Barry Rotman, MD

Unlock Your Potential: How to Naturally Boost Testosterone Levels

Every time I see a commercial for testosterone replacement, I cringe.

The United States is one of just two countries that permit direct-to-consumer pharmaceutical advertising (the other being New Zealand). As a physician with almost four decades of medical experience, I find it concerning that Congress believes 60 seconds of information delivered to a non-professional should influence my prescribing decisions.

It’s through this lens that I consider the surge in men seeking testosterone therapy.

The Challenge With Self-Diagnosis

Advertisements promoting testosterone therapy paint a broad picture: mood swings, depression, anxiety, low self-esteem, mental fog, fatigue, reduced sex drive, increased body fat, decreased muscle mass, sleep problems — what man hasn’t experienced some of these symptoms at some point?

From 2003 to 2013, testosterone prescriptions increased fourfold for men aged 18–45 and threefold for men aged 56–64. The rates keep climbing. “Men’s health clinics” — often just testosterone prescription centers — have multiplied across the country.

If someone’s only tool is a hammer, they’ll treat everything like a nail. Yes, some men have low testosterone and would benefit from replacement therapy. But many others could naturally boost testosterone levels by addressing underlying causes.

For instance, I recently saw a patient — a healthy man in his 40s — whose testosterone levels dropped after a weekend of heavy drinking and poor sleep. His first instinct was to ask me about testosterone replacement options rather than examining his habits.

The Leaky Roof Problem

Think about a leaky roof. Your body not producing enough testosterone is like that roof leak. You have two options: put on a raincoat or fix the leak.

In this case, testosterone supplementation is the raincoat, and addressing the root causes of low testosterone is fixing the leak. The raincoat might keep you dry, but wouldn't you rather repair the roof?

Why Your Testosterone Might Be Low

Low testosterone stems from two main types of hypogonadism — a medical term for when your body isn’t producing enough testosterone. Basically, something in your body isn’t optimal, and your evolutionary quality control is putting the brakes on reproduction.

In other words, Charles Darwin doesn’t think you should have kids right now.

Primary hypogonadism occurs when your testicles can’t produce enough testosterone on their own. Think of it like a factory that’s lost its manufacturing capability. This can happen due to:

• Inherited disorders
• Physical trauma to the testicles
• Hemochromatosis (iron storage disease)
• Cancer treatment side effects

Secondary hypogonadism is more common. Here, the problem lies with your brain’s signaling system — the hypothalamus and pituitary gland don’t send proper signals to tell your testicles to make testosterone.

This can result from:

• Abnormal hormone levels, like prolactin
• Iron storage disorders affecting the pituitary gland
• HIV/AIDS
• Thyroid disease
• Chronic pain medication use
• Type 2 diabetes
• Kidney disease
• Liver disease
• Lung disease
• Sleep apnea
• Steroid medications
• Alcohol overuse
• Severe stress
• Nutritional gaps
• Too much or too little exercise

Nature’s Warning Sign

Low testosterone acts like a canary in a coal mine — a warning that something needs attention. When your body reduces testosterone production, it’s indicating that conditions aren’t optimal for reproduction.

This signal deserves investigation, not just medication.

In fact, using testosterone or testosterone-like supplements can actually suppress your body’s natural production. Some men, particularly younger ones who misuse these substances, face permanent fertility problems even after stopping.

How to Naturally Boost Testosterone Levels

To naturally boost testosterone levels, start with self-reflection. Take an honest look at your:

• Sleep quality and quantity
  • Get tested for sleep apnea if you snore
  • Aim for 7–8 hours of quality rest
  • Maintain a consistent sleep schedule
• Stress levels
  • Build stress management habits
• Exercise habits
  • Balance exercise without overdoing it — both overexercising and underexercising can lead to low testosterone
• Nutrition
• Alcohol consumption
• Medication use
  • Talk with your doctor about alternatives to steroids or opioids
  • Never stop medications without medical guidance

The Smart Path to Natural Testosterone Production

Some men need testosterone replacement, particularly those with age-related declines not linked to correctable conditions. However, many can naturally boost testosterone through lifestyle changes.

