TNF-alpha, and other things like that are driving some of these pathways and then leading to some of the developments of connective tissue and vascular changes.

You will see it in different areas. You see it in the brain, especially in Alzheimer’s patients and those with other neurodegenerative disorders. Why is this? What did we just learn about Viagra and the PDE5 inhibitors and what it does to the brain? Seventy percent reduction in Alzheimer’s. We’ve known this. We’ve understood this. We’ve thought about it. We wonder, “Is this going to happen?” Boom. Now we know it happens.

It’s all going through this process of inflammation at the most important interfaces, the cellular interfaces of our different systems. Instead of thinking about individual organ systems, when we back up and adopt a bigger awareness of the common thread of the entire system, it’s this interface between inflammation, oxidative stress, and the other mediators like nitric oxide, which, when decreased, can lead to more oxidative stress. 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: I think that’s a great overview, and I think it’s a complex web. For each of these topics—we’re talking about endothelial dysfunction, inflammation, oxidative stress—there’s probably 50,000 papers about this stuff. It’s really great to have the high-level view of how they’re interconnected. We’re really talking about the blood vessels and how we get oxygen and blood to all parts of the body—the basic framework required for essentially all aspects of health.

Our current diet and lifestyle are completely throwing a wrench in that system. That’s a key takeaway for people. I was talking to an orthopedic surgeon who’s very much aligned with a lot of the things we’re talking about, and very metabolically focused. He mentioned rotator cuff injuries, which are on the rise. Most people are not making a link between metabolic issues and something like a rotator cuff injury, but for muscle to be strong and not tear, it needs proper blood flow. It needs good metabolism.

He talked about how rotator cuff injuries are like erectile dysfunction of the shoulder. It totally makes sense. If you’re getting these microvascular issues in this tissue, it’s going to become weak. It’s going to be changed into a different type of tissue that’s weaker, and you’re going to be more prone to tears.

Eating for good vascular health can potentially help with prevention of a sports injury, about which we may think, “Oh, we’re getting older and we played tennis and now we screwed up our shoulder.” But how could we have built more biologic resilience by optimizing our blood flow to prevent something like that from happening, or just lowering the risk? I just love the erectile dysfunction of the shoulder—that just cracked me up.

I’d love to hear your thoughts on how metabolic issues lead to low testosterone. I know there’s some data around fat aromatizing testosterone to estrogen. How should men be thinking about how their weight and other issues like cholesterol affect their testosterone, which then feeds into both erectile dysfunction and sperm production?

Dr. Merrill Matschke: As an andrologist, I see the health of the man through the two outputs of the testis, which is sperm and testosterone. The exocrine output and the endocrine output are dropping more quickly than ever. Sperm counts have gone down by 50-to-60% in the last 40 years. Testosterone is also decreasing, not quite as significantly, but it’s certainly going down.

It tends to go unrecognized, and I don’t feel that the endocrine world on the mainstream is recognizing the importance of healthy testosterone levels as it applies to insulin sensitivity.

As men get heavier, they start to develop deposits of fat. When you get visceral adiposity, that’s the hormonally active fat with the IL-6, the TNF-alpha, and all these other inflammatory mediators. This is active fat, and those mediators act in multiple areas. It can act centrally, and it can act in the testis.

We’ve learned that when you have metabolic dysfunction, hyperinsulinemia, and obesity, you see an increase of these cytokines, which are acting centrally. This increase appears at the hypothalamic level. Whether it’s working through kisspeptin or through the nerves involved in the hypothalamus for the release of gonadotropin-releasing hormone (GnRH), you’re seeing reduced GnRH production. You’re seeing lower gonadotropins out of the pituitary, specifically lower luteinizing hormone (LH) and follicle stimulating hormone (FSH).

You’re seeing a central component, but you’re also seeing these inflammatory mediators impacting the cells within the testis. It’s touching everything. Obesity, inflammatory cytokines, and these 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 hypothalamic-pituitary-gonadal (HPG) axis as well.

Then you see T come down, which impacts the efficiency of nitric oxide production. You’re now promoting endothelial dysfunction. I often tell my patients, “ED equals ED equals ED: Erectile dysfunction equals endothelial dysfunction equals early death.” I try to tie it all together.

