- Over the past year, I've learned a whole bunch while doing this podcast. I've even changed my mind on a few things. Today, let's dive into what I've learned and what I've enjoyed looking at the last year of podcasts. Here we go. Welcome back team to the Building Lifelong Athletes podcast. Thanks so much for stopping by. I really appreciate it. For those who don't know me yet, my name is Jordan Wrennke and I'm a dual board certified physician in family and sports medicine. And the goal of this podcast is to keep you active and healthy for life through actionable evidence form education. And what we're talking about today is Podcast 100 for me. So this is the 100th podcast I've done. It's kind of crazy to think about it for a hundred straight weeks. I've been here just talking to you, talking to the void that is this camera and microphone. But for anybody listening here who's a real human and not just AI or robot, I really, really appreciate it. Thanks so much. And today we're kind of going back and covering the last 50 or so episodes. So about a year, I think a hundred is kind of a good time to say, hey, let's reflect back and say, I think it's worth celebrating and talking about a little bit. So I'm gonna go back and kind of talk about the things I learned, things I changed my mind on and kind of just going from there. So really kind of a review of the big things I think have changed. And I think I wanna do this every so often, maybe 50 or a hundred episodes, just to kind of say that, hey, it's okay to make mistakes and change your mind and do that. And I'm hoping to use this as a way to kind of make sure I'm holding myself accountable that I'm learning things and I'm changing my mind. So that's kind of where we're at today. And so let's dive in. All right, and first I wanna talk about our testosterone series. So the testosterone, we ended a whole entire season of that and we'll kind of talk about the future moving forward, whether they're doing seasons or not, but I did a whole season in this, so a bunch of testosterone ones. I did this 'cause the internet is just rife with testosterone. Everyone talks about testosterone things and it's crazy. I mean, everywhere you go online, specifically like the bodybuilding world, you talk about testosterone, testosterone, you talk about biohackers and this, it's all testosterone. So I was like, okay, what actually is the deal here in terms of what do we actually know? What is the science show? And so overall I learned a whole ton here, which has been great. And if you wanna dive into it as well, there's a whole entire series, multiple episodes. You can hopefully learn something from that as well. But overall, the big takeaway from the testosterone series was that there are huge variations in testosterone testing. And I kind of learned a lot about the indications for actually testing. And so the big document that I went through is the Ennequin guidelines. So essentially they're, Ennequin Society came up with these guidelines saying, "Hey, when should we test for testosterone?" And the spoiler alert is it's not every single time you feel tired. That is pretty much what you read online. They're like, "Oh, you're tired? We should do that." That's not necessarily the case. They specifically say you're looking for clinical hypogonadism, right? So hypogonadism meaning we're not having a response from the testes, we're not creating testosterone that we want. That's like the big thing. And so they're saying, "Hey, what other symptoms are that? Is fatigue one of those symptoms?" Absolutely. But there's also the big thing they talk about is having issues with like things like erectile dysfunction or inability to climax, all those different things, any sort of sexual dysfunction. It's usually that plus something else. And then we say, "Okay, maybe it's time for testing." But at the end of the day, I'm not here to keep testosterone testing. I think a lot of people I know specifically in primary care are afraid to do testosterone testing because they don't know what to do with it, right? So the problem is you get, it's low, like what do you do with it? And that was me a while back. And that's part of the reason I did this series because I was like, "Okay, I need to become more comfortable with this because I'm seeing people in clinic." And specifically what was happening is a lot of people are coming from these outside testosterone mills, essentially. What I mean, testosterone mills is they see on the side of the road, men's clinic, they come there, they get a testosterone checked and they get started on testosterone and then you're dealing with it. Also, they come back to primary care and they say, "Hey, can I get it through you? 