If you think you might have low testosterone, start by examining your habits and health. If you still feel testosterone therapy might help, work with a medical provider who will thoroughly evaluate all possible causes — one who looks beyond quick fixes to find the true source of the problem, like the physicians at Banner Peak Health.

Don’t just buy a raincoat. Fix the roof.

by Barry Rotman, MD

Anabolism vs. Catabolism: How to Balance Both for Healthy Weight Loss

This year, my Thanksgiving dinner table conversation included weight loss efforts. My friends and family members reported their eating and aerobic exercise habits. No one mentioned resistance training.

Resistance strength training is essential for successful weight loss. To understand why, we must first understand anabolism and catabolism.

Anabolism vs. Catabolism

Catabolism is the process of breaking complex molecules into smaller ones to release energy as ATP, a chemical fuel for the body. ATP allows cellular functions, growth, and movement.

Anabolism builds complex models from simple ones through a process that requires ATP.

Anabolism and catabolism exist in a balance called homeostasis, which reflects the body’s metabolic condition.

Weight Loss Isn’t Just Superficial

Weight loss’s effects go beyond physical appearance. It improves almost every aspect of your health, including your health span (the number of years you enjoy optimum health).

To do that, we need to increase muscle mass and reduce fat tissue. How we lose weight determines what happens to those two components.

In traditional caloric restriction dieting, we consume fewer calories than our bodies metabolize, i.e., the body eats itself. When this happens, about 25% of weight loss comes from muscle and 75% from fat. For example, if you lose 10 pounds, 2.5 pounds will be muscle, and 7.5 pounds will be fat.

Fat cells are endocrinologically active. They skew our bodies metabolically in negative ways, and we want to get rid of them.

Muscle cells skew our bodies positively. Losing muscle puts some people at risk for sarcopenia — a lack of adequate muscle mass.

Muscle Mass and Metabolism

The body metabolizes (i.e., burns up as energy) 70–90% of its glucose in the muscle cells. The more muscle cells we have, the more adequate our glucose balance and quantity, and the healthier we are.

Muscle mass is how we:

• Preserve function, including our ability to move and perform tasks, and our ability to stay strong and balanced to reduce fall risk
• Preserve our quality of life
• Preserve and extend our life expectancy

As we age, we produce less hormones involved in muscle maintenance, such as human growth hormone and testosterone. People also tend to do less weight-bearing exercise as they age, so the muscles receive less stimulus to maintain their mass. And as we age, anabolic resistance (where it becomes harder for the muscles to build up from anabolic processes) makes it harder to maintain muscle mass.

Think of muscle mass as money in the bank. We invest our money early to ensure a comfortable retirement decades later. In the same way, lay down muscle mass when you’re young and energetic so it’s there to maintain later.

Balancing Anabolism and Catabolism

This brings us back to anabolism and catabolism.

You lose muscle mass if your body skews toward catabolism. Be exceptionally careful during that catabolic process to maintain muscle mass. Otherwise, you risk sarcopenia.

The Dangers of Weight-Loss Drugs

You’ve probably heard of a new, powerful class of weight-loss drugs, including Wegovy, Mounjaro, and Ozempic.

These GLP-1 receptor agonists (such as semaglutide and liraglutide) induce such strong catabolic states that they’re associated with 10–40% of weight loss as muscle mass. This happens because:

• Your body is strongly catabolic, breaking down lots of tissue.
• You’re making behavioral modifications. People often use these drugs in conjunction with dieting, markedly reducing caloric intake. However, calories provide the fuel your body needs to function. A person’s body can’t keep up with normal activity during rapid and extreme diet and weight loss, and muscles atrophy because of this reduced activity. With less energy for anabolic processes to maintain muscle, the balance shifts further to catabolism.
• Your appetite is suppressed. Patients taking GLP-1s crave carbohydrates and fat instead of protein, leading to muscle loss.

