Geoff

I know we wanted to talk about sexual health and sex, probably. Of course, something that all humans think about in some form. Not necessarily my academic or intellectual wheelhouse, but, obviously, something that we all have personal experiences or thoughts about, so happy to engage in this topic.

Priyanka W.

Well, anyone that's born, basically is a-

Geoff

There are asexual people.

Priyanka W.

No, but you can be asexual, but you were still born from someone.

Geoff

Based on sex.

Priyanka W.

Yeah, so everybody has something to do with sex, so it is pertinent to everyone. Whether you want to procreate or not or whatever, it doesn't matter what your sexual orientation is, there are still some health-related issues that I definitely want people to know about that I don't think is common knowledge.

Geoff

Yeah, absolutely. Yeah, I mean, my sense of it is that sexual function is one of the most downstream obvious effects of healthy function.

Priyanka W.

Exactly.

Geoff

I think it's a good benchmark or a good prediction factor around if you can't have sexual function or you're some sort of dysfunction, you're probably not healthy.

Priyanka W.

Exactly. That's exactly it. I think there's a big problem right now with the medical community where people don't feel comfortable talking to their doctors about their sexual health. They think maybe it's not pertinent or they're embarrassed about it. I think that shouldn't be the case at all. If people out there listening are having sexual problems, they should bring it up to their doctor.

Geoff

Yeah. I think that aspect's actually more interesting to me. I think the sociological effects where I think within just recent online discussions, there's like the incels, or involuntary celibates. There's, I would say, more and more discussion around egg freezing and all of that, so I think we can touch upon the physiological side, as well as the sociological side given the changing demographics and the changing behaviors of humans, so a lot to dive into. Should we toast with a shot of ketone here?

Priyanka W.

I would love to toast with you. I said I would only agree to do this podcast if we were going to toast ketones.

Geoff

Okay. Cheers.

Priyanka W.

Cheers. Cheers.

Geoff

Are we going to shoot this or are we going to sip it?

Priyanka W.

No. I can't shoot this. It's too strong for me. I only do six at a time.

Geoff

Okay. Yeah, well, we'll-

Priyanka W.

I was telling him I keep it in my purse and I take sips slowly over the course of however much period.

Geoff

Yeah, how's your experience with the ester been so far?

Priyanka W.

I like it. One of the things that I like about this as opposed to other kind of similar-ish products or exogenous ketones, is that it's pure, that you don't put anything in it, but real talk, I'm not going to lie. It tastes super bitter.

Geoff

We're working on it.

Priyanka W.

That doesn't bother me, actually. I don't mind that at all, but I could see how if you were someone who's more sugar addicted, it would be problematic, but yeah, no, it's cool. I do.

I keep it in my purse with me and if there's a situation where, let's say, I'm on the go and I don't have access to food for whatever reason, it's super helpful.

I just take a sip and then go on. I'm not downing it and then doing a one hour, hardcore workout or anything like that. I'm just like a busy professional. Yeah, it works for me.

Geoff

Yeah. I think that's a use case that we want to explore more and more. Obviously, a lot of our customers today are involved with extreme athletic performances or the military and I think that the broader use case, hopefully, is busy professionals an eventually just part of a daily caloric content for people.

Priyanka W.

Yeah, exactly. I mean, it's super strong. It's potent.

Geoff

Yeah, you'll feel it. You've done the finger prick on yourself, right?

Priyanka: Yeah. Yeah. I think the average person out there doesn't necessarily need to ingest such high, intense doses. It obviously has different effects versus someone who's kind of in a light ketosis at baseline. What I've noticed is that because my ketone levels typically at baseline are in the like one-and-a-half region, more or less.

Geoff

That's solid.

Priyanka W.

Yeah, but when I'll take a sip, it'll bump up to like two-ish. I'm not going into the fives. I don't think I need to. I'm chilling. You know what I mean? And it works for me.

Geoff

Yeah, exactly, so some of these insights, hopefully, will have some products address that, where it's less intense and more sippable and at a better price point, so stay tuned.

Priyanka W.

Right. Right.

Geoff

Yeah, we're thinking all about that. I think that's like a broader use case. Obviously, not everyone. It's like a Navy SEAL or a professional cyclist.

Priyanka W.

Exactly. Sometimes you're just a regular female living in San Francisco trying to get by.

Geoff

You're pretty spectacular in terms of your background as a doctor, obviously. I'm also curious to hear about the comedienne side of things, as well. Obviously, that's a very interesting combination of your skillset and interests. Yeah, I mean, maybe we should start with just following, from our last conversation, probably nine to 12 months ago, how has the community evolved and shifted the language on ketogenic diets? From our perspective and our community, we've just seen a lot of this notion maybe a year, two years ago, still kind of fringe. Now it's fairly, I would say, probably at least half the people that I talk to are interested, familiar, have heard of it, at least have some sort of opinion on keto.

Priyanka W.

Absolutely. People are talking about lowr-carb diets now more than they were 10 years ago. I mean, I was walking downtown the other day and I overheard a conversation. This guy in the conversation, and I quote, was like, "Yeah, I don't eat carbs. I haven't eaten carbs for a while." This was a random downtown experience, so people are talking about it. It's in the news now. Articles are coming out. Movie stars are talking about their experiences, so it's becoming more popular and who knows if this is just the tipping point. I have a couple theories. If enough people are talking about something, eventually it'll get the attention. The other aspect is that the obesity epidemic is worsening, so 50% of Americans are now prediabetic. Could it just be that we're all getting so sick now that people are asking for solutions and now this is the obvious logical answer? I don't know. Maybe it's a combination of both.

Geoff

In your clinical practice, are you just seeing more interest in going on a ketogenic or low-carb intervention?

Priyanka W.

Most of the people that approach me at this point are looking for guidance in that department, yeah.

Geoff

So maybe one, two, three years ago was it more you having to introduce people into the ketogenic lifestyle whereas now maybe it's shifted more towards, what, 75% of people just coming into your practice?

Priyanka W.

Exactly. Exactly. I'm involved at UCSF, the Osher Center for Integrative Medicine. We just finished a six-month trial where we took people with type 2 diabetes and we put them on a ketogenic diet and we looked at two groups. One got mindfulness training. The other one didn't. That phase has now ended and we're recruiting now for a one-year trial for this. What we're finding with the people that we're interviewing to bring onto this trial is that we have many more people now saying like, "Oh, well, I tried a keto diet," or like, "I tried Atkins. I have experience with that," which, when we were recruiting the last time, was not the case, so the word's out, for sure. That can be a good or bad thing because people who say that they're doing keto, but they're actually doing it wrong and then they have side effects from it can actually be really detrimental, so I don't know what to say. I do think it's a good thing that people are becoming more aware that, for example, eating sugar is really harmful for your health. I'm glad that that language is becoming more popular.

I think it is an overall good thing if more people know about this because eventually, the food market and the economy of the food that we eat and sell, the entire food industry will actually change.

I think this is going to take longer, though. I think this will take at least 10 years. It's not something that's going to happen by the end of this year or next year.

Geoff

Yeah, we're changing culture.

Priyanka W.

We're changing culture, for sure.

Geoff

And culture is ingrained in how you're raised, what kind of propaganda/news you were just inculcated as you were growing up.

Priyanka W.

Absolutely.

Geoff

So we're reverse programming the previous generation and, hopefully, educating people in the next generation, the current generation in a more enlightened path for dietary considerations.

Priyanka W.

At least in my practice, I am seeing the damaging effects of the low-fat movement. There's a lot of people that I'll see and they have nutritional deficiencies in certain important fat-soluble vitamins because they were on a very low-fat diet for all these years. They have an omega deficiency or they're Vitamin A deficient, really important things that are important for life. This is the aftermath of the low-fat movement. They were doing the advice that they thought were best for them at that time and now we're sort of repairing the body at that stage, so it's really crazy if you think about it. I try not to think about it too much because I think it can get overwhelming.