'Cause I can get it through insurance and it's cheaper." And then you're like, "Well, what do I do with this?" And so that's really the inspiration behind why I did this. And I said, "Well, I don't know how to do these people." And so that's why I want us to learn. And I feel much more comfortable and confident with that now that we can do that. And the big thing that I really wanna take away is that there's a couple of them. In terms of testing though, is the importance of a morning fasted testosterone. That's like the biggest thing. A lot of times these people will go into clinics, you know, walk in there and they do testosterone late in the afternoon and they say, "Hey, you're low." And then they'll get prescribed testosterone, which is honestly malpractice, I think. You know, you should have at least two readings of that. So two morning fasting readings. I think that's the most important thing that I wanna think about. So two morning fasting readings. And then from there we can make the diagnosis of hypogonadism. And I'm not gonna go into specifics here. There's a whole season on that. But you know, using your threshold, a lot of times you have local thresholds, depending on what your local lab is. But that being said, a lot of people say, "Oh, it should be up in the high normal, right? Like everyone should be at 700, 800, 900." There's just no evidence for that. Will you feel better there? Maybe, I don't know. And that's the thing. We're walking around who feel miserable at 700, 800. We have people who feel fine at 250. And so it's very variable. And that's the biggest thing as well, is that your number does not equal your symptoms. Meaning, hey, if your testosterone is 300, that does not mean you're gonna have any sort of symptoms or any sort of problem or any sort of sexual dysfunction. It's just a number. And for you, that might be normal. For you, that might be high. And also may depend on your SHGB and all these other things. So there's just lots of variables that go into this. But that is one really important thing, is just don't get a single reading in the afternoon and say, "I have low testosterone. We wanna check in the morning. Wanna repeat." All those things. So from a testing perspective, that's huge. And then another big takeaway I had in this series was the risk of heart disease, essentially is what we're looking at. As a primary care doctor, you are so worried about this. This is what you've heard through my training was, we wanna be really careful. The biggest things you worry about are prostates and clotting and heart stuff. That's the big thing. Prostate risk, kind of hit or miss. That's up for debate. Clotting, absolutely. If you start getting you're manic too high. But the biggest thing everyone worried about was cardiovascular disease. We don't wanna be causing more harm to these people. We don't wanna have that at all. And so that's the one thing we looked at. The really big study I looked at here was called the Traverse Study. Essentially what the Traverse Study was, it looked at those who were already at risk for heart disease and those who were on testosterone. So essentially men who were clinically hypogonadism, where they had a clinical hypogonadism, they were low testosterone, other symptoms as well, but they also had high risk for heart disease. So people who had known cardiovascular disease or something like that, or at high risk for other risk factors. And they looked at this population. They say, hey, they compare these people on testosterone to placebo, and they looked at MACE. So major adverse cardiac events. And what did they find? They find that there was no real difference between testosterone and that. There was non-inferior, testosterone was non-inferior to placebo considering MACE outcomes. Meaning there were no more incidences on average in the testosterone group versus the placebo group. And that's pretty crazy. 'Cause at the end of the day, most people, the big thing they're worried about was cardiovascular risk with testosterone, right? And I think overall, I'm much less worried about the cardiovascular risk of testosterone now after the T And that being said, when you step back, they were looking at regular physiologic doses, right? Not super physiologic doses, physiologic doses. And the difference between that is, you know, someone who's taking testosterone to get their testosterone up into the thousands or something like that. Just really pumping up, whether it's a bodybuilder or just someone who's been misinformed or doesn't have the right provider kind of following them. That is not what they're looking at. They're looking at getting those people kind of like smack dab in the middle. And that was what their goal was. And for these people who did not seem to have a high risk. What this doesn't tell us is about those people who are chilling at like a thousand plus saying, "Hey, I like dealing this way. Do they have the risk?" I don't know. I don't know that I can't say that from here. But the reason I like this study is it's looking at our most essentially fragile and high risk people. And we didn't see an increased risk. So I think getting testosterone replacement back to a physiologic dose, I think that looks relatively safe from a cardiovascular perspective. And that is something I changed my mind on. I was