How to Optimize Anabolism and Catabolism to Lose Weight Safely

Prioritize losing the right weight: fat, not muscle mass. At Banner Peak Health, we don’t think about weight in isolation. Instead, we consider the relationship between anabolism and catabolism, and we use several techniques to facilitate fat loss and preserve muscle.

If you’re on a GLP-1 receptor agonist, you’ll complete an InBody composition scan every time you visit the office. We’ll measure your muscle mass vs. fat mass to ensure you lose less of the former and more of the latter.

We also help our patients increase their protein intake as a percentage of reduced total calories.

Healthy weight loss requires work — aerobic exercise, strength training, and protein consumption — and our physicians are here to help. Reach out today and tell us about your weight loss goals.

by Barry Rotman, MD

Beyond the Pill: Natural Ways to Fight Depression

Unfortunately, depression isn’t rare. Approximately 3.8% of people experience depression at any point during the year (including 5% of adults), and every individual has a 29% risk of being diagnosed with depression in their lifetime.

Although medication is a common treatment for depression, it’s not a cure-all. The response rate of a major symptom reduction is usually only 50–60%. (A placebo’s symptom reduction rate is 30–40%.)

Introduced in the 1980s, Prozac was the first selective serotonin reuptake inhibitor (SSRI). However, the difference between the drug effect and the placebo was slight, and so few studies showed efficacy that Pfizer had to cherry-pick studies to get FDA approval.

Drugs don’t cure depression. We still don’t understand the biochemistry behind depression, which is why our drugs’ efficacy is so poor.

Therapy has documented efficacy for depression. It’s harder to study than drugs, but medication and therapy combined can achieve up to an 80% reduction in symptom scores.

Because we don’t have a single depression-busting magic bullet, we treat it through stacking (also called the “everything but the kitchen sink” method). By bundling modalities, including natural ways to fight depression, we see more benefits than with any single treatment. 

So, can depression be treated without medication? Absolutely.

A Physician’s Caveat

Medical literature offers varying degrees of support for natural ways to fight depression.

The safer a treatment, the more likely I am to recommend it to a patient even if it lacks strong, supportive data. It all comes down to the risk-benefit ratio — if a treatment’s risk is low enough, I’ll try it.

These therapies are safe, and I’m not bothered by the paucity of data on their efficacy. That said, don’t consider or use them in lieu of medication or therapies prescribed by your physician. Talk to your doctor first.

12 Non-Pharmacological Treatments for Depression

The following are my top recommendations on natural ways to fight depression and other non-pharmacological treatments for depression:

Sleep Enhancement

Sleep impairment is associated with emotional illness, including bipolar disorder and depression. Any action taken to enhance sleep mitigates these conditions’ symptom burden.

Every other treatment on this list improves sleep.

Light/Chronobiology

Circadian rhythm is a large component of emotional illnesses such as bipolar disorder and depression. Re-synchronizing your circadian rhythm with light therapy can play a prominent role in these therapies.

At Banner Peak Health, we recommend the TUO light bulb to help re-sync your circadian rhythm. Get as much morning light as possible, and be cautious of using sunglasses during the first few hours of the day. Morning light is a powerful signal for your circadian rhythm.

Fish Oil

While literature supporting its effects on the heart is controversial, literature supporting fish oil’s antidepressant effects is strong. Just one to two grams daily helps manage depression (and may also improve your heart health).

Meditation

Mental health is associated with greater sympathetic discharge (cortisol, stress, and anxiety). Meditation, including breathing exercises, reduces your stress response and improves your mental health.

Exercise

Aerobic and strength training exercises reduce stress, enhance sleep, and improve mood. It’s a valuable weapon in the fight against depression.

Nature

We’ve evolved over hundreds of thousands of years to exist in nature. Our urban environment is so new that we haven’t evolutionarily adapted to it yet. Exposing yourself to nature helps you harness your evolution to your benefit.

Pet Ownership

People who own pets or even have access to visiting pets in nursing facilities have better mental health.

We live more solitary lives than ever before in our evolutionary history. Any contact with human beings or pets connects us to how we evolved to survive, both physically and mentally.

Nutrition

When our mental health declines, we crave substances like sugar, fats, and caffeine that worsen, rather than improve, our emotional state.