Geoff

Well, I think on some of the low-carb conferences, it becomes almost dogmatic or religious. It becomes cult-y, where it's like oh, the low-carb people are being oppressed. I think there's some truth to that in terms of the language is pretty aggressive, I would say, on either side, but I don't know if that's the best strategy to convince people. I don't think people want to be like oh, the low-carb people are being demonized or like there's propaganda against us. I think just having open conversations where we can just talk about data, talk about people's clinical experiences, which I think are very, very valuable.

Priyanka W.

Look, I don't think there's one diet for the world. You know what I mean? I think at the end of the day, diets should be tailored to the individual, to the individual's preferences, lifestyle, and their metabolic profile. We shouldn't be proselytizing one diet for the entire human race. You know what I mean?

Geoff

Yeah.

Priyanka W.

I think yeah, there is a lot of like cult activity with both camps. The low-carb camp can get really intense. I call them the carbinazi sometimes.

Geoff

I like that.

Priyanka W.

The vegan camp can get really intense. PETA can get violent sometimes. You know what I mean? I think on some level, everyone needs to chill out a little bit, but I do think there are some hardcore truths. I think there's enough overwhelming data that has been published that shows that sugar is actually quite harmful for one's health. I think there are some undeniable truths that I think-

Geoff

I don't think anyone would seriously dispute that, that refined carbohydrates is bad for you, like refined sugar is bad for you, which is good.

Priyanka W.

Which is relieving, yeah.

Geoff

I think there's really good data that low carb, ketogenic diets are good for glucose control, insulin resistance control. Some of that, I think, is becoming more and more mainstream and I hope that that gets disseminated, but also that we don't overshoot and become overly dogmatic on the other side. I think that's the danger where I could see on the vegan or the low-fat people where it's like you guys are becoming overly religious on only eating 80% fat every single day. It's just like okay, let's find some sensibility around personalizing diets for everyone's own individual goals and their own makeup.

Priyanka W.

Exactly.

Geoff

I think we can agree on that. I'm actually curious in terms of just again, to your clinical experience has the questions or the pitfalls changed over the last few years? Are people coming in just smarter around how to go on a ketogenic diet?

Priyanka W.

That's a really good question.

Geoff

Like when you said people are doing it wrong, are they doing it wrong in a less wrong way or are they doing it in kind of a funky way? What's that difference?

Priyanka W.

The number one issue that people face is that they think they're eating keto, but they're actually not and when I say they're doing it wrong is that they're actually eating more carbs than they realize. There's a lot of hidden carbs in things that people don't realize. I think the most common stuff, like sauces have a lot of sugar in them and people have no clue about this. Barbecue sauce should be renamed sugar sauce because it's super high in carbs. A lot of salad dressings, like sometimes people think balsamic vinaigrette doesn't have sugar in it, but I have been in situations where standing at Trader Joe's looking at two balsamic vinaigrette bottles. One has no sugar in it. The the other has no sugar in it.

That is a lot of hidden carbs, so they're actually eating more than they realize and then they're not losing weight or in ketosis.

Again, sometimes people, when they say they're sort of doing it wrong, they may not be eating enough fat and so they're feeling really tired or they're not taking enough salt and water and so they feel like crap and they think oh, well, it's because I need carbs to live, but it's actually no, a salt issue. There's so many nuances, right?

Geoff

Yeah.

Priyanka W.

I think it's really important to work with someone that knows enough about it to give them guidance because you could run the risk of screwing things up.

Geoff

Yeah, cool.

Priyanka W.

Then you're going to go around and give keto a bad name. I'm like if you're going to talk shit on keto, at least do it right. You know what I mean?

Geoff

Yeah, no, fair enough. I think there is a lot of nuance there and I would say that part of it is that people have tried to figure out this current, standard Western diet over decades. People have like tuned Cheerios and carb-y stuff, so you can make the same argument that it takes some time for people to figure out what is sustainable and what is easy to eat on a ketogenic diet.

Priyanka W.

That is so true. That's so true.

Geoff

I'm curious, so sexual health, is it something that you're always interested in? Was it a offshoot from being interested in metabolism?

Priyanka W.

I think on some level, I grew up in a very conservative Indian family. We didn't talk about sex at all. That was something that was just never addressed. Then when I went to medical school, one of the first early, sort of sexual health related memories I had was learning about birth control and before I went to med school, I thought oh, I know what birth control is. You just get on the pill. Then when I went to med school, I was like no, no, no, no. There's a bunch of birth control options. There's a lot of education out there that I had no clue about and that sort of started this whole process of like well, what else can you learn?

Long story short, I basically realized that understanding your own sexual health is a form of empowerment and it's like you hit the nail on the head. It is a type of health and if there's sexual dysfunction, it is an offshoot of health problems. I think currently, in the medical realm, for example, if a man comes into the doctor's office complaining of erectile dysfunction, the current paradigm is to prescribe some sort of erectile dysfunction medication. This is not correct. This is not the standard of care. It should not be the standard of care. If anyone suffers from erectile dysfunction and they go see their doctor, they need to be screened for high cholesterol, for diabetes, for thyroid dysfunction. They need to be tested for medical causes of this before even having a conversation about prescription medications. I don't think a lot of males out there realize this, that if they're having ED problems, they need to get some blood test to make sure they don't have diabetes.

Geoff

Right. It's not just like give me some Viagra and like past your problem. You're saying hey, this is a fundamental issue with your body.

Priyanka W.

Exactly, and it could be a serious medical issue. Many men who suffer from erectile dysfunction actually have undiagnosed diabetes. I don't think that is common information.

Geoff

How is that related? Let's walk through that connection.

Priyanka W.

Diabetes is a vascular, neurosensory disorder. When diabetes is in full flare, it affects the vasculature. In an erect penis, basically, erection happens when the penis engorges with blood through vascular tissue. If the vascular tissue isn't properly functioning because of the diabetes, there will be erection problems. It's not a very complex issue.

Geoff

Right, kind of like a high blood sugar is inflammatory and that harms the vasculature of the blood vessels.

Priyanka W.

It causes direct damage to both big and small vessels.

Geoff

So over time, obviously, your entire blood vessel system is affected, but obviously, your penis has a lot of blood vessels, or someone's penis.

Priyanka W.

Yeah. Your penis has a ton of blood vessels, sometimes more than you actually should be having. No, but if you think about diabetes, diabetes is a disease that affects every blood vessel in the body. This is why diabetes is associated with dementia, vascular dementia, heart attacks, vessels in your heart, erectile dysfunction, vessels in your penis. It affects everything, so if there's anything that people listening get out of this talk today, I just want them to know that-

Geoff

Don't just pop some Viagra. Check-

Priyanka W.

Do not take Viagra, yeah.

Geoff

Check your H1d or A1C.

Priyanka W.

Yeah, go get your fasting glucose checked. Check your insulin levels. Make sure your cholesterol is in check. Don't just pop the pills.

Geoff

Have you corrected people's ED in your practice with diet, with dietary interventions for diabetes?

Priyanka W.

In what I've seen so far, if someone is getting erectile dysfunction and their hemoglobin A1C is kind of in the prediabetes range, so it's pretty early, you can improve things. However, the thing is important to note, it's individual, so just because your hemoglobin A1C isn't that high doesn't mean there's a lot of vascular damage that's already happened. This is why it's important to get this stuff checked out way sooner than when things start to develop.

Geoff

I see. So you're saying that vascular damage is, essentially, hard to repair once it's done.