very worried about this and it's become more obvious to me that it's much more safe than I thought it was. Obviously it's not without risks. Absolutely. It's a medication. You're giving medication. There's always gonna be risks. And that's kind of something I have changed my mind on and much more cautious on previously. And now I've kind of loosened the reins a little bit. Not that I'm just giving out testosterone willy nilly, far from that. I think it's still kind of in line with you should have symptoms and all that stuff. But I'm much less scared to do it when I feel like it is appropriate. And just a side note, testosterone is so interesting because this is probably the one thing, this and hormone replacement therapy for postmenopausal women. This is one thing that almost everyone agrees on in terms of, hey, let's do this. Most people who say, I don't wanna, I just wanna do everything natural, everything natural, but I'll actually take testosterone or I'll take whatever. And then the medical establishment as well. So we kind of have both sides, traditional and alternative medicine. This is where they come in the middle and they're like, okay, we can use this. Maybe we're a little more gung ho on the non-traditional side versus traditional, but it's kind of where we meet the middle. I find this funny 'cause this is a medication, just like any other medication. People who are adamantly against any sort of medication for their cholesterol or blood pressure, they say, no, no, no, no, I don't want meds. But I'll take testosterone. And I find that to be interesting and thought provoking 'cause you have to think about, hey, where is this coming from? This is coming from pharma as well. And so pharma doesn't do all bad things. Does it do bad things? Absolutely. But I'd much rather have you taking the controlled testosterone, knowing the dose you're getting, knowing the levels, all those things. So that's just a more of a side note that I find that interesting when people say, I refuse to take medications, but I'll take hormones. It's like, well, it is a medication, but hey, that's not what this rant's all about. But that is essentially what I've learned over the past however many episodes I did on there. I thought it was super interesting. Next, moving on to exercise as medicine. So I did a whole series on exercise as medicine. And I already realized that I have an enormous bias towards exercise. So I'm never not gonna recommend exercise. That's my whole job. I'm a sports med doc. I'm gonna always recommend exercise. But going through this season as well, I didn't really realize how effective it could be for multiple issues. Once again, this was a deficiency in my knowledge base. So I said, hey, I wanna go after this. I wanna learn more about this so I can prescribe it better and understand the benefits of it. And so that's really the idea of the whole series here. Essentially, I was interested 'cause, specifically looking at disease pathology, right? So some medications, we know what they're doing, right? But exercise can be as beneficial for some medications. Specifically looking at things like antihypertensives or antidepressants. I couldn't believe that first line, antihypertensive, we might get anywhere from five to 12. If you're starting it up in the double digit range, it's probably a little bit of an exercise. But if you're getting on the lower end, exercise can drop your systolic anywhere from four to eight-ish is kind of the idea of millimeters of mercury. And that's kind of in line with antihypertensive. So you're kind of there. And then the big thing I thought about was exercise in terms of had some efficacy that was similar to antidepressants. And I thought that's super, super cool. And obviously that's a whole can of worms. You can say, hey, just exercise yourself out of depression. What if you can't get out of bed in the morning 'cause you're so depressed? If it's like, oh, you're just gonna exercise. I'm not saying that at all. But I do think about using exercise as a prescription, right? We don't do that a lot. And that's something that's why I wanted to learn about this. Hey, how can I do that? And what can we, what does it look like? I know I've talked about how to prescribe exercise using the FITT, frequency, intensity, time, and type. So you're kind of talking to patients that can be as simple as, hey, what are you doing? Oh, you're doing nothing? Okay, well, we're down. We've got some mild depression. I'm not saying severe depression, mild depression. What kind of exercise you wanna do? Okay, cool. You wanna do, you can go on a light jog. Great, let's do that. Let's do it for 10 minutes, three times a week at a moderate pace. And you use a moderate meaning doing the talk test. You can talk a little bit, boom, that's it. That's prescription. And I can write that down and I can give that to patients. And I've started to do that now with certain things, especially with diabetic patients start prescribing exercise. And so really that's what it's