To improve your mental health, adopt a healthier diet.

Avoiding Substance Abuse

When we’re not feeling our best, we gravitate toward substances that hurt our mental health. We’re better off when we eliminate marijuana, alcohol, nicotine, and other counterproductive exogenous substances from our lives.

Acupuncture

Acupuncture is a proven non-pharmacological treatment for depression. Anyone who’s had it has felt its calming, centering effects. It’s worth a try if it’s available in your area.

Vitamin D

Higher vitamin D levels are associated with many better medical outcomes, including mental health. However, whether taking supplemental vitamin D improves medical outcomes remains controversial. Fortunately, taking supplemental vitamin D is safe in almost all circumstances.

Of note, please discuss this with your doctor, as there are some rare conditions in which over-the-counter vitamin D may not be helpful.

Herbal Supplements (e.g., St. John’s Wort)

St. John’s Wort is one of many substances and herbal supplements recommended for treating depression. However, the data documenting their efficacy is meager, and the side-effect ratio for some supplements is not as benign as other modalities we’ve discussed.

For example, St. John’s Wort can cause the following side effects:

• Headaches
• Dry mouth
• Confusion
• Anxiety
• Stomach upset
• Drug interactions

I’m including St. John’s Wort and other herbal supplements for completeness, but the risk-benefit ratio is not as good as the other modalities on this list. People inevitably ask about them, but I’m not bullish on them.

Today’s Takeaways

Stress and depression are ever-present in our modern world. Fortunately, there are many effective non-pharmacological treatments for depression with exceptional risk-benefit ratios.

If you’re struggling with your mental health, please reach out to a therapist or schedule an appointment with a Banner Peak Health physician. We’re here to help.

If you need immediate assistance or know someone who does, help is available 24/7 at the Suicide and Crisis Lifeline. To access it, dial 988 from any phone.

by Barry Rotman, MD

How to Keep Your Knees Healthy: Preventing Injuries and Pain

With enough wear and tear, all mechanical devices (e.g., engines, hinges, tires, etc.) degrade.

For many years, conventional wisdom said the same about our knees. They were just biological hinges that would inevitably give out over time, especially with overuse, such as running. Trying to figure out how to keep your knees healthy was a lost cause, especially for athletes.

A study that began in 1984 turned this notion on its head.

How to Keep Your Knees Healthy: The Shocking Truth

Doctors at Stanford tracked two study groups to test the hypothesis that knees are analogous to mechanical hinges that wear out over time.

The study followed 45 recreational, long-distance runners and 53 non-runner controls over 18 years. The participants were predominantly men with a mean age of 58. The runners had at least 10 years of running experience and ran an average of five hours per week.

At the beginning of the study, 6.7% of the runners and 0% of the non-runners showed X-ray evidence of arthritis. The participants had X-rays of their knees taken every few years.

At the end of the 18-year study, the results flabbergasted everyone: 20% of the runners had evidence of some form of arthritis, while 32% of the controls did. Even more startling? Only 2.2% of the runners had severe, disabling arthritis, while 9.4% of the controls did.

The non-running controls had over four times the rate of severe arthritis in their knees as the runners. The results contradicted the original hypothesis and debunked the myth that running damages knees.

Important Caveats

The study’s participants were:

• Uninjured
• Mostly men
• Over age 50
• Recreational, long-distance runners

The study definitively answered whether knees wear out over time for that population. They don’t.

Unpacking the Conventional Wisdom

Where did the notion that athletes have “bad” knees (or are destined to) come from?

Countervailing literature on high-intensity sports, including ballet, soccer, wrestling, and weightlifting, shows that athletes can have three to six times the level of degenerative arthritis as non-athletes.

When you examine the literature for sports that have increased rates of degenerative arthritis and remove injured athletes, there’s no increased risk of degenerative arthritis. The literature tells us that running makes a healthy, uninjured knee healthier.

Conversely, a sport that injures a knee causes the knee to wear out faster. The goal is to safely participate in sports that can strengthen the knee without injuring it. How can you find the right balance?

