Well. Hello, everybody. Welcome. This is a really, really important episode, so please take out a piece of paper, a pen. Listen carefully. Share this with people.
I have the famous Doctor Geo Doctor Geo Espinosa beaming in from New York City. This man is very well known. He's in the field of urology and is on the faculty of NYU Langone Medical Center.
It's a very prestigious center. And, he is well-respected. He's been a friend of mine, and he is a urologist. And his focus is male health, of all kinds.
And that's such an important topic, you might say, why on a hard summit, why don't we figure out on hard some? And so thank you, Doctor Geo, for taking time out of your busy, busy practice.
Doctor Kahn, anything for you. And you know that, one clarification point. I'm a natural Pathak doctor that specializes in urology, so I'm a natural Catholic urologist.
I want to respect the urologist for their type of training and what they've done. I work closely with them and I can see what they do, so I. I don't do the surgery nor the penile implants or anything like that.
Well, have, people come and see you in your practice? And of course, you do also telemedicine. Yes. They practice. They probably, hopefully won't need surgery because you have that natural orientation.
That's so wonderful. But let me just ask a blunt question. A man listening right now, or a woman who has a man that she cares about, is concerned about a new problem with erectile dysfunction.
God knows a common problem. Maybe libido is down, or maybe libido is still good, but there's just no response. Go see a family doctor. Go see an internist.
Go see a cardiologist. Find a natural Catholic urologist. There's not many because you're very special. Or find a, you know, medically trained urologist.
What do you think would be a good stop or in your opinion. Of course, a natural Catholic urologist. Right. Look, if somebody has erectile dysfunction, well, let's just say if somebody comes to see me with erectile dysfunction.
Right? And, they're relatively young and they haven't had an erection in about three months. We need a cardiovascular workup. So maybe what I'll do is get some blood work.
And with the blood work, seeing something that is not manageable by me, I'll send them to you, actually, as a cardiologist, because to me, that's a bigger sign.
And I want to I want them to get a full cardiovascular evaluation, I think, to make sure that these arteries are in good shape, that they do, you know, calcium scores and things like that.
Because one thing is that they're coming to me because they want quality of life and they want to engage sexually. We we need to look at the bigger picture here.
Oftentimes, look, the penis is a is a proxy to a man's health. So, you know, this is one of the things that we have that women don't have. So and they should get erections at any age.
Had an 80 year old man yesterday in my office, looking to get better erections, no prostate problems. Or at least he wasn't complaining about it. Actually, truth be told, his, his girlfriend, who is 79, asked him to come see me because, you know, things go around working as well as they should.
And bottom line is that, you know, even if you're 80 years old, it doesn't matter. The age should get an erection. That's a proxy for for good health, any man.
So I get concerned in that regard if they haven't had an erection for a while. So just in case somebody listening hasn't, really studied the field, why in the heck is a erectile dysfunction a potential clue to heart issues you just mentioned?
Even a referral to a cardiologist or a heart calcium CT scan you mentioned. Let's just unpack real quickly that possible connection. Right. So, there is likely, arteries that are blocked in the penis.
Now, there are smaller arteries that you find elsewhere, certainly around the heart, but that can be an indication that there's clogged arteries somewhere else, potentially around the heart. So, and it could be multiple arteries to if a man does it getting an erection due to circulatory reasons, it's not one artery that's blocked.
It could be multiple because if it's just 1 or 2, you still get an erection. So there's many arteries, penile arteries, what they called. So, so that's, that's the main reason.
Now, maybe it's not clogged arteries. Could be diabetes, could be prediabetes. Actually, if it's full size diabetes, you know, for some other reason. But pre-diabetes, that could be a cause actually.
So then you do the blood work, you do the work up, and, you know, the insulin is very high or, or their, hemoglobin A1, T is very high. And then we can address that as well.
Excellent. What else in your panel this 80 year old man comes to see you. And he certainly could have gotten a disease that age. So you mentioned you you know, you checked in a blood pressure to check in some, cardiac risk factor labs.