Priyanka W.

Once there is vascular damage, you want to prevent the progression. You really want to prevent. You want to slow it as much as possible. It's not just for men, too.

Geoff

Is there a female analogy?

Priyanka W.

Yeah, so there's a disorder called hypoactive sexual desire disorder, which is basically a female version of sexual dysfunction, where you have trouble with arousal and there's many causes for that. There can be psychological causes, but there can also be medical causes for that.

Again, diabetes is a disease that can cause neuropathy and essentially, if you have decreased nervous sensation in the clitoral area, it can affect your sexual arousal.

Geoff

Right, because you just don't feel anything. You're just like eh.

Priyanka W.

Exactly. Obviously, in terms of female sexual dysfunction, there's a lot of different things, like you can have dyspareunia, which is pain during sex or vulvodynia, which is vulvar pain. There's lots of things that can cause that, like infections or urinary tract infections or bacterial infections, lots of different things, but at the same time, you don't want to forget about anything that can affect nervous innervation in that area. Again, this has to do with insulin resistance, so it's all connected, my friends.

Geoff

Yeah. The more and more literature you dive into this space, it seems like insulin resistance is a core, root cause for so many end functional problems.

Priyanka W.

I mean, it's the elephant in the room. It's like it's really the giant elephant in the room. We're sitting here looking at cholesterol and whether we should prescribe statins and all this stuff, but we're missing the big point that insulin resistance is the elephant in the room.

Geoff

Yeah. It just seems like the current culture within medical practice is to wrap the symptoms. Statins is like treating the symptom of high LDL, so you just kind of jam it down with statins or-

Priyanka W.

Or even high LDL, yeah. Yeah.

Geoff

Yeah, and then like Viagra, just like all right, there's some blood flow issues. We're going to just loosen your blood vessels, essentially, is what Viagra does and you're not treating the root cause, which you're suggesting is from insulin resistance.

Priyanka W.

I think insulin resistance is definitely something you have to make sure you don't have. There's other things that can cause erectile dysfunction, but I think you also need to make sure that you don't have that. You know what's interesting? I do think that this system, the fact that we're pushing all these pills and all that stuff, has to do with the current medical system, the fact that we have built now a medical system where doctors are pressured to see people every 15, 20 minutes. You can't talk to someone about diet, nutrition in 15, 20 minutes well. It's a lot faster to just prescribe a medication. This is a huge systemic problem. Think about how much you've read about the keto diet on your own time, how many hours you've put in to then be able to be like okay, now I understand what this is and I'm going to do it. To have a physician now explain all of that to you in a 20-minute block because insurance companies say that that's what you need to do, it doesn't make any sense.

Geoff

It's impossible.

Priyanka W.

It's impossible.

Geoff

Yeah. This is a conversation that I don't think we've had, but something that has been something in my mind, just the infrastructure. The structure of American healthcare is just messed up.

Priyanka W.

We have serious problems.

Geoff

It's also just kind of intellectually weird why you have insurance or the payer sitting in between the doctor and the patient.

Priyanka W.

Honestly, I think it's unethical to create a system that profits off of people's illness because that's essentially what these insurance companies are doing. They have a bottom line and they're profiting off of the idea that people are sick and that's the business, so if you're running a business like that, it's in your best incentive to run a business where people stay sick because if they're not sick anymore, what are you going to do?

Geoff

Well, I think part of it is that the insurance companies are forced to pay out a percentage of their premiums because it's like a standard capitalist system, then you'd want to maximize difference as much as possible, right? I collect premiums and I hope that my people don't get sick so I don't have to pay out bills for doctors and medicine, so then you can actually capture that difference. For the current system, the government actually regulates that a certain percentage of the premiums need to actually be paid out, so there's less of an incentive now for the insurance companies to really negotiate or really push down costs because they have to spend 90-plus percent of the premiums on care, so I think it's this weird mishmash of capitalism and socialism into this weird gargoyle of a system. Maybe you go completely like Medicare for all or you go completely capitalist and it might just be a more simpler, pure system. I think that's a current debate that's happening with people on the left and the right. I don't know if anyone has the right answer. I know so many people are just arguing about in Congress all the time.

Priyanka W.

I mean, I'm an advocate for a single payer. There should just be one system and that's it. There shouldn't be all these other systems. That's what I think. It should be about the physician and the patient. That should be the relationship. There should be no people getting in the middle telling doctors and patients how they need to be treated, but this is a huge debate. I mean, we could do a five-hour podcast on this, I feel.

Geoff

Yeah. I think it's not something that I've read enough about to really have, I think, an informed discussion, but I think there's some things attractive with a single-payer system, but I also just have a natural affinity to marketplaces. If you just let people compete, that's worked for every single system in terms of building businesses, building services, and why would medicine or education be different, so I have some affinity to that argument, as well. Just let people compete to provide better services. My skepticism for single-payer systems is like when has government done something really, really good and efficiently? It doesn't mean it's like a nail in a coffin for me, but it's something that I need to understand more to really make sure that hey, if we have government-mandated system, if it's run as well as the DMV, that might be just even worse, but if it it just as well-run as an elite unit in the military or something, maybe that could be really streamlined. That's an experiment to be run, right?

Priyanka W.

Right. Well, the current experiment that's going on right now is not going well. I mean, let's be real. We're getting sicker. The current guidelines aren't being helpful. I think the one saving grace would be somehow convincing life insurance companies to get in on this game in the sense that if you convince life insurance companies that hey, if you spend more time on preventing these illnesses from occurring, you're going to get a healthier population living longer that'll pay into your life insurance system, so you'll end up making more money. I think the life insurance lobby is probably the only entity left now that could potentially change the current landscape.

Geoff

Interesting.

Priyanka W.

Because pharmaceutical companies have no incentive in getting people well and off their medications, right?

Geoff

Right. That's correct.

Priyanka W.

So that's a conflict of interest.

Geoff

Right. Then there's no negotiating power with insurance companies because payers aren't jamming down costs, right?

Priyanka W.

Yeah, so my money's on the life insurance lobby.

Geoff

Yeah. This is something I've been thinking about recently, actually. Can we incentivize things like fitness goals or hemoglobin A1C goals as a way to reduce premiums? I think that there is that argument that maybe that's making the healthier, giving them even more advantage towards people that are sick and there's often socioeconomic lines that overlay on top of these things.

Priyanka W.

There's a couple of things about that. First of all, right now, Medicare does look at things like hemoglobin A1C in terms of outcomes. The other thing that I think, though, is that life insurance-

Geoff

But it's a healthcare mandate, right?

Priyanka W.

Yeah, it's a healthcare mandate.

Geoff

So everyone is flattened out now. Even if I'm obese, have diabetes, I pay the same premium as the healthy version of me.

Priyanka W.

Right. My biggest issue with that is first of all, I don't even think hemoglobin A1C is a really good screening test because you can get complications of diabetes at hemoglobin A1C numbers that are less than seven, so I also have a problem with that. The other thing is that, at least right now, life insurance companies, they will make their kind of-

Geoff

So life insurance will discriminate.

Priyanka W.

Exactly. Life insurance is the only-

Geoff

But health insurance can't do that anymore.

Priyanka W.

Yeah. No, correct. Right. The last time I checked, no, but I don't know. With our current presidency, I don't know what's changing.

Geoff

No. I think Obamacare is intact.

Priyanka W.

Every day is a different story.

Geoff

Yeah, but I would think that, again, if you allow people to compete and add different incentives to people, it could one ... Maybe this is a naïve approach, but okay, if I am incentivized to now have to prove that I exercise 10 hours a week or I'm incentivized not to eat so much soda and hamburgers every single day, could this marketplace incentive around reducing premiums or a tax reduction be a positive force here because people are incentivized by money.

