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Some men suffer from “Superman syndrome,” or the belief that they’re healthy—when their insides tell a completely different story, says Shefaly Ravula, PA-C, a board-certified physician assistant specializing in integrative and lifestyle medicine and nutrition in Round Rock, Texas.
Until recently, Ravula worked at a urology clinic that treats urological conditions and has a unique focus on men’s overall wellness and disease prevention. She was the first prescriber in the wellness role in the practice, using her training in functional medicine and nutrition to treat urology patients. And she noticed that many patients were being treated for low-T (testosterone) or infertility with underlying metabolic dysfunction. This is usually the first time they’ve heard that they have prediabetes or are on the road to developing it. Her role at the clinic was to help patients optimize their nutrition as part of treatment to improve metabolic health and body composition, as well as address androgen deficiency (having lower levels of sex hormones) or problems with fertility.
Trained at the Institute of Functional Medicine, Ravula talks about the type of food plan she recommends, the value in treating low-T for your future health, and why her number one goal is to get you to make an appointment for your annual physical.
You are a physician assistant and an integrative and lifestyle medicine expert who works at a urology clinic. What is your role there?
Many men referred to me are young men in their 30s and 40s. They have infertility and low testosterone (low-T). After struggling with low-T symptoms, such as fatigue, decreased libido, decreased muscle mass, and lack of muscle endurance, many pursue testosterone replacement therapy treatment at a low-T center (medical clinics that prescribe testosterone replacement therapy). And that’s because they often don’t have a primary care physician (PCP). So, the low-T clinic gives them testosterone and then eventually might recommend they see a urologist for an evaluation. This is one example of how, for many men, their first entry point into a medical establishment is the urologist, especially if they’re in their 30s or 40s.
If many men avoid regular checkups, what do you discover about their health when they come to you?
Because they don’t have a PCP who they see regularly or at all, they’re unaware of what’s going on with their metabolic health. We think of hypertension as a silent illness since it typically doesn’t manifest in symptoms. But much of early metabolic dysfunction is silent as well. Think of the onset of belly fat and increased waist circumference, the nighttime awakening (could easily be a form of dysglycemia), the sneaky cholesterol panel, and of course, insidious inflammation. The urology team at our clinic is good at drawing basic labs on these men, not just urology-specific labs, including a complete blood count, chemistry panel, lipid panel, A1c, and hormone panel. We’d find that if the patient were in the prediabetes range, the urologist would refer to me, and I’d meet with them, further their evaluation with other assessments like labs or macro tracking or body composition analysis. We would begin a therapeutic relationship involving lifestyle and nutrition strategies to improve their metabolic health. I also saw patients for weight management (and other urologic diseases such as prostate cancer), but of course, we all know that one can have metabolic dysfunction in the absence of obesity and certainly often in the presence of cancer.
Metabolic health has a significant role in testosterone levels and male fertility. Can you explain that connection?
There’s a bidirectional relationship between low testosterone or androgen deficiency (known as hypogonadism with metabolic syndrome) with obesity, hypertension, dyslipidemia, hyperglycemia, and insulin resistance. And we know that treating and improving testosterone deficiency can improve insulin sensitivity, body composition, and lipid profile. A major consensus group calls testosterone deficiency (TD) a “well-established, clinically significant medical condition that negatively affects male sexuality, reproduction, general health, and quality of life.”
About obesity, excess aromatase activity (an enzyme that converts androgens into estrogen) from increased adipocyte numbers (cells that store fat) in obese men suppresses gonadotrophin-mediated testosterone secretion, leading to progressive hypogonadism, which is when the gonads produce little or no sex hormones. Research shows that weight loss can help reverse this process.
How do you think about the value of testosterone replacement?
When it comes to our holistic approach to urology, the practice addresses testosterone deficiency. Using a root cause approach is best, along with specific lifestyle modification. Still, we’re not opposed to using testosterone replacement therapy because we need to improve those levels for cardiovascular protection along with other benefits of T therapy. Cardiovascular risk assessment is even in the American Urological Association algorithms for treating testosterone deficiency.
How deep do urologists go in helping patients manage their metabolic health? With how short medical appointments are, do they have the bandwidth to handle that?