been for me and what I've changed my mind about on this. Well, not a whole lot. I knew exercise was good. This is one of those ones where I came in very biased. Like, okay, let's see how good it is. Not like open my eyes. Let's see if it's actually worthwhile because there's so many benefits I was never gonna not recommend it, right? So even if they said it wasn't as strong as hypertensive medications or antidepressants, would that sign for prescribing it? No, 'cause we know it's so good for so many things, but it's really kind of changed my mindset where I wanna double down on prescribing exercise, right? So now I'm gonna talk with patients all the time. I talk to them where they're at and then prescribe exercise for them. And I think this needs to be considered a medicine and I'm really trying to work on spreading this message. So once again, it's not necessarily the easiest thing when you're in primary care and you got 15 to 20 minutes in there and you're moving in and out, but when you're very good at prescribing medications 'cause you learn that, right? I think a lot of times we just haven't learned about exercise as a medicine. And so it should be something we should be going for, should be something we're doing. And I think that's something I'm working on as well, but I wanna get to the point where I'm prescribing exercise just like I'm prescribing a medication and I'm getting my colleagues to do that as too. That's like my main goal. Moving on to the next series here, talking about osteoarthritis. So I kind of picked out common issues or common talks in primary care, so prominent MSK conditions, something like that. I kind of went through a whole season of that. And I wanna talk about osteoarthritis 'cause I thought this was interesting. The old theory was that we had kind of wear and tear, right? So osteoarthritis was the wear and tear and that you hear all the time. You still hear it in clinic. People say, "Hey, this is wear and tear." And it's a nice, easy theory, right? It's easy to explain like, "Hey, as you age, things wear down, this is wear and tear arthritis." But it's kind of not necessarily true. The new theory is that it's actually still very metabolically active and inflammatory nature. It's not quite inflammatory like rheumatoid arthritis, psoriatic arthritis, anything like that, but it's not benign either. It's not just like, "Oh, wear and tear." There's some inflammatory nature of that. And so for me, I've kind of shifted my viewpoint and I'd say there's kind of two buckets here for arthritis, right? There's people who like rupture their ACL when they're young and now they're having post-traumatic arthritis or had a car accident. Like that is significantly different than the standard run of the mill arthritis. If you had that trauma, you're probably gonna get post-arthritic changes. That's common after ACL or big trauma in the knee. So that's not what I'm talking about here necessarily. What I'm talking about is someone who just chronically had, you know, quote, "bad knees" and "I got arthritis." And just the more and more I learned about it, I've kind of doubled down on the idea that adiposity and excess adiposity specifically is a risk factor for developing osteoarthritis. And there's a strong correlation between the two. So I think essentially having increased visceral fat, having adiposity, having obesity, all these things increase your risk for OA. And so I've kind of spun it now thinking that if I'm treating non-traumatic osteoarthritis, right, I should be treating the metabolic health of that patient as well. So that's a big, big change for the entire field of orthopedics, right? 'Cause traditionally orthopedics, not the non-operative folk, but if you do orthopedic surgery residency, you go straight into orthopedic surgery, right? So that's what you do, it's what it is, it's not necessarily thinking about metabolic health. What's kind of unique about our pathway as primary care sports medicine is I learn all about primary care first, right? So I've dealt with metabolic disease, diabetes, hypertension, insulin resistance, you name it, I've dealt with it and done it. And then now kind of looking through that lens, seeing what's happening and what we're learning about arthritis, it's very interesting to say, hey, maybe there's this huge metabolic component that's actually there and how do we change the metabolic health and will that treat OA? We're still very, very early on in this and so I'm not gonna say, hey, I have the answers, but I've just kind of been seeing in literature and we're kind of tying consistently with OA and obesity and adiposity and diabetes, all these things that we'll never think, okay, could treating the underlying problem of those things improve our OA? And a lot of times the treatments are the same, right? We're calling exercise and nutrition, all those things, and we might lose weight and that might improve it as well in terms of just decreasing the metabolic or the mechanical load on the knee, all those things