What's your hormonal workup for? You know, a 39 year old or an 80 year old who's got that three plus month erectile dysfunction? Well, here's the thing.
There's three things. There are three things that are required for a medical erection. If you have, if you don't have one of these three things, it gets more difficult.
And certainly you don't have 2 or 3. It gets even more difficult, or you're not getting interaction. The more it is your nervous system. Nervous system needs to work properly.
So if there is some sort of, nerve issue, whether is due to Parkinson's or Central nervous system issue, whether it's from, treatment from prostate cancer that affects the nerves, then all bets are off the other component is circulation.
So we talked about that. You need the arteries to dilate, you know, nicely. You need enough nitric oxide in there like you need in the rest of the body to even lower blood pressure.
Right. Nitric oxide. The third is hormones. Now, I'll be brief, but I could tell you that the hormone situation is, at least in my mind, is a whole lot different.
How so? When I get patients that are coming in and they go to these aging clinics and they're really just looking at total testosterone, period. End of story.
If your total testosterone is high, you should be good. But I don't feel good. Well, you know, it's 800. How can you not feel good? Maybe, you know, maybe it's you.
Something is off. What can be off? Number one, there's not enough free testosterone. It doesn't matter. You need to listen to this and hear this, audience and even doctor can't.
It doesn't matter how high your total testosterone is, it doesn't matter. What does matter is to have enough free testosterone, roughly about 2%. How do I know this?
How many patients do I see? They have, testosterone levels as low, normal, 303 50, and their free testosterone is perfect. Do they have a libido problem?
No problems, no sexual? No. None of these issues. I see men 707 and 50 low, free testosterone. They're having symptoms. That libido is low. They're having all kinds of almost, like, hyper gonadal symptoms.
Does that number one. Number two, the ratios. Matter ratios, matter ratios between what ratio between the testosterone industry and estrogen or estradiol.
Right. That should be roughly 20 to 20 to 40 to 1. If it's 10 to 1, you're you're not going to feel, your libido is not going to be so great, for example.
And by the way, you do need estrogen to have enough libido as the man, by the way. So this notion of let's just get everybody on aromatase inhibitors to bring down estrogen, no good.
I the last time that I've recommended an R open taste inhibitor might have been over a decade ago. I don't recommend them, even in guys that are on TRT, where their total testosterone is really high and sometimes they're estrogen is really high as well.
As a result of that, the rate of the ratio is 20 to 1 or 40 to 1. I leave that alone because you do need some estrogen and you need about that ratio. So that's that's one of the ratios.
The other ratio is testosterone to DHT. Dihydrotestosterone. Here's the deal. You get somebody coming in and say, doc, you know, Doctor Khan recommended this topical testosterone and I apply it, but I feel like crap, I feel lousy, I feel worse even before I start.
I'm like, well, what happened there? That enzyme five alpha reductase, right, is an enzyme that converts testosterone to dihydrotestosterone. That enzyme is very active on the prostate.
That's why they have all these drugs that lowers, lowers DHT. There are five alpha reductase inhibitors. That enzyme is highly populated on the skin, on the skin.
What happens if you apply testosterone? Too much conversion going on. Too much conversion. So now the testosterone to DHT is, it's off. It should be around 12 to 1.
We're talking about sometimes 1 to 1, 2 to 1. It's really bad. They feel like crap. They're not making more testosterone. You just feel lousy. So anyway, testosterone, cortisol and things like that.
So you want to look at free testosterone and the ratios between, testosterone and estrogen, testosterone and DHT, testosterone and cortisone, those kinds of things.
Excellent. So it's, reasonably complex in a lab panel. Do you do DHEA to correct. So, so sorry, I, to your question. Okay. Do your question. The lab panel looks like this.
It looks like total testosterone, free testosterone, s-h b g sex hormone binding globulin. Estradiol, DHEA s sulfate, and cortisol. Though I also do cortisol, whether in saliva, urine.
