Episode 3: Becoming an Optimal Man with Dr. Mark Holthouse, MD
Updated: May 23
Podcast Drop Date: 11/2/22
FMF: Welcome to Functional Medicine Foundations podcast, where we explore root cause medicine, engage in conversation with functional and integrative medicine experts and build community with like minded health seekers. I'm your host, Amber Warren. Let's dig deeper. So we're back with episode three, Amber Warren here at Functional Medicine Foundations. And I'm interviewing again our medical director, Dr. Mark Holthouse. We've already talked about female health. We touched on hormonal imbalances within our female patient population, and we're now here talking about the guys. So I can't speak as much to this, but I know Dr. Holthouse, this is one of your really big passion areas of expertise that you love talking about. So we have this this program called Optimal Men, and I think it's such a great name in you know, you obviously see more men in your your patient population than I do, but they come to you, most of them probably a little bit encouraged by their female counterparts to come and see you. Right. They maybe are getting into their thirties, forties, fifties, they've got dad bod thing going on, their cholesterol starting to climb. Libido is not where it was. What's your approach? Where do you start?
Dr. Mark Holthouse, MD: So the first thing I do is kind of give him an atta boy on the back, like, I'm glad you're here. We try to quickly get over the my arm. I'm here because my arm has been twisted behind my back. My wife gave me an ultimatum and I try to win them over because that's where they're going to get the best benefit. Usually that takes about 5 minutes because I'm a guy, because I'm middle aged and because I've experienced some of the frustrations a lot of them are having. And, you know, you can kind of relate and and I kind of know what they're after. Some of them are are really proactive. You know, they've done their homework. They they're aware of every podcast, wherever, every YouTube. They've been to summits and webinars. And they've got a little bit of knowledge, sometimes enough to be dangerous. Sometimes they're really sophisticated and it's fun, they're motivated. So I get everybody that whole spectrum kind of like I'm here because the wife told me or else, and then I've got the biohackers that are there to stump the doctor. And I love those guys because.
Amber Warren, host: There's more and more, more and more of them coming.
Dr. Mark Holthouse, MD: Out, more of them. And I'm always learning from my patients. Have you heard about Methylene blue? Yeah, The first time I heard that was from a testosterone patient that was was seeking support on that. And I said, you know, I've heard about it when I was in in undergrad, and we used to use it probably to stain slides and things, Right. What are you talking about in a medical context? So, yeah, you get the whole spectrum. But the way I start with these guys is literally to try to build rapport with them so that it really guys are we're very clannish. If they feel that I am and I am, I'm very genuine in the way I approach medicine in it for them, in it for their quality, in it, for optimizing their life, I get their ear and then they're loyal. You know, it's long gone that I was initially here because my wife had gave me an ultimatum. It's like, No way, man. I'd come see this guy once a week if I could get off work. And that's my first goal is to build rapport. You know, anyone acquainted with this therapeutic readiness to change stages know that if you don't have rapport, you're kind of dead in the water.
Dr. Mark Holthouse, MD: People aren't buying what you're selling. And what I'm selling is a team approach to getting them back to being an optimal male. So we start with rapport. The second thing we do is I really try to work with them and this is really part of that same issue where they're at. Some guys are coming in, you know, they're already on testosterone, they're already doing HCG injections, they're already doing Clomid, they're already doing peptides and they're doing this Ester, this variety of testosterone, you know, this day a week, and they're following it up with an aromatase inhibitor 5 hours later and they're just like an engineer. They've got this thing Excel, spreadsheet it out. And I'm just I'm saying, Wow. And then we've got the guys that are coming in saying, My wife says I'm a jerk. And they're kind of looking at their shoelaces and begrudgingly admitting I'm irritable. I don't know what's wrong with me. I feel depressed. I've never felt so unmotivated in my life. I used to be athletic. I can't even get out of my chair.
Amber Warren, host: I don't have the endurance I had.
Dr. Mark Holthouse, MD: Yeah, my stamina is gone and everyone in between. So I meet them where they are after gaining rapport. And then we start with these same things we talked about in our last episode with women with the Radiant Women Program, with therapeutic lifestyle, testosterone. In my experience, more than any other hormone is influenced by lifestyle. We say that there are kryptonite or weaknesses that can take potshots at testosterone levels. One of them is stress. The other one is, and that's because of cortisol. Cortisol is definitely the kryptonite to t. The other one is sleep deprivation, poor sleep, because we, after all, secrete most of our testosterone in a pulsed dose fashion while we sleep. And it happens in a part of our sleep architecture that really it's a jealous mistress. It has to be healthy good quality sleep, not Jack Daniels, and do sleep where I'm unconscious and not really getting good quality sleep. And we talk about lifestyle and the fact of exercise as well. So the right kind of exercise, the whole toxin discussion, super important with the interference of testosterone. You know, we see so many people that have phthalates, which are a class of chemicals and self care products, things that make guys smell really good during their shower without incriminating any labels can be filled with these things.