Priyanka W.

I don't know. You should run for office or do something. You should get involved.

Geoff

I think hopefully having conversations and educating people is something we can do that's more high leverage, but these are topics that end up being something of interest. If you think about these problems at a individual level or at a community level with the podcast, then it's only natural to extend it out. Okay, like we're thinking about this stuff and oftentimes, I think that we think about it at a deeper level than politicians then yeah, we should have some sort of strong opinions here.

Priyanka W.

Absolutely. It affects all of us. It's impacting all of us.

Geoff

Yeah. We're all paying taxes.

Priyanka W.

We're all paying taxes and I don't want to see sicker Americans. When we're not sick, we don't go into work. We're depressed. It affects everybody. I want our world to thrive and I think it starts with the dinner table. I think it honestly starts with what we eat. I think food is the foundation for health. I think nutritional deficiencies lead to a lot of medical illnesses.

Geoff

I think maybe this is under credit to folks like yourself, but I think it's also the role of doctors, who also serve as guides or coaches in some way because I think another thing that I've been puzzling about is that there seem to be more of a standard of performance in culture in a previous generation. What I mean by that is there was like certain fitness goals that you had to pass in physical education and I feel like a lot of those goals are drawn back or reduced because it's not politically correct or you don't want to hurt the feelings of obese kids. I think you don't discriminate or you don't overly criticize people for being out of shape, but I think that there is some value in having coaches, doctors, professionals saying, "Hey, you should work toward these kinds of health goals." Maybe it's like a fitness goal, but maybe it's like a biomarker goal.

I think the problem with this directionless freedom that we have in America is that there's nothing to work for, so it's like okay, we're all living these happy lives, but what am I working towards?

What's my goal? Usually, people come to you like okay, I'm sick. My goal is to get back to normal. I don't think that's good enough. I think we always have to be fighting against dying.

Priyanka W.

Yeah. Yeah.

Geoff

If I came to you and you're like, "Hey, these are pretty good. I would consider working towards improving your aerobic capacity or reducing your fasted insulin levels," and you being able to tell me that when I check in with you every six months or year and we do that across the population, I think that would change the dynamic of our country's health.

Priyanka W.

It would change the world if we approach things like that. Hippocrates said, "Let thy food be thy medicine." We physicians should understand nutrition and the principles of nutrition and what it means to actually be well and exactly like you're saying, setting those goals. A lot of times, people come to the doctor because they think they want to lose weight or they should lose weight. Usually, weight is like the big thing, "Doc, I need to lose weight." What's interesting though is that, at least in my practice, I never tell someone you need to lose X number of pounds. I actually can't remember the last time I've said to someone you need to lose X pounds, five pounds, whatever. I look at the biomarkers and I say okay, let's say you have diabetes or you have prediabetes. I want you to change your diet so that this can go into remission. You might lose weight as a side effect of that. That's great, but I'm not telling you to lose weight. I'm telling you to change your diet to become healthier so that later on, when you-

Geoff

That's actually more actionable, too.

Priyanka W.

It's more actionable.

Geoff

It's like oh, I got to lose weight. I don't know what to do, but you're telling me okay, don't eat donuts, whatever. That's actually I can do that.

Priyanka W.

Right. I actually don't care about how much someone weighs. I care about their quality of life. I care about what's going on inside their blood work and their heart and their organs. I care about their organs. I don't care about how much they weigh. If there's any doctors listening out there, I don't believe in telling your patients hey, lose 10 pounds. Lose five pounds. Tell people to adapt your lifestyle to lose the disease states.

Geoff

And the nice side effect, oftentimes, is that weight loss.

Priyanka W.

Weight loss is a side effect, yeah, but it should never be the primary goal.

Geoff

Yeah. I think this is a more sensible approach because I think when people just get hey, lose weight and I think there's enough fat shaming and just social pressures around that where it just a hard topic to broach, but if you focus on the biomarkers, I think you-

Priyanka W.

Then it has nothing to do with how much someone weighs.

Geoff

I think the end outcome ends up being they lose weight, which is what you want objectively. That's probably a healthier body mass index and all that, but I think it's a more amenable way to convince someone of what to do and it's more actionable because you're not just telling them something that seems impossible for them. If they knew how to do it, they would've done it. I don't think people want to be fat, right?

Priyanka W.

Absolutely. That's also true.

Geoff

If you're just telling them actionable, step-by-step things they can do that's changing their lives that's tractable, I think you end up with happier patients.

Priyanka W.

I can tell you that because I'm board certified by the American Board of Obesity Medicine and after I did that board certification and learned about nutrition and then started implementing certain principles into my practice, I can tell you I got a lot more hugs because it's just so satisfying when you're helping people getting healthier. You're not keeping them sick. You're getting them better. Yeah, it's nice to get hugs throughout the day.

Geoff

I imagine that that's probably why, at least that's my hope, is that that's why people get into medicine, I hope.

Priyanka W.

Well, I think that was the original reason, but I think things have changed. The system is so broken now. The insurance companies have basically devastated the physician-patient relationship.

Geoff

So you guys are just more technicians.

Priyanka W.

I think things have really changed. I still really love helping people. Don't get me wrong, but the worst part about the current system is the bureaucracy and the insurance companies telling you whatever. You can't order this or this isn't covered. It's painful.

It's painful to hear patients complain about how much they got nickel and dimed because their physician wanted to order some blood tests on them that they felt were pertinent.

It's not right. I don't know. I want to go back to the old days where people would give their doctors a cow and a goat and that was their payment. Then the doctor would like, I don't know, take out their appendix or whatever.

Geoff

Yeah, yeah. No, no, I've read about how medicine was practiced before. It was like the town doctor. It was just like you have a relationship with like your football coach, you have that same sort of familiar neighborhood relationship with your doctor.

Priyanka W.

Yeah, no, I think back in the day-

Geoff

How do we get a little bit closer to that state?

Priyanka W.

No. Doctors used to be respected members of society. You know what I mean? Now I'm basically on food stamps here in San Francisco, so yeah, no, you used to be a integral member of the society and you would help people. If a town got ill, the doctor was the one that would help.

Geoff

Yeah, you're authority figure.

Priyanka W.

Things have totally changed now. Many are shift workers. You're just passing people off. Patients are viewed as entities now. They're viewed the same as companies looking at widgets. The whole process is dehumanized and I think that should change. A lot of patients already-

Geoff

Yeah, it's not good.

Priyanka W.

It's not good.

Geoff

Because I think it's also pushing people towards like gurus that aren't scientific, which is also a huge problem, right?

Priyanka W.

That's exactly what I was going to say.

Geoff

Like it's personality driven now or then it's like okay, I'd much rather talk to someone that's actually qualified, actually studied this, proper medical school, proper certifications than some guru that's just talking about diet and, I don't know, writes some internet blog post.

Priyanka W.

Well, I see a lot of people, basically, who look at the Western system and they feel like it's failed them. The thing is, I don't blame them for thinking that. They feel like they've been gypped by the Western standards and so they seek alternative solutions. They're leaving the current system to go talk to guru diet person.

Geoff

Yeah. I think it's right for people to search for things that work, but again, it think it's, again, similar to the keto, the carbinati and vegan battle. You don't want to pull a Steve Jobs for eating all-fruit diets to try to cure cancer.

Priyanka W.

He was a fruititarian?

Geoff

Yeah, something like that.

Priyanka W.

Oh, wow. I didn't know that.

Geoff

Yeah.

Priyanka W.

Oh, no. That's so interesting. Speaking of radical diets, when I was reading about the sexual health history, one of the things that I came upon how historically, many major religions implement fasting and not eating meat products because they felt it would affect libido, so especially like in Catholicism for Lent, they sort of said in-

Geoff

To reduce libido.