And I'll just throw one more in. Do you do a prolactin level if we. Do locked in an LH luteinizing hormone. I do sorry, I do fs h lh prolactin because it's just part of the panel, but it doesn't give me a whole lot of information.
Sometimes the prolactin is too high. Then, then that lowers testosterone as well. That's a rare case. In my lifetime, I've seen it in a, you know, maybe thousands of patients, like five times.
So it's just rare. And if I, But it's just part of the panel. You know, that that that I, that I, I click a button, all the other hormones I look for, but yes, LH and FSH because you know that that is directly connected to testosterone production.
Okay. I want to circle back to this. You know, you said three foundational physiologies to have good erections is a man. One is circulatory, one is neurologic, and one is hormonal.
I mean, I'm asking you. I'm not trying to, you know, catch you, but how long is the connection between erectile dysfunction and cardiovascular disease generally been?
No, I mean, roughly. Well, roughly. So, you know, it's incredible the amount of data to support that, right? I and where I'm known to who. Well known to the data that comes out.
But even before then, I mean, you see, it's like, okay, when you see the connections, I've seen things, I often times I see things in my clinic before the research actually comes out.
Because you see what you see, I would say minimum 20 years. In terms of data, systemic reviews and all sorts of things and if not longer. I mean, I've been in practice for about 22 years, so, that.
I, I would answer the same at least 20 years. And I ask it for a reason that I remember reading. I didn't look it up just now, but there's been several Princeton, university panels that get published between neurologists, cardiologists and the chronologies that have been making the point now that erectile dysfunction can be cardiovascular disease.
But, you know, I think by far the most common thing happening in a family practice and internal medicine office is, hey, Joe, here's your prescription for Cialis or Viagra or, you know, Bob, here's your prescription. And, there's, you know, there's not a hunt, even though it's 20 years later.
And like you say, how many publications have tried to educate the medical world? And I think that's you know, part of the purpose of this conversation is if we catch one person with erectile dysfunction and now goes and gets a cardiovascular workup and finds cardiovascular disease for this reason, you know, we did that one person a favor and hopefully we'll help a lot more than one person.
I've heard the term canary in the coal mine. Are you familiar with that? Yes, I am, so tell it. Tell me, you know, listening audience, what that means in relationship to this topic.
We're talking about. In relationship to this topic. Actually, it's a very common you know, I have to admit, I've heard it maybe, I don't know, 100 times.
Yeah, it is one of those things that, I don't know precisely, certainly this topic, what it means. Maybe maybe you can educate me. Well, that's fine anyway, I'll just tell the audience, you know, you have Cuban background.
You were. That's right. You weren't born in Pittsburgh in the coal mine. So I'll give you I'll give you a chance. But that not American problem. Proud Cuban American, but a Cuban American.
That's right. Just there. But as I understand it, I've heard this statement so many times that 120 years ago, before technology miners would take a bird canary in a cage into the coal mine.
And if the bird stopped chirping and actually particularly if it fell off its perch, the carbon monoxide levels might be so toxic that the bird died before they would be potentially sick and they would exit the mine and save their life.
So it's an early warning system. A canary in the coal mine is an early warning system. And I love you know, I did not know that actually. Well thank you.
If I take if nothing else from and from this conversation, I can actually the next cocktail party or something. You're not you're well and, you know, the reference is that a man with erectile dysfunction might be three years away from a heart attack.
It's an early warning system, so don't wait to fall off your perch and can't breathe. Go get a cardiovascular workup from Doctor Geo or your primary care doctor, or find a cardiologist.
And you know, as you said, even if it's just a coronary artery calcium scan that comes back clean, you've achieved a lot, never comes back bad. Like all my patients.
And you better start working with somebody. So, you know, just we won't go into every detail about how you treat erectile dysfunction. But I want to shift a little bit, to talk a little bit about nutrition.
We're talking a lot about nutrition in this summit for cardiovascular disease, for hypertension, for cholesterol disorders. But I mean, are there a few foods.
And please try and leave the spare ribs and the French fries off the list. Are there a few foods that's important nitric oxide or supplements? Let's talk also about supplements that support erectile dysfunction.