Let’s examine the knee’s anatomy to understand why this happens and how to keep your knees healthy with appropriate exercise.

The Knee’s Anatomy

The knee contains “hard stuff” and “less hard stuff.”

The “hard stuff” is bones:

• Femur
• Patella
• Tibia
• Fibula

The “less hard stuff” is cartilaginous tissue, tendons, and ligaments:

• Lateral meniscus
• Medial meniscus
• Lateral collateral ligament
• Medial collateral ligament
• Anterior cruciate ligament

The lateral and medial meniscus act like washers to cushion the areas between the bones. The ligaments connect the bones and align your knee.

When the anatomy works well, exercise perfuses the soft tissues and cartilage. Cartilage is avascular, meaning it contains few or no blood vessels. The medial meniscus, for example, gets nutrition from the synovial fluid.

Synovial fluid bathes and lubricates the entire knee joint when you move your knee. The more effectively you move your knee, the more you nourish those soft tissues.

If you injure your knee — for instance, if you tear a meniscus or ligament — you change the knee’s mechanical alignment. At that point, you’ve disturbed the anatomy of the knee and changed how the force is distributed within the joint, which increases your likelihood of generative arthritis and joint wear.

In contrast, maintaining an injury-free knee strengthens it.

How to Keep Your Knees Healthy

With this understanding of anatomy and pathophysiology, here’s how to keep your knees healthy:

1. Exercise. It strengthens the bones and enhances the knee’s surrounding musculature, protecting and aligning it. Exercise also moves the synovial fluid around, maintaining cartilage health.
2. Practice extreme caution with high-impact, injury-prone sports. Every sport, even running, can injure you. If you participate in high-risk sports, maintain your flexibility and strength, and don’t overdo it.
3. Remember that running is a double-edged sword. When done properly, it’s good for your knees, but if you injure your knees while running, your risk of arthritis increases. Practice safe running techniques:
   • Pay attention to your gait. Watch videos online or talk to a coach.
   • Wear appropriate footwear. Use insoles if you need them for proper alignment.
   • Avoid carrying extra body weight if possible, but if you must, maintain strength and flexibility. Extra weight demands more of your knees.

If you feel pain, remember that musculoskeletal pain is a message from your body. Don’t ignore it. Figure out what your body is trying to tell you.

Knee pain can be a valuable lesson if you listen to your body and decipher its message. Did you run too far? Do you have a bad gait? Do you need different shoes? Listening to your body is the best way to keep your knees healthy.

At Banner Peak Health, we’re proud to offer the resources you need to achieve optimal health through our Outperform program, including access to fitness instructors. Contact us today to take advantage.

by Barry Rotman, MD

Your Guide to Belly Breathing: Benefits, Techniques, and More

I’m 62 years old and have taken about 500 million breaths. Recently, I learned that most of these breaths were done improperly.

Why do we breathe? We take in oxygen for our metabolism to generate energy. We exhale CO₂ (metabolism’s byproduct) to expel it from our bodies.

Given the vital necessity of breathing, we’ve evolved a complicated, sometimes redundant breathing mechanism. It involves a multitude of muscles that expand the lungs (to inhale) and natural elasticity that contracts them (to exhale). The muscles involved are:

• In the neck
• In the shoulder girdle
• In the chest wall
• The diaphragm (one big muscle that lines the bottom of our lungs and depresses)

These muscles make up the redundant anatomy, which we use in different combinations.

Different Forms of Breathing

There are two types of breathing: chest breathing and belly breathing.

Chest breathing is the predominant type and involves the muscles on the sides of the rib cage, in the neck, and in the shoulder girdle.

Belly breathing, or diaphragmatic breathing, relies on the diaphragm to depress the lungs into the abdominal cavity and enlarge them.

How Breathing Develops

As newborns and young children, we default to belly or diaphragmatic breathing. It’s more efficient — bringing the diaphragm down expands the lungs more efficiently than chest breathing.