Priyanka W.

To reduce libido, yeah. The point was to not have this high libido. There were also stories of Buddhist monks becoming vegetarian because again, it would reduce libido.

Geoff

That makes sense. That makes sense.

Priyanka W.

If you think about it, cholesterol is actually a precursor of testosterone, so their thinking was very interesting and historically, it really goes back.

Geoff

It also makes sense from a evolutionary biology perspective. If you're starving, your body's not trying to procreate, so it's just conserving longevity pathways rather than creation pathways, which makes sense.

Priyanka W.

Totally. It's just funny that yeah, even if you go back to Catholicism and in Islam, as well, during fasting periods of Ramadan, it's just a interesting thing.

Geoff

Yeah, no, bring back sexual health. I'm actually curious in terms of it sounds like you obviously like to coach and work with your patients more than traditional current standard of care. Have you had success stories or case studies or anecdotes around how you're able to coach people through some of their sexual dysfunction issues?

Priyanka W.

In terms of success stories, sexual health is very kind of complex.

Geoff

Broad.

Priyanka W.

Yeah. It's very broad. When it comes to sexual health, I see a lot of women that have dyspareunia, which is pain during sex, and many of them are postmenopausal, after menopause. After menopause, there's a lot of hormonal changes that occur and many of them come to me basically because they want to have more meaningful sexual lives and they feel like it's almost like after menopause, sex is over. I think that should be a point. You can absolutely have meaningful sexual life postmenopausally. It's not a death knell, like oh, just you might as well call it quits and head thee to the nunnery or anything like that, so a lot of times, I do counseling about how to help their dyspareunia. In terms of diet changes, it-

Geoff

Tell me what does counseling look like? Is it just-

Priyanka W.

Number one, identify exactly what the problem is, so if they say, "Hey, I'm having pain during sex," the first thing you do is you do an examination and then you check the anatomy to make sure that there's not excessive dryness or there's not prolapse of some sort of area. Then based off of that you can make an assessment. A lot of times, it might be something as simple as hey, they just need lubrication every day or it could be something more serious that then requires maybe treatment with either antibiotics or referral to a specialist. Those are, honestly, the more bread and butter, the more common cases. I'm trying to think with men, a lot of times, when I see men, they tend to be older and it's funny because a lot of times, they come in wanting Viagra prescriptions and then I have to be like well, hold the phone, mister. We're going to have to do some other tests first before you get this because we need to screen you for all this stuff. Usually, they're pretty happy about that because they don't know. They have no clue. Then yeah, depending on that, then you can make-

Geoff

It stands to reason, right? I don't think, at least speaking just personally, I don't want to be reliant on a blue pill to have an erection, right? It's like if you can solve the root cause, great. I'm not dependent on drugs to have sex.

Priyanka W.

Right, and not only that, those medications are expensive. I don't think insurance covers them. They're fairly expensive. The last time I checked, I thought they were quite a few bucks per pill, so it's a lot cheaper to not take them, if you can.

Geoff

Interesting. I guess kind of on the sociological line, been these online forums around incels, involuntary celibates. I think this is less of a physiological side, but how people are navigating sexual health, so I think this is more attuned to more of, I think, the lack of discussion around sex in culture. I would say that in some ways that people are having more and more open discussions, but I do sense that there is like a Puritan strain within America where people really don't want to talk about it.

Priyanka W.

Oh, yeah, we're super prudish.

We're total prudes about sex. There's certain enclaves where it's much more discussed, but I think mainstream sex, it's like forget the doctor's office.

Even outside, in public, a lot of, let's say, college kids, for example, they don't know much about sex and I think that's really dangerous. I think especially young populations, adolescents, they should absolutely know the basics of sex, even things like what is consent. What are you comfortable with?

Geoff

What was your education in high school like? I remember that in like 10th grade, you had to take a health class which talked about like this is how you put on a condom. I don't really remember. It was kind of like it's one of those joke classes that oh, like-

Priyanka W.

Well, okay, I remember I was in high school, they basically showed me the most awful photos of STDs. It was literally traumatizing. I've been a physician and I have never in my career seen cases that were the photos of what they showed us. They showed us, basically, I mean, I don't even know how to describe it, just like the worst STDs ever. Basically, it looked like they had cauliflowers coming out of their genitals.

Geoff

Fucked up genitalia. Okay.

Priyanka W.

It was like endstage, like stuff you never see. They were basically like if you have sex, this is what's going to happen to you and so, of course, I swore celibacy after that just because I was scared and it wasn't until much later that then I was introduced to the idea of oh, you can have meaningful sexual encounters that are safe and are very pleasurable and are very empowering. There was no talk about teaching pleasure in high school. It was all just very fear-based.

Geoff

Like scare the crap out of you so you don't have sex.

Priyanka W.

It just scared the crap out of people. Sexual desires are normal human experience, especially if you're growing up. Kids are going to want to have sex. You need to arm them properly. Don't scare them. I don't think scaring people works. I think you have to empower people, teaching both guys and girls.

Geoff

Yeah, what is something that's actionable? What would you recommend or if you could design the system? What would it look like, what age? Let's explore this a little bit.

Priyanka W.

Well, first I would lay out the idea that intimacy is not just about sexual intercourse, that you can actually have intimate experiences without having sex because intimacy starts, I think, with touch, like just from something as simple as holding hands and feeling comfortable with that to maybe kissing and making out to then having full-blown sexual intercourse. I think it's a spectrum. I think there's a lot of people out there right now that think intimacy is just purely based off of sexual intercourse, so that would be the first thing. Now, you can actually obtain pleasure by just very simple things like that. That would be-

Geoff

Even just helping people structure their thinking a little bit. I think that's actually helpful to in this discussion, right? I think that's true. You don't really think about it structurally. You're just like sex stuff in the bucket. It's like yeah, maybe it is worth just like okay, there's the different escalation steps and how you think about them or how you treat them differently. At least it's worth like a good thought experiment just to structure this thinking a little bit.

Priyanka W.

Especially in this day and age where we live with so much access to sexual information and stuff in the internet, I think there's a lot of misinformation, like in pornography, for example. I think many young people and older, many people in general rely on pornography as their sole example of what sexual experiences should be like. I think that's very misleading and potentially dangerous. There are situations now where-

Geoff

Yeah. It's hard to project, like if you just see hardcore porn, it's like that's what we're supposed to do?

Priyanka W.

Exactly.

Geoff

Yeah. I don't know. Do people actually think okay, you got to like ...

Priyanka W.

Yes, they do. I think especially the younger kids that are growing up, their first sexual experiences are through pornography and so if you grow up watching porn and watching porn stars have sex, the first time you're with a real, normal, non-porn star person-

Geoff

Your, mimicking that.

Priyanka W.

You're actually going to have a serious disconnect of what even arousal should be like. This is a real thing where this is extreme case, but people suffer from porn addiction and then actually have trouble with true intimacy with real human beings. This is a big disconnect, so teaching basic intimacy face to face on a human level that isn't skewed by the entertainment industry or by the porn industry, I think, is really important to teaching intimacy and what it means to have pleasure from a physical standpoint. There's a lot of females out there that probably watch pornography and think that oh, that's what my body's supposed to look like and the reality is normal human beings don't have porn bodies. There's a whole spectrum of the way people should look. That also is part of the misinformation. That also plays a role in self-love. If you see certain images your whole life and you think a sexually charged person is supposed to look like this, but when you look at yourself in the mirror and you don't see that, it would be a natural progression to think oh, I'm not sexy. Therefore, I'm not loved. Then that can lead to a whole other set of dysfunctional issues.