Low T is a bigger deal than I think we realize. I’m only talking about men here. I do have some experience taking care of women, but, really, I’ve been focused on men for the last five years or so.

The impact this has is staggering. I have been trying to educate the local endocrine system providers with the data out of Europe on long-term testosterone replacement in people with Type 2 diabetes with low T and ED. 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 2 diabetes.

A study came out about two years ago. It was a long-term, real-world, clinic-based study. This is what we need to pay attention to. We don’t live in vitro. We live in vivo. Too many studies right now are based on in vitro data; they don’t take into account the real world experience. But this study was an 11-year study. It looked at hundreds of men with diabetes and low T. Half of them took T, and the other half did not.

They’ve been following these men for 11 years. After 11 years, 34 percent of the men treated with testosterone were no longer diabetic, and most of these men had improved measures of A1C, fasting plasma glucose, and fasting insulin.

In the group that elected not to take testosterone, none of them were cured. In fact, their condition worsened. The only difference was that the other group got a testosterone undecanoate, and normalized their T. This improvement is probably happening at the level of the nitric oxide synthase, in addition to the ability to maintain more lean muscle mass. Then you lose that visceral adiposity, and lose that drive of those inflammatory cytokines.

There’s also a 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.

I get upset when some of these people lock onto one thing. They say, “Testosterone causes prostate cancer.” I say, “First, you’re wrong. Go read. Secondarily, you just blocked that guy who I put on T who was getting better. Now you scared him with misinformation. Go back and read, and see how we now know that testosterone does not cause prostate cancer.”

Some other providers, with their old training and not keeping up with the latest research, gum up the works to start getting people back to healthy lifestyles. It’s just so unfortunate when you really start helping people, and then they get derailed. But it’s part of the torch I carry now. We all do, because we have to deal with the knowledge that we’ve acquired through functional concepts and integrative medicine, the traditional medicine we should be offering as a first path.

Lifestyle is Key

Dr. Casey Means: You mentioned that both sperm count and testosterone are declining at large. What are the main lifestyle and dietary factors leading to that? Is there anything people can do to naturally increase their testosterone? 

Dr. Merrill Matschke: Absolutely. Our diet, exercise, and sleep are the first three things I’m going to talk about. Diet, diet, diet. Nutrition, nutrition, nutrition. Diet is a four-letter word to me. I talked about lifestyle changes, nutritional aspects, and getting to a clean diet. As we’ve all said, shop outside of the grocery store. We’ve all used that line. Stop eating out of bags and boxes. Stop picking up food that has a nutrition label on it. It’s not food. 

If I need to, I’ll employ the guy next door, the exercise physiologist who works across the hall from us, to try to help anyone with some barriers (like a bad back, for instance) to understand what he may be able to do to exercise. But it’s nutrition, movement, sleep, and 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 I maintain and increase my own testosterone.

I could just get people to do that. That’s our problem today. We want the pill that’s going to make us better. That’s what you hear from so many people because that’s the way our system has developed. We want something now. We want it free, and we want it to work perfectly. Some of this is hard work. You have to wait for that motivating thing to happen for a guy to want to engage in the work. But once he wants to, we’ve got all the knowledge and ability to help him help himself.

The Endocrine Society, as I just mentioned, just presented brand new information on young children and adolescents with endothelial problems, hyperinsulinemia, and elevated fasting glucose. They already have smaller testicles. We are seeing this. We don’t call Type 2 diabetes adult-onset anymore. 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. 

It’s nutrition, movement, sleep, and anything having to do with chronic stress. Those are the answers to how I maintain and increase my own testosterone.

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: vascular disease, neurodegenerative disorders, and cancer. Now we’re going to see it earlier. We’re going to shortchange everyone’s healthspan unless we step in. We’ve been here for 200,000 years in our current form, and we’ve only been living this way for the last 50 to 100 years. Modernity is killing us very quickly. 

If you look at what’s happening to testosterone, but more specifically to sperm counts, this is a big problem. As we’ve discussed, sperm counts have decreased by anywhere between 50 to 60% in the last 40 years. And that’s only in developed countries. What is that saying about our ability to propagate our species? 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.