Let's leave prescription drugs off that you found helpful. And of course you have your own supplement line. Feel free to tell us what might be in those that help erectile dysfunction.
All right. So, thanks for that question. Very good question. First, before I answer that question, I need to say that erectile dysfunction is not a disease, is a symptom, is a symptom that something is wrong.
Now it could just be stress, by the way. It could just be a warning sign. Like you're stressing a lot like you usually get good erections and now you know, you don't.
Nothing to worry about. Just manage your stress. But it is a sign, a a symptom that something else is is going wrong is very important to look at it that way, because a lot of guys is like, oh man, I can't.
And they just want to get going. And it's great, I get it. I'm a man too. Sometimes you just want to get going, but make sure you try to address the underlying cause.
What are some of the things that may work in the natural world? Look, we we big picture, deal with and address metabolic dysfunction, right. If you address metabolic, what does that mean?
A metabolic dysfunction is when you have many things going on at the same time, perhaps a, a big waistline, hypertension, bad, high bad cholesterol or Aids.
I hate using the word bad. It's such a misnomer. Right. But, you know, to make it easy for, for folks, low HDL, high triglycerides and glucose, if you have, you know, like three of these things out of the 5 or 6, then you have metabolic dysfunction.
So get metabolically healthy, right? Lose the weight that you need to lose. Not only the weight lose the body fat, the bigger you are not muscular wise, but the bigger you are with body fat tissue, fat tissue, the more estrogen you make.
There is aromatase enzyme that converts testosterone to to to estrogen, in in fat tissue. And so typically the bigger you are, the lower your testosterone to estrogen ratio.
Let me also say this a little bit. As an aside, the bigger you are oftentimes the lower your PSA is. But that's a false that's a false low PSA. In other words, you go to your doctor and you are 53 years old and you are overweight and they take a PSA.
So, you know, not to worry is still is to two is a little bit high for 53 year old. But you know, nothing to worry now. No that's not really a to that two.
It can be a four. And and what the reason for that is because you're overweight. So it's very important to know that because you, you may be hiding prostate cancer and other things. So, so let's lose the weight.
So what's the method of losing the weight? At the end of the day, it has to do with calorie restriction, consume less calories that you use, less energy that you use, and you will lose weight.
You know, I just finished, I today's day five for me. Joel. The fasting mimicking diet day five for me. Talk about calorie restriction. You really learn.
You really learn how much you love food. In addition, I had the great pleasure today of interviewing for my podcast Doctor Volker Longo. So it was just the whole FMD, day to day and so I say that because this is one method of reducing your, the calorie intake, calorie restriction.
Obviously you're going to love this because, yes, a plant based diet by default, if it's a plant based diet. I don't know about you, Joe, but people say they do plant based diets.
They're not healthy diets that they're doing. So it literally is. You eat plant, not what you don't eat is what you eat. So, a plant based diet is low calorie.
You'll lose the weight. These have ingredients that help your blood vessels, maintain their health. It has ingredients that can promote nitric oxide. For example.
Beets. Beets are phenomenal. For nitric oxide, no question about it. I don't Joe. Forgive me. But I don't necessarily. I look into real good whole food.
And so if a, a patient comes to me and I say, look, I'm vegan. Great. Let's figure out how to do the best vegan diet you can. I don't try to change their diet if they're paleo people.
Great. Let's figure out how you do the best paleo diet and include plants. What do you think? You wear orange tie better than I do. We have trouble with that too.
Let me ask you about supplements. You know, you have a line. A man has erectile dysfunction. What? What are you putting in those supplements that might naturally support healthy nitric oxide?
Healthy erectile dysfunction? I'm trying to hold back because I don't. I don't push my own products. And I appreciate you allowing me to plug it in. Joel, so much, and it's not because obviously, I formulated.
So I do believe in it, and I see good results. Right. There's been several generations of this x y vegan GR supplements. Why? Because I want to get it right.