The next step in terms of understanding what intimacy is I think would also be understanding your own body and learning to love that in and of itself.

That also involves knowing how to pleasure yourself because I think a person that doesn't know how to pleasure themselves can expect any other person to pleasure them. It starts with you. That would be like the fundamental tenets of what I would create to create, I don't know, a much more sexually healthy world.

Geoff

I think those are all really good points. It's almost the reverse of what's being currently taught.

Priyanka W.

Oh, totally.

Geoff

Are people out there not telling you to masturbate, essentially?

Priyanka W.

Exactly.

Geoff

They're like don't. I don't even know if they talk about it.

Zhill

Well, there's this thing no fap that's really popular.

Geoff

Yes.

Priyanka W.

What does that mean?

Zhill

When you don't masturbate for like-

Geoff

Again, this is similar to ...

Priyanka W.

Oh, god. That sounds awful.

Geoff

... the community that these online men who talk about no fap or incel, so incels are involuntary celibates. These are disenfranchised men who don't have relationships with women and are involuntarily celibate. They're the more extreme, sort of associated with the alt right people. Then you have people in the no fap community. I remember engaging with some folks in that community and the whole notion there is that porn is addictive and these men get sexual dysfunction from porn where they can't have erections in a normal intimate situation and then they just swear off masturbation and swear off porn for days at a time.

Priyanka W.

Let me clarify, though, so swearing off masturbation is different than swearing off porn or is it that they don't masturbate while watching porn or they stop masturbating period because if they're like in-

Geoff

I think there's probably different classes, but I think that they often are intertwined, where they're just going to quit porn and they quit masturbating and if you go to like Reddit r/NoFap you can see people with-

Zhill

Day 400.

Geoff

... like day 400. It's in their thing, like their little flair right next to their screen there.

Priyanka W.

Yeah, yeah, their like signature.

Geoff

I haven't masturbated or watched porn in like 200 days.

Priyanka W.

Wow. See, I could understand the no watching porn thing because you can not watch porn and still have intimate encounters and be sexually active, whatever, but to not masturbate, to me, that's like why would you give up something that's so it's cheap. It's free. It's free. It relieves stress. It takes like no time. You know what I mean? I don't know. To me, that's like what a loss of a good resource.

Geoff

Yeah. I remember looking at some other reasons why they say this or why one would consider this is that they often say that they have more pent up aggression towards actual interactions with women or people, so instead of-

Priyanka W.

Oh, so like they're more present with actual other people or ...

Geoff

Yeah. They feel like they keep their sexual energy pent up so they can actually have, I would say, more alpha, more aggressive interactions.

Priyanka W.

More mana. More mana.

Geoff

Yeah. That kind of thinking.

Priyanka W.

Well, so they're still sexually active, so it's not that they're not sexually active, so then that's a little bit of a misnomer.

Geoff

Yeah, so I think it's a very different class of people than the incel people, which oftentimes are spawning kind of crazy school shooter types.

Priyanka W.

Wow. Geez. Yeah, it makes you wonder how those school shooters, if someone had taught them intimacy at a younger age and taught them to be more connected with their body, would the outcome have been different? I don't know. I'm just saying self-love, I think, is really powerful for being not a school shooter.

Geoff

Yeah, no, I think all those things that you mentioned I think are just valuable for life. It's kind of like life coaching.

Priyanka W.

Totally.

Geoff

That's another thing I've been puzzling about.

I think in the classic public school education system, there is no longer that mentor/mentee or that guidance-apprenticeship-type model that helps train young women and young men to be fully self-actualized adults.

I think some of the things you talked about around what does it mean to be intimate with someone? What does it mean to love your own body? What does it mean to know how to pleasure yourself? I think there's a huge health component to it, but it's really just like how do you live life in a well thought out way?

Priyanka W.

Absolutely.

Geoff

So I think it's even a broader question, like how are we educating people?

Priyanka W.

I do think if people were more sexually connected, I do think that also has the ability to change the world. I do think it's that powerful in the sense that connections with one's body then plays a role with connections with your external environment. If you feel a disconnect, things will change then to create harmony with that disconnect. I think it has rippling effects.

Geoff

Right. I guess I know from like a devil's advocate perspective, correct me if I'm wrong, you're not saying hey, just have super casual sex or just sleep with everyone you want. I want to just like benchmark what's the territory you're talking about here?

Priyanka W.

Yeah, so I'm talking about advocating for intimacy and pleasure and by no means ... I'm not saying like oh, just start having meaningless sex at all.

Geoff

I think people on the right would say hey, okay, now you're just promoting just free love.

Priyanka W.

So what is free love, right? It's about having sex with intention. It's about having sexual encounters that are meaningful because you've ascribed some sort of value to him. That's not to say you can sleep with a lot of people if that's what's meaningful to you. It's not assigning a value or shame to anything. If you want to be monogamous or you want to be polyamorous, you can. Whatever works for you works. There's no judgment. It's the fact that you are choosing to do that. Nobody's telling you that that's what you're supposed to be doing. You have looked inside yourself and you found that that is what you want and that's why you're doing it. That is what I'm advocating for. There's a big difference. Yeah.

Geoff

Yeah. I think I can agree with that 100%. You are self-empowered to make your own choices around your sexual behavior.

Priyanka W.

Exactly. Yeah. I think that is something that right now, a lot of people don't realize that they have that choice. Society tells us that we're supposed to be a certain way sexually and I'm trying to say that even outside of the medical doctor's office, there's so much that you can learn about your sexuality and you should learn it and you should understand what you like and what you don't like and in the meantime, also get tested for diabetes and all the other stuff. The thing is, a lot of people are embarrassed to talk to their doctors about this sort of stuff. One thing I just want to say is that doctors have seen it all. I've probably looked at more penises and vaginas in my life now that I don't even know how many. It's just the human body. You know what I mean? There's nothing glorified about it. It's just a body and-

Geoff

Like when you're in your practice, it's just like day on the job, just like looking at a car engine and you open the hood up.

Priyanka W.

Yeah. It's not a big deal. I think people need to get over that embarrassment that somehow they're inconveniencing their doctor by bringing this stuff up. That's what they're there for. You know what I mean? Don't be embarrassed about that.

Geoff

But I feel like you're like a rare doctor or like an uncommon doctor where you're more approachable in that way where you're just telegraphing that out. I think I was actually growing up, I was probably more intimidated by doctors because they just seemed very busy. They're kind of like jump in, look at your little paper and then rushing out. You're like I don't even feel comfortable with this human being because it's-

Priyanka W.

I know. I've been trying this thing out actually. I should ask you what you think. I've actually been trying where I don't wear a white coat in the visit because I think it makes people feel more on edge when someone's wearing the white coat. I don't know. Let me just ask you as a curiosity. If you went to go see your doctor and they were not wearing-

Geoff

More casual.

Priyanka W.

Yeah, they were not casual. They still had the stethoscope and stuff.

Geoff

Well, you look professional, right?

Priyanka W.

Yeah, but you weren't wearing the white coat. Do you think that would make you feel less comfortable or more comfortable?

Geoff

I think I would add some subtlety there. I think if I knew that you were credible, smart, legitimate, I knew you were a proper doctor and then you opened up and were in more of a human confrontation, I think I would respond better.

Priyanka W.

Than to not have it?

Geoff

Yeah, to not have it, but that's assuming ... I think part of it it's like a sign of authority, like you've earned the right coat. If I know that from you, you don't need to have that shield anymore. You should be able to open up to me as a pure human being.

Priyanka W.

Yeah, for sure.