we're thinking about. But I think thinking about it as a metabolic disease, like kind of equivalent, meaning, hey, you have metabolic disease, now you have OA, you kind of go hand in hand, I think it's kind of paradigm shifting and it's not widespread yet and I think it's gonna get there. And that's like my bold prediction for the next couple of years is that we're gonna learn more and more and more and start to shift and see arthritis, not as a wear and tear, but as another chronic disease that is potentially preventable through lifestyle changes, which is crazy to think about and I'm not entirely confident in that. I'm not hanging my hat saying, this is definitely it and there's nothing, we do see a higher prevalence in older age, but we also see comorbidities in older age. So that's my kind of like general idea, general idea. And going in the future, will we start seeing weight loss prescriptions, medications used for OA? I don't know. So obviously people who have getting GLP-1 agonists or anything like, or the GIP or getting any of those medications, a lot of times they have risk factors, right? They have obesity, they have maybe insulin resistance or diabetes. So using those to help lose weight and improve those things, will that improve osteoarthritis? I don't know. I'm pretty much willing to bet that it will, not necessarily explicitly from there, but from the other side effects of losing weight and improving insensitivity, all that stuff. And that's kind of where I think we're going. And this is research I've kind of looked at was help me realize that inflammation due to adiposity plays an impact all throughout the body, right? So it's not just like we used to think fat is benign or adipose tissue is benign, it's not, it's very inflammatory, it's very reactive. And so adipose tissue plays a pro-inflammatory role in the body, all throughout the body. And it looks like that is the same for arthritis as well. And so what I'm kind of thinking here moving forward is how do I treat someone, obviously not only short-term, like, hey, they're here for short-term pain, but how do I treat them long-term? And I think a lot of times it's been about counseling. I've definitely found myself doing that more and more with my patients talking about that. Obviously time permits only so many things in terms of long, deep dive discussions on what's going on, but it's definitely something I've, it's opened my mind and I've kind of been more open to it and I'm looking for it. Next, moving on to our lab work. So the lab work was kind of a fun one. We looked at different variables and different labs and how they are affected by exercise or whatnot. And I thought it was super interesting. I thought, I was really surprised at like the normal variance in labs. That was like the big takeaway is we think our labs are super accurate and they're really not. It was a pretty decent amount of variance. And so someone have to consider when ordering and interpreting labs is, hey, what's going on there? Some have tons of variability. So we need to consider that when ordering. Just the other day I was on inpatient and we had a patient whose hemoglobin was, let's just say nine, right? We'll say nine, say, hey, it's like trending down. Like, oh, I'm worried about it. And we rechecked it again later that afternoon. And it was back up at 9.4. And it's like, did it really shift that much in a day or was that just the variability? And so I had a good discussion with my residents saying, hey, when we order things like hemoglobin, there's a certain amount of variance that we're going to see. And that's just under important understanding, making decisions. If you hit a quote unquote threshold, right? By one test and say, oh my gosh, I'm worried about it. But then the next test might be very different. It might go the other direction. So a lot of times I may trust, but then verify again, meaning if you have a lab work and you don't necessarily agree with it or you're making a big decision off of it, a lot of times you want to confirm and redo it to make sure you're in the right direction. So that was one thing is just the variability and that I don't have as much trust in labs as I did before, which is kind of interesting. I still use them. Obviously every day of my life, I'm ordering labs. That's what it is. In general, they're very good. They're still very good because the variance that they have is usually not clinically important. And so let me say, I say there's lots of variants, but not like huge wide ones. That's why our most common tests are really good because they have a narrow window, but they have a window. And so that's why being granular, like your human global A1C, it's like, oh man, it went from like 6.3 to 6.4. Like it's heading the wrong direction. Like are you or could have been 6.2 if the variability was there. So assessing trends can be difficult, but overall we still know that it's pretty tightly controlled so they're still trustworthy labs. I'm not saying throw out labs, don't get labs. I'm just saying interpreting them, understanding the natural variance is something important. And the other big takeaway I took from this was exercise affects a ton of labs. That's one thing specifically I've been working on and looking at and understanding, hey, how does this happen? 