Those studies have been starting to pour out since the late 80s and early 90s. They all contain the same message. We’re doing something wrong. Testosterone is definitely dropping each decade. A 30-year-old now has a testosterone level that’s lower than a 30-year-old of 20 or 30 years ago. 

Some recent data came out of the University of Miami. They followed young men and have been seeing this obvious downward trend for each decade. The biggest thing we’re attributing that to is obesity, probably through obesity genes at the hypothalamic level, as well as endogenously in the testis. 

We’re having major issues there, and it’s not just lifestyle. We’re now seeing the epigenetic impacts of these young men’s parents. This is why it’s so complicated. The methylation patterns we’re seeing are different based on who their parents were. Was one of their parents insulin resistant? Did they have Type 2 diabetes? That will then increase the risk that their offspring also has smaller testes and lower testosterone. It’s all intertwined. If we just start doing the right things and right the ship, our bodies are pretty amazing. I went through it myself: You do the right things, the body rights the ship.

It doesn’t happen right away. That’s why I go back to that study from Europe about the 11-year experience with testosterone replacement. You’ve got to follow them for many years so you can see some of the chronic effects we’ve talked about. For instance, in the penis, when you have elevated T levels, you will maintain the preventative mechanisms of that smooth muscle tissue. If T is low, that preventative maintenance is gone. It’s going to be the same thing in a vessel in the brain or in a vessel in the heart. If you have low T, you’re going to see the progression of your problem.

On the other side, when we talk about sperm count decline, it is real and it is multifactorial. A 2017 meta-analysis looked at over 40,000 men from westernized and non-westernized countries. It was only in the developed countries that they saw a decline in the semen parameters. In the more tribal communities in Africa and Asia, they didn’t see any declines. The quality and the amount of data were not quite as robust, but it was still there.

Only in developed countries like ours do we see this decrease in the semen parameters, which are precipitous. It corresponds to the generalized decrease in fertility we’re also seeing. The use of assisted reproductive technologies, or ART, whether it be through insemination or IVF, is going up five to 10% per year, and we’re not really responding to this.

I was disappointed when the 2017 paper came out. It got about one second in all the main media outlets. Then GQ came up with an article on it. It included what we consider one of the fathers of andrology, one of the big fellowship guys. He has a line in there saying something along the lines of, “Well, they are going down, but it doesn’t matter. We have ART, so we’ll always be able to get people pregnant.” Why are we playing Whac-a-Mole? Why are we putting out the fire? Why not take away the match?

We have an opportunity to impact someone early on when they come in with infertility, low T, or ED. We can improve their lifespan and their healthspan, but we just don’t do it. The reasons we’re seeing low sperm counts are multifactorial, but it is going to be tied to our obesity and metabolic health epidemic. 

Number two, it is absolutely going to be due to sleep-related issues, stress, and nutrition, which really should be the number one factor. Way back, when someone started talking about the quality of our food,endocrine-disrupting chemicals, phytoestrogens, and xenoestrogens, a lot of people just wrote them off. But we now know it’s real. We are seeing real changes related to estrogenization, including anogenital changes.

Things that have been conserved for millennia are now changing and are pointing to changes in our hormonal milieu, in utero and during life. These are very big issues, whether you’re talking about insecticides, pesticides, or estrogen that’s getting into the water system, or estrogen mimickers and plastics that end up in your water bottle. When you crack open that top, those are estrogen mimickers. 

In the past, we probably wouldn’t have been susceptible to some of those, but we’ve destroyed our gut so that the tiny lighting between the outside world and our immune system is now paper thin. Our immune system isn’t supposed to be seeing these things, but now it sees stuff it’s not supposed to, and it’s confused because they’re imitators. They look like estrogen, and now we’re activating our immune system in ways that are leading to other immune disorders, including skin diseases and GI issues. It all ties together.

What we put in our bodies is telling us that we need to make some changes because yes, it’s nice we have ART—I have four kids from IVF—but we should recognize that this is a signal. Remember that horrible story of the Homeowners’ Association building in Surfside, Florida that pancaked on itself? For years they 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 rusting rebar—almost like the lack of nitric oxide—and what happened? 