Dr. Mark Holthouse, MD: Parabens and phthalates that we know are known endocrine disruptors, heavy metals, a lot of guys that are doing indoor shooting here in Idaho. Yeah, there's a lot of lead that they're inhaling. And we know that lead and mercury in particular affect testosterone levels. So we talk about their community involvement. Do they feel isolated? Do they feel loved by their significant other? Are they eating fast foods and just grab and go foods and living on energy drinks? A lot of these guys will come in and they're you know, they're cross fitting to beat the band and they're doing carnivore diet and they're really stressed out. You know, they're going through hard times. They're not sleeping well. They're a business owner. And they might look really good. The outer package might look really cut and really ripped until we start. Unappealing, the layers of the onion, looking at labs and such. So we always start with therapeutic lifestyle, with the guys, with this program.
Amber Warren, host: Wow. So you laid out a lot and there's a lot of different directions we can go there. I think one that stands out most to me as a provider and honestly, probably it's the nail on the head for most of our providers is the concept of stress, right? Busyness society. I mean, how does how does stress directly relate to low t hormonal imbalances? Inflammation in our inner men?
Dr. Mark Holthouse, MD: Yeah, just like in the in the females, we've got this kind of hierarchy where when we're stressed we tend to make cortisol and we will do that in preference over testosterone in this discussion and estrogen. And so when guys have unrelenting stress, I'm not talking about jumping out of the way of the speeding bus, adrenaline surges, which we all need. There's healthy and there's unhealthy stress. It's that unresolved. I really don't like my supervisor. I don't like my job. My wife and I are arguing, yeah, we're having issues over finances that are just there day in, day out. Yeah, That's the kind of hyper cortisol state that brings testosterone down. So we know that cortisol is is a big deal from emotional stress. It's also a big deal, though, with chronic pain and a lot of a lot of the guys I see in all ages have pain that they deal with. You know, some of these guys are retired football players or, you know, they were jocks and they've got back in knee issues that they're living with still.
Amber Warren, host: Or they just have a ten hour a day desk job and they have really poor, poor form at work or they lift poor and they don't have great form as they are trying to exercise to improve their health.
Dr. Mark Holthouse, MD: Right. Shift workers. Yeah, they're they're doing jobs on a on a medevac chopper or they're firefighters or their law enforcement. A lot of them are in health care now. I'm glad I didn't know what I know now about the lifestyle of a resident. Yeah. You know, it's like, how did I father children? You know, I think I slept 6 hours total every three days for many months at a time, early on in residency. So, yes, sleep deprivation is part of that whole hyper core Islamic State, just like we talked about in the women. So cortisol is probably one of the strongest leverage points in moving the needle towards raising T by by muting that modulating it. It's hard to get guys to go do things like yoga. Yeah, it's hard to get guys work. Yeah, yeah, right. They want to get home and they want to get their remote in their hand and kick back with a brewski and just like watch football. And so that's the last thing on their mind. Yeah. So we try to work with where they're at. What can you give me when you start your day as a tradition? You know, if you're not going to do mindfulness based meditation activities, maybe you'll do a guided imagery. Maybe you can use the power of a narration that's an audible thing you listen to that uses the power of your imagination to go to your happy place. And it's funny, surprising how many guys get into this. And then once they start doing it, they're they're almost more committed than a lot of my female patients is getting them to start. Yeah, which can.
Amber Warren, host: Be a buy in.
Dr. Mark Holthouse, MD: Yeah, the buy in. So I often have to show them their labs first. And again, we'll do salivary testing. Looking at cortisol curves. Yeah. Especially some of these shift workers. And they're like, Wow, that's normal. And here's me. Yeah, it's like I'm making my own curve and I'm like, Yeah, you're like, Never normal. So how can your t ever have a chance? So, yeah, addressing their stress, whether it's chronic pain, whether it's problems with the stress of having obesity, you know, carrying a lot of central tummy fat that's driving inflammation, which is very stressful.
Amber Warren, host: I'm always redefining stress for my patients. Hey, your marriage might be great. You might have a job that you love, that you can work part time and still be a mom, but you're sleeping 6 hours a night, right? Or or you're taking a lot of really low quality supplements with a ton of fillers or you're on a lot of medications that are very toxic for your system or your nutrition's really poor. You're actually not getting enough quality nutrition or you're eating too many foods that your body can't recognize. So stress is not just psychological, right? Like you kind of touch on that.