Geoff

I think it depends on the context, so I think it's a good, easy, cheap way to establish authority, but if you already have that in your practice or you have that confidence, just projected authority through your knowledge, then I think that having that dichotomy of having authority through your content and knowledge, but projecting a very open, warm physical experience I think is a interesting combo. I would personally respond well to that.

Priyanka W.

Better. Yeah. Yeah.

Geoff

Because then it's like hey, we can have a real conversation about my issues and my goals rather than this person's kind of shielded up.

Priyanka W.

Right, and it focuses more on the interaction and the healing and less about the power dichotomy, right?

Geoff

Correct.

Priyanka W.

The only downside to not wearing a white coat is that the white coat has pockets and it's really helpful to carry stuff in the pockets, so that's the only downside. It's a minor thing.

Geoff

I think it's interesting tradeoff. I would say that if I saw my doctor and they were comfortable, I think, projecting a little bit of their human side and kind of the mentor-coach side of things, I think that would be of benefit. I feel like I just connect with you better.

Priyanka W.

Up to a certain point, like obviously, you don't want your doctor in a tank top and shorts and sandals.

Geoff

Like professional, like they're treating this seriously. I'm treating this seriously, but I'm not going to Best Buy to buy a computer and you're in your little Best Buy uniform.

Priyanka W.

Best Buy. I would love to try that one day. No, not really. I've seen patients in a Best Buy outfit.

Geoff

Do you feel like your comedienne life informs and helps your medical practice? I imagine that the bedside care, the ability to open people up and, I would imagine, the ability to read people, in terms of reading a crowd is an asset.

Priyanka W.

So full disclosure, I'm pretty serious in the office. I'm pretty professional. I'm not cracking jokes or anything like that. I think, though, if there's anything comedy has taught me is keeping it real, so the situations in which I think I've been grateful to know standup is like if let's say I was talking to a patient and I started to get the vibe that the patient wasn't on board with whatever I was saying for whatever reason, I think because of comedy now, I can call it for what it is and just call them out and be like you don't sound convinced. You don't look happy about this or just say it for what it is, which is something I learned performing onstage and interacting with audience members and playing off of their energy and calling them out for what it is. Obviously, on stage, it's much more exaggerated, but then a milder version of that is helpful in person and I like that because it keeps it real. You're just being honest with them and that's what comedy is, too.

The best comedy is honest comedy where you're just being vulnerable and the audience can tell when you're not being honest.

They can sense that and so the funnier you are, the more honest and vulnerable you are. You're going to those places where other people are afraid to go. If there's anything that that has trickled into the office is trying to keep it real because it's already super stressful to go see your doctor, like driving out and then parking and then waiting and all that shit, then the blood pressure machine and all that and then meeting them and whatever it is. There's already so much hype, you want to minimize that and just remember hey, this is a person. They're helping you. It's just human to human, which is hard to remember sometimes.

Geoff

No, I think that's good way to put it. I just remember some of our audience questions here and also just relates more on, again, to the sexual health topics. One of our audience members asks, "Is there an equivalent of menopause for men?" We talked about female menopause and perhaps this is a certain segment of our audience, but also just I presume for folks in our generation, just something that we haven't yet experienced in our lifetime, but something to plan for or look forward to. Is there an equivalent for male menopause, something to look at or think about?

Priyanka W.

That's a great question. I think women have an advantage because when menopause arrives, it's super obvious. By definition, menopause is no menstruation for a year, 12 months, so you know okay, the change has happened. Men don't really get something as stark like that. With age, hormone levels do change for both men and women, so there's no question that with age, men's hormone levels will decline.

Geoff

So what is a hormonal signature for menopause? It's a drop in estrogen, right, just flattens out, right?

Priyanka W.

Estrogen levels go down and then there's change with follicular-stimulating hormone and luteinizing hormone. Don't quote me on this. You might have to edit this out. I believe LH and FSH go up and they don't go back down, but don't quote me on that.

Geoff

Okay.

Priyanka W.

Yeah, estrogen levels do go down. Even testosterone levels go down, so essentially, the menstruation cycle, it stops, yeah, and that's it.

Geoff

I'm actually curious. Is it more of a hormone driving menopause train or is it just your body runs out of eggs? What drives it?

Priyanka W.

Why does menopause happen?

Geoff

Yeah, what drives it.

Priyanka W.

That's a really good question. I know certainly at some point ovarian reserve is over, but what actually causes the hormonal switch, like genetically what are the triggers, I'm not actually not sure off the top of my head, like why someone gets menopause at 45 versus 50 versus yeah, I actually am not sure what the actual trigger is.

Geoff

Yeah. I wonder if it's a threshold of ovarian reserves where it's like okay. At a certain point, it's like ...

Priyanka W.

Yeah. That would be a good question for like a gynecologist or something.

Geoff

I'm just wondering maybe there's an internal sensor where egg quality is tapping out. Is there some way that you that?

Priyanka W.

I should've probably looked that up before.

Geoff

Okay. No, I was just throwing out there something that I was just thinking about.

Priyanka W.

Yeah, but to answer your question, there's no official menopause for men, but the short answer is that yeah, hormone levels do change with age for both genders.

Geoff

Right, and usually it's a crash in testosterone. It lowers and flattens out and-

Priyanka W.

Right, but isn't crash kind of a harsh word because I don't actually think testosterone levels ever crash. I think they actually gradually decline.

Geoff

Okay.

Priyanka W.

Yeah, if there was a crash, I think there would be a well-defined male menopause then, right?

Geoff

Right. Well, I guess the crash, I'm more thinking about an extreme environment. This is more with athletes or endurance environments where through like PTSD or something, like testosterone probably crashes.

Priyanka W.

Right, so that's pathological.

Geoff

Yeah, that's pathological.

Priyanka W.

But in terms of natural, non-pathological things, there shouldn't be a crash.

Geoff

It's like a linear decrease. Right.

Priyanka W.

Yeah.

Geoff

Yeah, no, that makes sense. I guess with men it's just more of a liner decline.

Priyanka W.

Yeah, exactly. Yeah.

Geoff

Okay. One thing that, perhaps, is something I've been seeing more recently, perhaps, it's my friends who are women in their 30s or approaching their 30s, a lot of discussion, especially in Silicon Valley, around egg freezing and how do you maximize fertility.

On the men's side, there's always these viral articles where men's sperm counts in modern society are dropping like crazy.

Priyanka W.

I did read those articles, yeah, so that's steady.

Geoff

Curious to talk about both cases. Those are probably just especially relevant for the millennial generation.

Priyanka W.

Right, so the study you're referring to about fertility rates declining in men specifically applied that if you read the paper for that, that was strongly true for men living in Western countries, so the developed nations and yeah, so there's no question if there are fertility issues, yeah, this could actually be related to other medical problems which again, it goes back to the same thing. Getting screened for things that can affect your fertility like diabetes, low testosterone, cholesterol issues, checking of various hormone levels and whatnot is super important because a male won't actually know he's not fertile until he actually tries to have kids.

Geoff

Right. Same with a woman, right?

Priyanka W.

Yeah. Technically yes.

Geoff

I mean, same with everyone.

Priyanka W.

Yeah. That's true. That's true. That's true. No, it's definitely a real thing. It's definitely happening.

Geoff

Do you have clients that come in are like hey, as a relatively younger male, like, "Hey, I'm curious about my sperm count. I read this crazy ..."

Priyanka W.

At that point, I usually refer them to fertility specialists because they're really good at doing those sort of things. I don't have the means of running a sperm count in my clinic, but yeah, I would send them to a fertility specialist and you can easily go to one and get that checked out, yeah. It's funny you mentioned that because a lot of times, people always assume that it's the woman who's having the trouble with conceiving, but that's so not true. The guy plays just as much of a role with it, as well. I think it's really important for men to also make sure that they're fertile, especially if they're planning on having kids.