I tried to explain this to my leaders. I said, “We really should elevate this concept of prevention because there are some signals we’re blowing off.” One of the biggest is the semen analysis data that has been reproduced so many times. Some evidence-based medicine aficionados kind of normalize it and say, “Well, this study showed this. I don’t know if this is real or not.” Back up and look at the big picture.

Dr. Casey Means: I could listen to you talk all day. Everything you said is so important. You touched on the microbiome, endocrine-distributing chemicals, leaky gut, chronic inflammation, and sperm counts. It’s amazing. And then you have what’s happening to our youth, which cannot be overstated.

A Need to Change the System

Dr. Merrill Matschke: I’m not doing this to pat myself on the back. I’m here to show that the value is there, and the end user is asking for it. There are handfuls of doctors like me who 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.’” We have offloaded that responsibility in this world of Medicare and payers. People might think, “Insurance doesn’t pay for this. It must not matter.” It drives me crazy.

I have to try to hook the patient however I can. I was talking to my leader about this, and 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 gave me this blank stare. “You’re a urologist,” he said. “We don’t know how to compensate you. Are you primary care? Are you endocrinology? Are you infertility? Are you urology?” I looked at him and said, “I’m a doctor. I am a men’s metabolic health doctor. If you can’t understand that, we’ve got a bigger problem.” That’s when I have to be honest with myself that I can’t come from the well side of medicine to the sick side and fix it.

I have been told, “You may not be a good fit. You don’t bill like a urologist. You don’t do this.” I said, “I’m happy with that.” I now feel empowered because I know my end user is feeling better. When I close that door, I’m not working for the entity, I’m working for that person, which is what makes me come back to work every day. 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. There are so many other signals out there that our current delivery system is not working well.

Dr. Casey Means: I just got shivers when you said that line. As a medical culture, we have gotten far off course. Through the lens of billing, what you are doing could look like a failure in some ways. You’re still billing a lot, but it’s crazy that the success criteria is not based on how well the patient is doing. It’s based on the relative value units (RVUs) and the billing. Where did we go so far off course? 

This is a machine, and that doctor who’s seeing 50 patients a day, no matter what is happening with those outcomes, is going to be celebrated. Obviously, terrible patient care is a problem. But generally speaking, that person is going to be the star of a department. O think, “What are we doing?”

Dr. Merrill Matschke: When the measuring stick is only volume, that’s the culture. The culture here is not one of promoting health, it is promoting illness. I said, “We’ve got to change that.” And they said, “Well, no. It’s our structure that does that.” I said, “You can use those words interchangeably, but culture is defined by what you do, not what you say. When you sit here and reimburse someone and compensate them based on volume, that’s what you’re incentivizing.” 

To do metabolic health well, it takes time. One guy said, “You just have a TRT clinic.” I said, “Yeah, but you know what TRT is? 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 because he looks at you and he’s inspired by your story. 

You start giving him a product. You give him a DEXA scan. You give him a fasting insulin number he hasn’t looked at before. You check his c-reactive protein (CRP) levels. You do things other doctors haven’t done, and you make a change. You bring them back and you say, “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 are empowered to advocate for themselves. 

There are so many opportunities in urology to do that well, especially in andrology. The people with my kind of mind are usually the guys who did an Andrology Fellowship because we had been exposed to hypogonadism. Then that opens up the whole world of metabolic health.

Taking Control 

Dr. Casey Means: How much of erectile dysfunction cases in the US are either preventable or reversible if we fully dialed in our diet and lifestyle and improved metabolic health?

Dr. Merrill Matschke: If you remove the spinal cord injuries and those other kinds of neurologic injuries, I believe that, of the vascular causes, probably 70 to 80% you could significantly prevent and improve. The question of prevention and rehabilitation improvement is a loaded one: How bad is it? How long has it been going on? That’s the whole concept of restorative and regenerative therapies for ED. 

Right now, shock wave therapy is a big one. But there’s growing interest in platelet-rich plasma and stem cell use. There are signals there that in the right patient, that can work, but it’s still in the investigational phase. With shock wave therapy, they’ve shown you can recover and rebuild smooth muscle content in a rat penis.

Shock wave therapy turns on some of these pathways to healing through vascular neurologic and stem cell recruitment pathways. We can recover some functionality of that vascular smooth muscle tissue. If you step in early with the appropriate diet and lifestyle changes, you can change and stop the loss of healthy smooth muscle content within the corporate cavernosa and maintain that function.