Dr. Mark Holthouse, MD: It's all areas of life. Everyone just thinks it's the it's the I got in a fight a minute ago and it's so much more we know and the sleep discussion that guys after just five nights of getting 5 hours or less drop their T 15% and that's in young man it's huge.
Amber Warren, host: Yeah.
Dr. Mark Holthouse, MD: So sleep sleep is a big deal.
Amber Warren, host: So most most men, they're black or white, right, Doc? Just tell me what to do. Right? Okay. Okay. You've convinced me. I see the labs. I see the salivary cortisol. How many hours of sleep do I need? What do you tell them?
Dr. Mark Holthouse, MD: Most of the data is pretty clear that seven is kind of the magic number. 7 hours is a minimum. Yeah, I'm looking at sleep architecture too. Some of these new wearable devices can help us. Yeah, the aura ring and some of the other things on the phones and whatnot that are recording sleep stages are important. We know that growth hormone and things like that are secreted during these very deep stage three, four delta wave sleep cycles and that things like testosterone are actually secreted during REM, which is a more superficial form of sleep that is come to find out incredibly helpful for logging in memories and learning from the day before into your long term memory. So sleeping quality and sleeping quantity are two questions that I ask all of the guys that come in for this program.
Amber Warren, host: How, how, how often or how much does do things like obstructive sleep apnea play a role in in upsetting testosterone, if you will?
Dr. Mark Holthouse, MD: Yeah, we like to say that obstructive sleep apnea is the number one underdiagnosed cardiovascular disease. I see this all day long and it's it's anymore in my 30 year olds as much as it's seen in my 60 year olds and all body types. Yep. I like you said earlier in our other episodes, I've seen this in £100 young females who are this big around, and I've seen it in my big football player guys with the big neck the size of my thigh, which is how we classically always thought of Pickwick and Syndrome or sleep apnea. It's extremely common. It's one of the first things we look at. We know that there's an association between sleep apnea, obstructive sleep apnea, and low t. We don't know exactly the relationship because it's interesting. And guys that have low T with apnea, if you treat them with CPAP. Their testosterone don't always recover. So there's something else going on there. We do see that it's related often to the obesity and to the hypoxia, the low oxygen levels that occur with apnea. But the obstruction itself, it's unclear. The relationship, it does seem to be mediated through a central mechanism. In other words, the little little messenger molecules in our brain as guys that tell the boys the gonads to make tea, that gets suppressed when we have apnea. So we always look for it. There's home studies you can do so you don't have to worry about.
Amber Warren, host: Those are those have become so nice people. Our patients don't want to go stay in the night in a hospital. 3000 sleep study. Yeah. These at home ones are really affordable. Really? I just did one on my son. Really easy to do. The convenience is great.
Dr. Mark Holthouse, MD: Great For convenience. You don't need a lot of time to get enough data. You know, these guys will come in and say, I slept 45 minutes in the hospital out of that whole night. That was a waste of my time. And I said, You know, you'd be surprised how little data they need to get what I need. But the home sleep evaluations have just made it so much easier. But apnea is one of the cornerstones in working a natural how to correct naturally.
Amber Warren, host: I love that. Something else I want to go back because I think I think this is I think I'm trying to go through your list that you laid out as kind of as far as order of priorities as I can. And toxins is just up there. It just is. We're bathed in this toxic soup. It's such a big deal. I see it impacting my patients health, see see it in their lab work. What do you recommend? How are you working this up? What are your how are you seeing this impact testosterone levels in your guys?
Dr. Mark Holthouse, MD: Yes, Thanks, Amber. Part of the questionnaire of our program solicits their risk. You know, do they work for a Terminix company? Are they are they the termite guy or are they the pest guy? Have they been working in a plastic manufacturing facility for years? Are they a firefighter? Some of my firefighters are end up with the highest levels of toxins that I see farming. Being an old farm kid, you know, I really my heart goes out to these guys. Yeah, we are exposed to a lot of things that we did not know were problematic back when we were kids as farm kids. And I see an Idaho here. A lot of people that are actively family farming still. So we'll ask them what their risk assessment is on these questionnaires. But we know that things like these personal care products, plastics, just simply drinking out of bottles that have been sitting out behind Costco in the July heat in Idaho on a pallet for a month that were leaching these plastic esters into the water, it gets cooled down and we drink it. We don't think it's in there, but it's still in there. And these things are acting like estrogens in our bodies. And so it's affecting our our hormone balance.