I'm never satisfied. I want to make sure that people get erections. So there was one, one, version where I had just things that promoted nitric oxide.
So we talking about l citrulline, pomegranate, pomegranate extract, resveratrol and and those kinds of things. And, I wasn't completely satisfied. I looked at their blood.
Well, their testosterone suboptimal. All bets are off. You can make all the nitric oxide you want if your testosterone is suboptimal is not happening this late.
This most recent version, the goal is to promote nitric oxide, along with what can we do from an herbal perspective to increase free testosterone. So this particular version, has the things that do that.
What are those herbs? Things like Tomcat Alley. Then you Greek. Ashwagandha. One that most people don't know. There is one good paper in 2018 that makes the connection.
Is ginger root? Oh, ginger root. It turns out that, when you're, when you have too much inflammation, that interferes the whole process of that or the cascade of creating proper testosterone and ginger root has been associated.
Again, there's no there's not a randomized trial here, but great paper, that it seems like it's a viable approach to helping, men optimize their testosterone levels.
So ginger root is one that we use. Another some other minerals that we use include things like zinc, boron and magnesium. And then for nitric oxide production specifically, I like I'll lean quite a lot.
I think I'll see what else actually does. Is it, is a precursor to arginine. And then the question is, wait a minute, why why not just take arginine orally?
Well, because you could take arginine orally. You would have to take a decent amount. There's a lot of arginine enzymes throughout the system in your gut, and in, around your liver.
So your body breaks down a lot of arginine. What else Citrulline does, is it re re circulates the arginine so it keeps enough arginine in the body. And and studies have shown that anywhere between 1500 to 3000mg a day helps with having enough arginine to make enough nitric oxide.
Studies have shown about, I think, 3000 more 3000 to lower blood pressure. So what have I seen in patients that, you know, Joe, they come into your office and they have, you know, they have, natural low blood pressure to go up.
So it's 100 over 70, sometimes even 90 over 60. Right. And they've always had a low they don't have a lot of wiggle room. So in those patients actually you got to be careful with all citrulline because their blood pressure will go down even lower.
So for most people they have the opposite problem with blood pressure, which is, you know, it's too high. So maybe they get a twofer, but certainly it works very well for erections because it helps with optimizing testosterone.
Okay. I think people took notes and it's a very, very good list that, very actionable. And again, you don't want to but just go over to doctor G-O dot com drdo.com.
And I'm sure there's a little button. We'll show you some of those very carefully designed state of the art supplements. The last topic just for a couple of minutes, we've been talking about erectile dysfunction and supporting it with healthy hormone levels, healthy blood for levels.
We didn't talk, you know, about neurologic support, but we talked about some of the diseases that affect erectile dysfunction. And there neurologic fair just for a moment shift to prostate cancer, which you see a lot of.
And there's so much of an even in my cardiology practice, I think I talked about prostate cancer every day to 3 or 4 or five people. Because it's so common, then, you know, the role, I just as a student of the literature, like you are, I'm seeing a lot of new data about nutrition, particularly plant based nutrition.
Actually, a brand new article published about simple white button mushrooms for prostate cancer and all the other wonderful polyphenols that are out there, like green tea and, turmeric and pomegranate.
But any comment on, you know what, you might advise a patient concerned about preventing prostate cancer or dealing with the diagnosis in the world of nutrition.
So, you know, one of my colleagues who first came into NYU, she was not a, nutrition expert at all. And so many of the papers that you've read recently has been by Stacy Loeb.
Yeah, yeah. So she's a friend and a colleague at NYU, and she's become a staunch leader. And this, this, you know, publishing on dietary approaches for prostate cancer.
Here's the thing. New. I've been doing, diet research and reading for 25 years. A lot of the books, some of the books behind me are old books. Anything from Atkins to you remember the, the food combining diet?
You remember that one by the Diamond's? I've been all in on diets for a long time. Here's what I know in general. In general, dietary, diet research, nutrition research is difficult.
Most of what we know is learned from observational studies. Food frequency questionnaires. It's hard to get, you know, cause and effect. You get associations, but difficult to get cause and effect.