Now, age alone plays a role; you’re not going to be able to stop it all, but I believe that for about three-quarters of this, we could really have a major impact. We haven’t even talked about CGM and what that does. But part of this is engaging a man right there so he understands the effects of his choices. 

If I’m going to get him to really think about what he is eating and how that’s affecting his erections, how it’s affecting his insulin, as in sugar, when we start to empower him with that kind of information, it’s fascinating—another big part of prevention of the sequelae of metabolic disease. It’s an amazing opportunity to build content and a path of education and empowerment.

Dr. Casey Means: That’s amazing. Those are big numbers: Three quarters could potentially be significantly reduced, especially if we’re talking about intervening early on. We’re really just trying to reverse the blood vessel issues before the penis has really changed, in terms of its architecture, from the long-term damage. That is so empowering.

Dr. Merrill Matschke: If you think about it, we don’t want to wait until the guy is 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 from some of those fibromuscular dysplasia (FMD) tests you can do or the brachial index test to check the distensibility of blood vessels. You can check IL-6 levels and different inflammatory mediators, and some of the carotid intima-media thickness tests (CIMTs) help detect early indicators of endothelial dysfunction.

If you can step in early on those, you can stop that progression rather than waiting. You see the people who were active, who didn’t eat out of boxes and bags, who had a real food diet and good social support—these are the people you walk into your office. You’re 85, you look like you’re 55. But I just had a 40-year-old in here who looks twice as old as you. For the people who do it right, who have a healthy lifestyle, the machine pays them back for that.

Dr. Casey Means: I was looking at a paper showing how people who were obese had a significantly higher likelihood of having semen with no sperm in it. I didn’t realize that was a thing, that you could actually have semen without sperm.

Dr. Merrill Matschke: There are some people who have a genetic issue. A guy I saw today was a triathlete, so he may actually have some oxidative stress related to overexercise. Then I saw another gentleman who has a Y-chromosome microdeletion. There are true genetic mishaps that lead to that, but the bigger impact is obesity, heat, oxidative stress, and what that’s doing to the spermatogenic potential in the testes. It’s a big deal.

Dr. Casey Means: I don’t think most people are aware that you can be having semen come out, but there’s no sperm in it. It’s amazing to me that it actually could be in some way related to our diet or our weight. 

What is the Dr. Matschke general dietary lifestyle plan to help men improve their sexual function and their fertility?

Dr. Merrill Matschke: When I see a gentleman with clear evidence of metabolic dysfunction and obesity, I don’t want to overwhelm him with the initial discussion of what to do with nutrition because if we go through everything, including fasting concepts and these types of things, it can overwhelm him. I try to look at what his diet is, where some of his problem spots are, and start working on some of those things first. I absolutely talk to them about avoiding added sugars, the 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, and truck drivers. They are in a situation where their choices are limited, so it’s very hard. You start to work within that. Look for the healthier proteins you can find; look for the healthier carbohydrates you can find.

I don’t start talking to them as much about food order and timing. 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. Then I start digging into the specifics about when he is eating. Is he eating late at night? You should be eating that heavier, carbohydrate-type meal earlier in the day, not later in the day. I will tailor my nutritional discussion to them based on their background and their knowledge base, all while trying 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.

The biggest thing is to reduce the bad carbs and sugar. That’s where I will hit first. Then I will rapidly move to some fasting concepts because they want to see changes rapidly. Guys want to see something happen. It’s the same thing as when I 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 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. It’s going to increase retention and compliance. 

Dr. Casey Means: 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?

Dr. Merrill Matschke: I’ve been seeing so many third-shift workers lately, and we know they are an at-risk class. They are now a studied group because of the 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. I think, “Wow. I didn’t know about that sleep issue and low T. I didn’t know how amazingly it would change your own insulin response until I got this thing and watched what it did in my sleep pattern.”

I explain it to them, and I show them. I’ll pull up my phone and I’ll show them my own curves and tell them what has happened to me. 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, maintain, and do what it needs to do to manage energy well and to manage food well.