Amber Warren, host: Can you break that down if it's acting like an estrogen? And I know as I love I love your workup when I see your workup on these guys, you're checking estrogen levels, you're checking THG. Let's nerd out a little bit. Why explain that relationship toxins, estrogen mimicking chemicals, why should guys care about testosterone levels with regards to that?
Dr. Mark Holthouse, MD: Yeah, a lot of the guys come in with the man breasts. You know, they're really upset that their their bra size is potentially bigger than their wives. They're they're feeling really disempowered and emasculated, to be honest. And I'll say, look, these are these estrogens that are potentially doing this to you, some guys that are overdosing tea that are aromatase causing their testosterone to estrogen can have the same issue. And that's where having someone that knows how to balance that aromatase transition is crucial. But these toxins, not only are they affecting their actual testosterone and estrogen levels, they're affecting their body fat, they're affecting their inflammation levels in their bodies through having excessive toxins and estrogen toxin, estrogen mimicking toxins. Fertility is affected. You know, in the last 40 years, we've seen about a 40% drop in sperm counts. And the World Health Organization is throwing their hands up saying we have really no clue. We suspect that it might be chemicals, these endocrine disrupting chemicals that are lowering not just testosterone, not just promoting erectile dysfunction, but also decreasing fertility and causing some fertility, which is just difficult fertility, not just in and in men, but in women as well. We're seeing it on both sides of the equation. So toxins are a huge part of testosterone optimization, evaluating them, looking at drug levels and and metabolite levels in urine with the special kits we use. And then using detox protocols to rid them specifically and buying these things and get them out of their body. It's all part of seeing if they really need a prescription the rest of their lives. I think that that's what we do better than other clinics in town is that we're looking at the long game. Anybody can write a prescription that's got a license for this stuff for testosterone or Clomid or HCG or what have you. I think it takes somebody that understands how testosterone works in the body within a world that's toxic and in in people that have imperfect quality of life and lifestyle practices to really do them justice.
Amber Warren, host: So we know there's all these things that you've identified that stimulate, stimulate aromatase. But a lot of these things, you can't reverse it overnight. Right, Right. So this this aromatase enzyme, which is so fascinating to me still. What are what are things that you implement in your practice that can help inhibit aromatase so that while we're working on root cause, we improve their libido, we get we naturally improve testosterone. What are you like?
Dr. Mark Holthouse, MD: Great question. And this is really the crux of my conversation with. It brings in kind of that cardiometabolic pre-diabetic situation to the hormone discussion, which these are my two areas that I'm passionate about.
Amber Warren, host: And you're so good.
Dr. Mark Holthouse, MD: At. Well, I'm always trying to figure out a way to tie it in because. Because they are so interrelated.
Amber Warren, host: Oh, yeah.
Dr. Mark Holthouse, MD: But yes, really, you've got to take a step back and say what makes aromatase the enzyme that turns testosterone into estrogen work more, which is what we want to fight against. Right in, guys. It's it's central obesity. It's inflammation, which is caused by all these things. We're talking about standard American inflammatory diet.
Amber Warren, host: Insulin does it. Still, 60% of our nation is pre-diabetic with high fasting insulin levels, which you're your typical primary care doc isn't even checking a fasting insulin, which is usually the first thing to go up. As most don't know they have it.
Dr. Mark Holthouse, MD: Exactly. Exactly. As of 2018, the CDC statistics are that 47% of us adults over 18 either are pre-diabetic or have diabetes, almost half of us. So and that's projected to be a majority very soon. So, yeah, I always tie those two things in, but it's that high insulin level of pre-diabetes that upregulates aromatase, high leptin, which is another topic, but associated with tummy fat, which is where leptin, the hormone of feeling full comes from.
Amber Warren, host: And we can check leptin in the blood.
Dr. Mark Holthouse, MD: And we can.
Amber Warren, host: Do blood testing to check leptin levels and it's not insane expensive.
Dr. Mark Holthouse, MD: Now fasting insulins and fasting leptons, you know, as a family practitioner, I never used to do that, right? As an integrated practitioner, we do that as part of the routine workup because so many of them are elevated. Mm hmm. Having insulin resistance, having leptin resistance, which is stimulating that aromatase is tied directly to inflammation that stimulates aromatase, being low in vitamin C, being low, and zinc, upregulates, things like aromatase.
Amber Warren, host: Again, all things we can test.
Dr. Mark Holthouse, MD: These are lifestyle, right?
Amber Warren, host: Lifestyle things. Yeah.
Dr. Mark Holthouse, MD: Chronic stress, lots of cortisol. These are the things. And BPA plastics are known to upregulate aromatase things that decrea