That said, I am not totally opposed to, so, observational studies that have, you know, that are monitoring a large group of people if they give me guidelines and especially when multiple variables are controlled as much as possible, again, not cause and effect.
He are that dietary guidelines. And actually talking to Valter Longo today today look 25 years in I'm always learning learning from you. Learning from Valter was the thing.
Oh, wow. Maybe, maybe I'll do that. He, of course said, one of his main things is that, IGF one that's too high is a signal for cancer. Many cancers, including prostate cancer.
So I like to, maybe, you know, I like to say, okay, who's right, what element. All right, so here's I so so I asked him I said so vulture what is the proper range, that you think is, optimal for IGF one, where, you clearly need some because you need muscle and, but you maybe not need maybe too much of a good thing is a bad thing.
His range is between 120 to 160. And that's based on, a meta analysis that I think he and his team wrote. Great. So I have a range. So if I can keep my people in some sort of a range like that, I'll be very happy.
Because again, you do need IGF one. So with that approach, I again, I don't, I want to include more foods. I don't want to exclude. I want to exclude the least amount of foods.
You and I will agree. Any person agrees. What do we all agree on? It's like politics. Democratic. What do we all agree on? Can we start there? Processed foods, fruits and vegetables, nuts and seeds.
What do we exclude? Ultra processed foods. Right? Right. Let's start there. If nothing else, sometimes I have to start there. Okay, well, this is too hard.
Okay. Eliminate, ultra processed foods. Let me tell you what that is. I'll see you in three months. Let's start there. Then we move on, and then we say, okay, include Whole Foods.
That includes a significant amount of fruits and vegetables and plants and seeds. Forget about the what you read that kale is bad because it has phytic acid and all these, nonsense.
To me is like, let's stop demonizing good foods. Let's stop demonizing soy paleo people and vegan people. Let's stop demonizing meat. When you look at the when you look at the studies as it relates to red meat and prostate cancer, it's very clear.
But people kind of twisted depending on their own personal views. But processed meats are a problem. So these are the ultra processed meats. So ultra processed it goes back to ultra processed foods.
Great great. Make sure to get enough protein in from those plant based from a plant based diet, which is definitely possible. And you could definitely get all the amino acids in great.
Now, I would say this, when somebody is trying to keep enough muscle, the the million dollar question is how many how much grams of protein per pound?
I know that people are saying a gram per pound. Listen, I've tried. It is impossible. I'm not eating 200g a day of protein. So you look in the literature very closely, the gram per pound is more bodybuilders.
Well, I'm not interested in being a bodybuilder. Neither are you, though. Your body full, you could kind of look like a bodybuilder, I think. You. What's that?
Plant based a documentary that they even had bodybuilders in a game changer. And they, I mean, they. And I see you in there posing. I not qualified for that.
So the so, so but you need to get. So I do think that you need somewhere between point five and point seven, grams per. And this is all the research that I've read.
0.5 2.7g of protein per pound. And yes, you can get that from, you know, as a Cuban guy, we shouldn't have any problems eating all the rice and beans that that we typically eat.
But soy is actually actually soy because it's not only getting enough protein. It's not protein is amino acids. And particularly the nine essential amino acids soy has the nine essential amino acids is a very good source of protein.
And knowing will not mess up your thyroid if you eat if you eat soy. For most people anyway. All right. Well, let's leave it there. And a two thumbs up for soy, a complete protein.
I want to thank you for your time. You've had a long day. You've seen patients all day. I just invasions all day. We're dedicated clinicians. Tell us again, if people actually want to do a consult with you, this guy seems sharp as a tack.
Plus, he's very handsome, and I want to arrange a telemedicine. Or maybe somebody lives in New York. I want to arrange an office. So where do they find you?
There's doctor, drdo.com, the doctor Geo prostate podcast, all things doctor Geo is on Doctor Goal.com. Thanks so much Rob. Okay thank you. Have a wonderful day and thanks for all your wisdom.
Thank you.