Because of the functioning of our nervous systems, most of us transition to chest breathing at some point in life. As we become more anxious, we become more sympathetically driven (i.e., the sympathetic nervous system, fight or flight) in how our autonomic nervous systems coordinate our breathing. We tend to take more shallow, rapid breaths with our chest walls.

Belly breathing is more calming. It involves a more parasympathetic (i.e., rest and digest) tone that consists of the diaphragm coming downward.

The Cycle of Stressful Breathing

Improper breathing creates a vicious cycle: We breathe improperly because we’re stressed, and our breathing mechanism becomes more stressed (sympathetically driven) because we breathe improperly.

So, how can we escape the cycle?

We can retrain our bodies to use distinctively diaphragmatic breathing like babies do. Watching a baby breathe, you’ll see the tummy move up and down. That’s the kind of breathing you want to mimic.

Retraining Your Brain to Breathe Right

The autonomic nervous system is a two-way street. It causes us to breathe a certain way; however, if we consciously breathe a certain way, we can rebalance our autonomic nervous system.

This rebalancing begins with consciously recapturing (or relearning) diaphragmatic breathing.

Benefits of Diaphragmatic (Belly) Breathing

Studies show many benefits associated with belly breathing. The most common are:

• Increased parasympathetic tone, which can lead to:
  • Increased heart rate variability
  • Reduced anxiety
  • Reduced cortisol
  • Reduced blood pressure
  • Reduced heart rate
• More effective and efficient breathing:
  • More oxygen is taken in
  • More CO₂ is expelled
  • Increased athletic performance
  • Improved cognition
• Reduction in GERD (gastroesophageal reflux disease)
• Reduced neck stress
• Improved posture

Organs below the diaphragm and muscles above it work better with belly breathing. People who belly breathe experience less stress in their neck and shoulder muscles and also have less gastroesophageal reflux.

How to Practice Belly Breathing

Although breathing is an unconscious process, we can reprogram our default (how our unconscious breathing works) through conscious training.

To apply this training, follow these instructions for five to 10 minutes, three to four times daily:

1. Lie on your back with your knees bent and a pillow under your head, or sit upright in a chair with your torso upright and your feet flat on the floor.
2. Place one hand on your upper chest and one on your abdomen, slightly below your ribcage.
3. Inhale slowly through your nose.
4. Focus on feeling your abdomen rise under your hand.
5. The hand on your chest should be still.
6. Exhale through pursed lips. You should feel your abdomen fall, and your chest should remain still.
7. Repeat for 5–10 minutes.

Let your hands guide you. If the hand on your chest moves, you’ve got it wrong. Correct your inhalation so only the hand on your abdomen moves.

You’ll have to think about every single breath. Eventually, this technique will lead to a shift in your automatic breathing.

As-Needed Breathing Techniques

We all deal with stressful situations in which focused breathing can help us relax. These techniques will help you do just that, and plenty of literature supports their efficacy.

Box Breathing

Box breathing is perfect for improving focus and marshaling your resources when you’re feeling overwhelmed. Don’t think of it as just another hippy-dippy, granola-loving new-age practice. Navy SEALs and tactical police officers use it in high-stress situations.

Here’s how to start:

1. Inhale for a count of four.
2. Hold your breath for a count of four.
3. Exhale for a count of four.
4. Hold your breath for a count of four.
5. Repeat.

4-7-8 Breathing

When you’re feeling anxious or stressed, the 4-7-8 breathing technique can help. Many people also find it useful when they have trouble falling asleep.

Here’s how to practice it:

1. Inhale through your nose into your belly (use belly breathing) for four seconds.
2. Hold your breath for seven seconds.
3. Exhale slowly through pursed lips for eight seconds.
4. Repeat.

Today’s Takeaways

After so many blogs chronicling stress’s adverse effects, I’m happy to offer practical, cheap, operational techniques to tip the scales in the other direction.

Try paying attention to how you breathe. See if making a conscious effort to revert back to belly breathing improves your life.

Identifying the latest science-backed ways to improve your health is a huge part of what we do at Banner Peak Health. If you want to learn how we can help you improve yours, we’re just a phone call or email away.

by Barry Rotman, MD