'Cause a lot of times there's this population, right? The people listening to this podcast, if you're not a healthcare provider, someone who's interested in this, a lot of times these people get labs and then may might have some abnormalities, especially if you're working out, right? If you have a lot of muscle and you work out, you can have abnormalities and then this leads to this whole wild goose chase, right? So the biggest thing specifically is people when they talk about their GFR, right? So glomerular filtration rate, things looking at their kidneys or their creatinine. If you have lots of muscle or you take creatinine, your creatinine might be through the roof and then all of a sudden your primary care doc's worried and then you're going to the nephrologist, the kidney doc and everyone's worried and then they say, you're good, man. Like you just eat a lot of protein and you've got a lot of muscle mass. And so that's been cool to see, but we see that affected for lots of different things. Obviously the answer to that is probably getting a sesatin C, which is a different lab that takes away the G creatinine out of the equation. So we get rid of that and it's very similar and it's not affected by body mass really as much. But the long story short is that if you're getting labs, don't work out that morning. I'm about to go get labs in the next couple of weeks. I'm not gonna work out in the morning. It's gonna ruin my whole day and throw off my schedule, but it's worth it to get a accurate depiction of what's going on with the labs. And so, but if we're gonna get labs within 24 hours, I tell people to hold off on exercise. I think that's really important. And so moving on here and looking ahead, what's in the future, right? So I'm excited for the next 50 podcasts. I've learned so much and I've changed my mind on things. As you can see, I've grown as a clinician and that's so cool. That's the biggest thing for me and I've just really enjoyed it. And once can I, anybody who's fallen along and finds this nerdy stuff I'm talking about interesting, I really appreciate you 'cause it is kind of a way for me to better myself and learn and make myself better. And that's really what I'm going for. And hopefully I'm just taking people along for the ride as well. And moving forward, I'm gonna try to switch up the podcast format just a little bit. I think I'm getting rid of seasons. I think a lot of times doing five to 10 episodes of the same topic can be a little long for people. For me, it works in my workflow of deep diving on stuff. But I think at the end of the day, this allows me to cover more topics and I can kind of adjust a little faster, talk about more timely things if need be. I think one thing that I really enjoy doing is finding things that everyone's talking about and talking about them in real time so that we can add my take to them as well. I'll still plan on doing deep dives every once in a while, but they're gonna be a little more flexible. So maybe I have a couple multi-part series or go deeper, but either way, we're gonna do a lot of different things here. I'm also gonna try to review a little more literature specifically, but then I'm gonna try to mix in research reviews, deep dive on topics, but probably not gonna have prolonged seasons like I have previously, just so we have a little more variety. But if you strongly disagree with that or want me to change, let me know. Please head over to my website and give me comments or leave a post on the YouTube video and say, "Hey, like Jordan, don't do that. That's a terrible idea." But that's kind of what we're looking at here. But overall, anybody listening, once again, thank you so much. There are a billion podcasts out here, but the fact that you're listening to me is truly humbling and truly amazing. It really is humbling and it means the world to me. But here's to another 100 podcasts. Thanks for keeping this going. And if you do enjoy it, please share this with a friend, give it a five-step review on your podcast, platform or choice. I really, really appreciate that. Now get off your phone, go outside, have a great rest of your day. We'll see you next time. Disclaimer, this podcast is for entertainment, education and informational purposes only. The topics discussed should not solely be used to diagnose, treat or prevent any condition. The information presented here was created with an evidence-based approach, but please keep in mind that science is always changing. And at the time of listing this, there may be some new data that makes this information incomplete or inaccurate. Always seek the advice of your personal physician or qualified healthcare provider for questions regarding any medical condition.