Sleeping is crucial, and it is hard. Some men just aren’t ready yet. You see what they’re ready for and then start to grab at those things that they’ll listen 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. You have to understand what their sleep hygiene is like. Are they on a 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 and caffeine are the obvious things we talk about. I talk about the lifestyle factors that are going to impede their 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 nutrition is a priority.

The stress aspect of it has impacted me massively. I show them the apps on my phone: Waking Up is the one that I just got, but I also have Oak and Calm. I said, “These are different techniques you can try. This is important.”

We now have 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. We are getting up in the middle of the night to check our phones, and it is impacting our brain’s ability to put itself away and rest. We know what it’s doing from a chronic stress standpoint to children because the studies have been done about device use and chronic interruption of sleep.

I said, “Whatever you can do to improve stress and quiet the brain is so important.” As I have a positive impact on men, I’m getting a huge amount of word of mouth. It’s not physicians that are sending a lot of these men across the transom of my building. It’s my other patients. Word of mouth, consumerism, and end-user demand are showing themselves. 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.” 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 how I look at him. What do you want to get better at? With one guy, it might be a cognitive issue. For another, it might be his erections. For another, it might be, “In the past, every time I worked out and cleaned up my diet, I lost some weight. It’s not happening anymore. What’s wrong?” Then I’ll drill down into the biochemistry and find out that they’ve got low T, usually, and address that. 

I’ve heard this from so many people. The n of one is very important. When you’re taking care of someone, 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 resonates with him. Everyone’s got to be dealt with individually because we’re all different, and women are a whole lot different.

Dr. Casey Means: That is so important. It’s not cookie-cutter. When I switched from ENT to more functional medicine, I was spending two hours with every patient. In an initial visit, it was about figuring out what the patient’s particular barriers to making successful behavior changes were and what was the lowest hanging fruit for that patient of where we can get some rapid improvement. It wasn’t about overwhelming them with ten different things, every pillar of lifestyle and diet, but figuring out the highest-leverage areas to start with that were going to be effective and adopted, and then let it evolve and build trust through that.

It’s an incredible dance when you have the time to dig into this stuff. When a recommendation is up against huge barriers in the patient’s life, it’s just not going to be effective. Then there’s, of course, discouragement. The way you framed it is beautiful. There are general concepts that are important: Don’t eat packaged foods, don’t eat processed foods, get sleep. Then we intersect that with the patient’s reality so that they’re going to be successful.

Dr. Merrill Matschke: I look at them and say, “You can’t be perfect. I’m not perfect. None of us are perfect. Allow yourself 20 to 30% of leeway. Seventy percent of the time, try to be tight on your diet. Twenty 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, including with those other compartments of lifestyle and behavior, you can do that. That allows for a meaningful, healthy life. I’m very careful with guys. When they come in and say, “I’ve been doing this.” I say, “That’s fine. You recognize it. You know that. Just make sure you try to keep it 70/30, or 80/20 if you can.” You’ll lose some people in it, but overall, you’re just trying to make incremental changes in improving their health.

Dr. Casey Means: I know you recommend Levels to some of your patients, and you’ve obviously used it yourself. How has that played into some of your successful patient outcomes?

Dr. Merrill Matschke: 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—the carbohydrates, the Mountain Dew, the energy drinks, 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 think, “Wow.” It just sets in and holds you accountable for what you just did. Those have been very important to me.

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

That’s probably working by dumping more glucose into the skeletal muscle because it’s opening up those blood vessels. That shows you, again, the systemic aspect of something I got interested in because of the penis, but now it’s acting everywhere. This gentleman said to me, “I’m sleeping better. When I sleep better, I’ve also noticed that this tracing comes down lower. When I put this CGM on, I was really amazed at a couple of things.”

The first thing he noticed was yogurt. He loves yogurt in the morning and will usually go with Siggi’s or something like that, which has lower sugar. But even some of those, and some of the flavored ones, have added sugar in them. I almost always now go with full-fat, plain yogurt. I’m very regimented. 

One day I got to work and realized I didn’t eat my yogurt. I went out to Starbucks and got one of their Dannon yogurts. I got the one with the least amount of sugar. That excursion took me to about 180. I came right back down. I’m a weird guy. When I first checked myself, before I got healthy, my A1C was 6.3. Now my A1C lives at 5.1 to 5.3, but my fasting insulin lives between two and three. My spikes go up fast, and they come right back down.