Geoff

Yeah. I mean, as a relatively young male, I don't think we really talk about, haven't really talked about it to people first, but second, I don't know anyone who has done a sperm count test, but I think it is kind of an interesting statistic for okay, it is strange that in Western society sperm counts are dropping. Is that due to lower overall metabolic fitness due to plastics in the water?

Priyanka W.

Right. Exactly. Right.

Geoff

Do you have any sense? No one knows. Do you have any hypotheses on why that's happening?

Priyanka W.

In that study, they don't get into the details and again, it's just observational, so it's not a super high quality study in that respect, so we don't know. We have some ideas. We, as a society, are getting fatter. We're getting sicker.

Geoff

Cellphones in the pocket.

Priyanka W.

Yeah. There's a lot of EMF exposure. There are a lot of pesticides in our environment, so there's plenty of things that could be causing this. There's no question about it. A lot of people also, this is an important thing, people think that it's important to be healthy after someone gets pregnant. This applies to a lot of women.

They think "Okay, now that I'm pregnant, it's time to get healthy", but a lot of people don't realize that the state of the baby is pretty much locked in at the time of conception.

The health of the father plays a big role on the baby's health, too, because all of that DNA-

Geoff

The epigenetics in the sperm are locked in.

Priyanka W.

Exactly, so for example-

Geoff

So I assume the epigenetics of the egg is also locked in.

Priyanka W.

Everything on both sides and so, for example, if a male is obese at the time of conception, the child has a greater likelihood of being obese, as well. The point is that if you're thinking about having kids, you need to optimize your health way before so that by the time you actually attempt conception, that is the set of genetic DNA that you want to put into the future child.

Geoff

Yeah. I mean, it's kind of crazy, like the Lamarckian notion versus Darwin, like Darwin evolution, where Lamarck says that if the giraffe keeps stretching its neck it'll get longer. It sounds like that's the epigenetic function if the male or the female is healthier that passes on to the next generation.

Priyanka W.

Yeah, totally.

Geoff

It's interesting to see Lamarck's theories actually come back into vogue after the knowledge of epigenetics, which is interesting because Darwin won that initial debate.

Priyanka W.

Hmm. Wow. It's been a while since I've even thought about Lamarck, so this is awesome we're throwing this back.

Geoff

Yeah, no, I wanted to also just talk about if there was a female analog towards the men's sperm quality decreasing. Is there something like that happening in Western women, as well?

Priyanka W.

Yeah, actually, there is, I think.

Geoff

Of like egg quality is degrading?

Priyanka W.

Well, I think polycystic ovarian syndrome, also known as PCOS is basically a infertility issue. It's very common. Some of the risk factors are it is basically insulin resistance at the level of the ovaries, so obesity is a risk factor for it. Part of the treatment involves weight loss and bringing the insulin levels down, as well as some other types of medication.

Geoff

Yeah, I read that. Yeah.

Priyanka W.

Basically, in a way, yeah, that is an example of infertility in the modern world because there is a huge obesity epidemic. PCOS rates are rising. It's one of the ways that you can not be pregnant. It's super interesting because my patients who have PCOS, if I put them on a ketogenic diet, I counsel them that hey, listen, there's a high likelihood you may get pregnant, by the way, so you want to make sure you want that before you do that, so just in case.

Geoff

You're going to be more fertile, just in case, yeah.

Priyanka W.

Yeah, so pregnancy is one of the possible outcomes of reversal of PCOS, so yeah.

Geoff

That's wild. I'm just thinking from a macro lens, it's interesting that with a lot of markers, humans are the most successful it's ever been in terms of as a species.

Priyanka W.

As a species, right.

Geoff

But in terms of individual fertility, it looks like just all of us broad generalizing are getting less and less fertile, which is strange.

Priyanka W.

Well, if you think about it, so when we studied biology and ecosystems, what happens in an ecosystem when one of the species begins multiplying a lot, the resources begin to dwindle and then eventually, that species decreases in number, right?

Geoff

Because of some crashes and then you get that drop.

Priyanka W.

Right, so I think we're reaching that point where there are limited resources in terms of diet and nutrition. I mean, eating a high carb diet is the current standard of care. If we switch to a low carb, high fat diet, it would change our entire economic structures.

Who knows what food sources would be available, what wouldn't be available, so we're reaching that point now where we're close to saturating our ecosystem, which is the Earth.

I think Mother Nature is, in a way, coming up with ways to regulate that. It's crazy if you think about it. I don't know if that came off as totally whack.

Geoff

No, I buy it. I think there's some truth there where it's like a local maximum, right? I think the way I interpret it is that we needed factory farming, a lot of these grain, carbohydrate-driven nutrition to feed an exponentially growing population, just easier to make bread than make a steak and now we're seeing some of the detriments of that, where these mass processed foods are actually reducing the fitness of each individual, whereas we are able to supply the whole species, each individual is a little bit weaker.

Priyanka W.

That's exactly the point, yeah.

Geoff

I guess we need to, as individuals and as people engaging with the community here, hopefully inspire people to increase their own fitness to reverse this decline.

Priyanka W.

Well, it's survival of the fittest. That's the laws of nature. That's the way it's always been, so, I mean, it's harsh, but that's the reality. Obviously, the individuals out there that are doing something to reverse the PCOS or to reverse their medical issues so that they can maybe potentially have kids or whatever, there's the advantage versus the populations that aren't. It's sad and it's frustrating as a physician to think about, but I don't know what else.

Geoff

Yeah, but I think it's funny that you mentioned survival of the fittest where I think if you just look at current fertility rates, it's oftentimes the lower socioeconomic classes that are breeding or creating children faster than the more well-educated, so it's not even really survival of the fittest. You're selecting for people that are, for whatever reason, more fertile in terms of producing children, which overlaps more closely with lower-educated groups. Basically, you can look at statistics. Very, very highly educated couples average one to two children, where the lower socioeconomic classes are averaging three, four, five plus children. It's just the Darwinian selection, natural selection process, like there is no selection process anymore. There's enough resources where anyone can procreate essentially.

Priyanka W.

That is definitely happening on some level.

Geoff

Well, I don't know what, as a society can or should a society do something about it because I think that's the wonders of modern civilization is that we can carry and let people do their individual actions and let them at least have some baseline success rate.

Priyanka W.

Totally, and I think you bring up a good point.

Back in the day before modern medicine, many women would die during childbirth. Having a child was a very life-threatening thing. It was very common to die during childbirth.

Now we have technology, C-sections, neonatal ICUs. We have it all, so we can get people to have kids and keep everyone alive in the process, so what are the consequences of something like that? We have more people, more population, more people on this Earth now, more resources being used, all of this. There are some consequences, right?

Geoff

Yeah, I mean, I think this is just an experiment that we're just in the middle of running.

Priyanka W.

Yeah, this is the experiment. Yeah. It's happening.

Geoff

Yeah, so hopefully, it turns out well. I don't think it's a point to be pessimistic here. I think there's enough smart people that want to see good for our species. I think people are working towards that.

Priyanka W.

Agreed.

Geoff

I think there is also just that instinctual desire to live longer and the rest of the society is crumbling around you, that's going to allow the individual to live longer either.

Priyanka W.

No. That will also play a role.

Geoff

I know we got to go now, but where do people follow you? Any last words here?

Priyanka W.

You can follow me on Twitter @WaliPriyanka. That should be enough.

Geoff

Yeah. Cool. Again, it's always fun to riff and explore these ideas with you.

Priyanka W.

Yes. Totally.

Geoff

I'm sure we'll have you back on soon.

Priyanka W.

We should do it again. We'll talk about something else, something wild again.

Geoff

Cool. Thanks so much for the time.