The way medicine is right now is super-specialized. We have specialists who focus on one organ of the body and don’t have time to connect the others. Maybe it’s easy to order an A1c and fasting insulin, but who has the time to manage it if it’s abnormal? Not urologists who are busy doing procedures and have full clinics of men of all ages (and women too, of course!). It needs to be an integrated approach, which is what’s unique about the clinic I was at: they created a separate wellness department. Because I’m so passionate about what I discovered in men’s health there, I ultimately decided to begin a membership micro practice of my own. I focus on being a metabolic dysfunction sleuth—using early detection, and applying nutrition and culinary and even digestive health expertise (I have a strong background in conventional gastroenterology) to help patients. After all, the idea behind functional or integrative medicine is to ultimately get at the root cause and prevent chronic illness using a multi-modality approach and a holistic health vision.
You’re focused on preventative care. What do men need to know about maintaining their hormonal and metabolic health?
It’s all about early detection. I tell everybody: Just go to your doctor for your annual physical. There’s essential hypertension (hypertension with no known cause), prediabetes, fatty liver, dyslipidemia, inflammation—all of which may not have any symptoms. Physicians can discover these asymptomatic conditions at a comprehensive physical.
So many of my patients tell me that they were in great shape in high school playing sports. Then college came around with the freshman 15 and drinking a lot, but still, they were okay; they could quickly lose weight easily and jumpstart a healthy life again quickly. And then they got married and got a job, and life stressors begin—and then they’ll say it just went downhill. That’s a classic story. Mid- to late-twenties is where these men need to start getting their physicals. And they don’t because they think they’re still young and healthy and can bounce back.
Another thing to consider is to think about your body composition. Just because you’re not overweight doesn’t mean you’re healthy, particularly in my ethnic populations. I’m of Indian descent, and heart disease runs in my family of very thin Indian, vegetarian people. Many people are TOFI (“thin outside, fat inside”). They have a lot of visceral adiposity and some subcutaneous fat on the belly. BMI is not everything. We have to look at waist circumference and body composition to understand if these people are metabolically unhealthy on the inside. I would prefer that their PCPs take their waist circumference and do a body composition analysis. This is rarely done, except at an obesity medicine specialist. And so, even with a regular physical, things can be missed.
When you evaluate a patient for male infertility, how do you step in to help them make the changes they need?
Infertility doesn’t always involve low-T. The evaluation looks at measures like inflammatory markers and sperm analysis. Our office believes that there is a strong relationship between infertility and inflammation. So they will send patients to me as an intra-office referral for an anti-inflammatory diet, which is strongly plant-based. But I don’t necessarily advocate for any one “diet” fits all. I think a food plan can be adaptable, temporary, and personalized to one’s biochemistry, labs, and function, and now I even use their genetics to guide a personalized plan!
When I see a patient with infertility, I often suspect oxidative stress at a cellular level, but on the surface, their basic labs will also reveal that they have prediabetes. I had a patient this morning who was going to the urologist for infertility. His A1c was 5.9%, and his fasting insulin was 15. He’s not in bad shape, his prediabetes is entirely reversible. Still, he’s been eating a high-carb vegetarian Indian diet with inflammatory seed oils, poor quality fats, and not enough fiber and not enough plants. These are the patients who are prime candidates for Levels. They need CGM data for the motivation and data to see, to change their diets.
I have begun to use the CGM for my patients. They help bring awareness to the savvy patient and drive behavior change. Truly, they will change the future of the prevalence of insulin resistance, which is a driver of so many chronic disease states.
You guide people on cleaning up their nutrition habits. Do you recommend a specific diet to your patients?
Diet’s a bad four-letter word. I like to call them food plans. If you look at all the short-lasting and long-lasting “diet” trends—Paleo, vegan, anti-inflammatory, Mediterranean, etc.—the commonality is vegetables. There are a couple of diets, like carnivore, where those are restricted, but in general, they all say eat more plants. Generally, I say plants are good, tons of research supporting this, but ultimately it’s still not a one food plan that fits all. You have to look at your diagnoses and goals and fine-tune your food plan from there. Is weight loss number one? Is it reversing diabetes or addressing infertility? Is it getting on the OR table for knee surgery? Do you have digestive issues like bloating or constipation? What are your genomics if we have them? We have to work towards goals and integrate the body as a whole. Sometimes that’s done through a stepwise approach. Maybe you do a therapeutic keto diet for a month or two to regulate blood sugar and then move into intermittent fasting. But it depends on each person’s goal, where they’re at in life, other family members, their labs, their genetics, and more! Food is medicine, but it’s also not always medicine. Food still has to be fun, enjoyable, and an experience. There’s often no need to make it a chore, a bore, and hopefully not stressful. I hope to continue helping patients see that because I certainly can’t give up on my love of food!