The added sugar in the yogurt differential test I did was interesting. I used to go to Potbelly, a fast-casual sandwich chain, for lunch. I no longer go there, not because it’s Potbelly, but because I couldn’t believe what the bread did to my levels, even if I got the one where they scoop out the inside. I now avoid bread as much as I can. 

Sleep was the other factor for me. I put in 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 above that, my baseline is lower. Those are big.

Now, we all know what stress does to cortisol and then what that does to your glucose and insulin levels. Whenever I’ve had a stressful meeting and I’ve got my CGM on, I see the response. It plays right into the physiology that we know out of the textbooks. When you see it for real, it really brings it home. This technology in the hands of a guy who chooses to try to understand it is life-changing because he can learn all these things that we know about. We can watch him learn it and then take on those more nuanced things like eating your fiber first, before carbohydrates. It’s not just what you eat. It’s not just when you eat it. It’s also the order in which you eat it.

I choose when to start to introduce some of this stuff, but it’s fun to play with it, especially if you’ve got the right guy who’s interested in it. We all sometimes 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 end up loving it. It’s a great tool. To build the content around it, about how it funnels into metabolic health, that is the creation of a path that fills in the cracks in our current healthcare system. But it’s not happening in the offices of most healthcare systems.

Whenever I’ve had a stressful meeting and I’ve got my CGM on, I see the response. It plays right into the physiology that we know out of the textbooks. When you see it for real, it really brings it home.

Dr. Casey Means: Hopefully, conversations like this will be part of changing that, because we’ve got to get it in the water. We’ve got to get it in our ears and share your incredible message with people. Thank you. 

Are there any last-minute words of wisdom to share with people? 

Dr. Merrill Matschke: To engage with patients, you have to offer them something new. You have to somehow capture their interest; you have to get to them at a vulnerable time. The important thing for men—and this phrase is 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. 

Then it’s simple. What we’re talking about sounds complicated, but it’s just simple changes that go back to healthy behaviors. If we can do it, it is a self-fulfilling prophecy. It is low-hanging fruit. It improves people’s lifespan, and it’s something that, sadly, is not happening within our mainstream medicine today. It is so important to recognize what our current healthcare system is doing. Are you aware of the Commonwealth Fund?

Dr. Casey Means: I don’t think so.

Dr. Merrill Matschke: The Commonwealth Fund is a large corporation that has evaluated healthcare systems on a yearly basis. They use four primary metrics: infant mortality, maternal mortality, lifespan after 60, and preventable mortality and morbidity. They look at 11 high-income countries. We are dead last. We have always been dead last. Not only are we dead last, but we are so low that they had to drop out the data from the United States from a lot of their data analytics because it skewed it. We spend twice as much as the next country above us. I get frustrated with some of our leaders when they talk about how good of a system we have and are creating their own metrics to measure themselves. If you’re going to create your yardstick, it’s going to make you look good.

These are standard metrics that you apply. They’re population health metrics. It’s scary. All you have to do is go take a look at what’s happening to our population in terms of obesity and metabolic health. 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; it needs to be more health-forward.

I do this with all my guys when they’re 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 there is in the history in your family. You don’t see it in the black-and-white photos. Now, look at your family outings today.” I said, “Our bodies have been here for at least 200,000 years, and in the last 50 to 100 years, we’re feeding and treating them differently, and we haven’t been able to adapt. Our bodies are showing us that. We’re overfeeding with the wrong kind of energy, and our bodies are rebelling.”

I try to present that in a positive way. Sometimes you can go into darker areas, but we have so much opportunity to recapture responsibility for our own health, and that’s where it starts. I love 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 a way that’s obtainable to them. 

That’s why I came out of the well side and back to the mainstream side: My goal is to find that path that allows us to push health and wellness first and have a health-forward path. We can do it, and it’s going to come through entities like Levels. There are other systems out there— Virta Health and some other places that are showing that you can do this. When you improve the metrics, they’re starting to get the payers to pay attention, too. I am hopeful that when you empower people, we’re going to be able to turn this ship more toward health.