You probably think of the health effects of sunlight as a mixed bag. On the one hand, sun exposure helps your body make vitamin D. But on the other, it can cause skin cancer.

To get around this conundrum, dermatologists frequently recommend avoiding sun exposure when you can, slathering on sunscreen when you can’t, and taking a vitamin D supplement to make up for the lack of sunlight in your life.

Yet in seeking to solve one problem, this advice may open up many others and be contributing to ill health in the West.

Today on the show, Rowan Jacobsen, a science journalist who has spent years investigating the health impacts of sunlight, will unpack the underappreciated benefits of sun exposure, and that, crucially, they’re not primarily a function of the production of vitamin D and can’t be replaced with a pill. We talk about what else is at work in ultraviolet radiation’s positive effects on blood pressure, autoimmune diseases, insulin resistance, mood, and more. We also get into how to weigh these benefits against the risk of skin cancer, why health officials in Australia, which has the highest rate of skin cancer in the world, have changed their recommendations around sun exposure, and if there’s a role sunscreen should still play in your routine.

Resources Related to the Podcast

• Rowan’s article in Outside magazine: Is Sunscreen the New Margarine? 
• Rowan’s article in the Atlantic: Against Sunscreen Absolutism
• AoM Article: Why You Should Become a Sun Worshipper
• Dermatologist Richard Weller’s TED talk: Could the Sun Be Good for Your Heart?
• Australian recommendations on sun exposure 

Connect With Rowan Jacobson

• Rowan’s website

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Read the Transcript

Brett McKay: Brett McKay here, and welcome to another edition of the Art of Manliness podcast. You probably think of the health effects of sunlight as a mixed bag. On the one hand, sun exposure helps your body make vitamin D, but on the other, it can cause skin cancer. To get around this conundrum, dermatologists frequently recommend avoiding sun exposure when you can, slathering on sunscreen when you can’t, and taking a vitamin D supplement to make up for the lack of sunlight in your life. Yet, in seeking to solve one problem, this advice may open up many others and be contributing to ill health in the West.

Today on the show, Rowan Jacobsen, a science journalist who spent years investigating the health impacts of sunlight, will unpack the underappreciated benefits of sun exposure and that, crucially, they’re not primarily a function of the production of vitamin D and can’t be replaced with a pill. We talk about what else is at work, and ultraviolet radiation’s positive effects on blood pressure, autoimmune diseases, insulin resistance, mood, and more. We also get into how to weigh these benefits against the risk of skin cancer, why health officials in Australia, which has the highest rate of skin cancer in the world, have changed the recommendations around sun exposure, and if there’s a role sunscreen should still play in your routine. After the show’s over, check out our show notes at aom.is/sunlight. Rowan Jacobsen, welcome to the show.

Rowan Jacobsen: Hi, Brett. Thanks for having me.

Brett McKay: So you are a journalist, and for the past few years, you’ve been researching and writing about the benefits of sunlight to our health, and how the injunction to religiously slather on sunscreen might be causing unintended health consequences. Let’s talk about the health benefits of sunlight. I’m sure listeners have heard and know that sun exposure increases vitamin D levels in the body. How does that happen? What is it about sunlight that causes vitamin D levels to go up?

Rowan Jacobsen: Yeah, it’s kind of this interesting phenomenon where we really are photosynthesizing. We don’t do it like a plant does it, but we are synthesizing these compounds with the help of photons from the sun. So the way it works, so I guess for starters, vitamin D is a hormone that is used for all kinds of different reasons in the body. Like it’s kind of misnamed as a vitamin ’cause it’s not like the other vitamins, which are these little things that you get in food. It’s a hormone that we use for lots of different things and it’s essential to health and we mostly make it in our skin. And the way that evolution worked this process out is that it makes these molecules that are similar to cholesterol, they’re sterols, it makes these molecules that are like a couple of chemical processes, chemical steps away from becoming vitamin D and that’s as close as we can make on our own.

And we do that in the skin, and then what we rely on the sunlight to do is the sun hits those molecules, breaks open one of the little chemical bonds between the molecules so that that molecule can then change its form into a different form, which is vitamin D or actually pre-vitamin D. And then that molecule goes into the body and gets transformed into the type of vitamin D that we use after going through the liver and sometimes the kidneys too. So it’s this incredibly complicated process, but the upshot is that there’s this one step that we need sunlight to break open the bond for us so that we can change that molecule into something else.

Brett McKay: So I know sunlight is made up of different types of UV radiation, including UVA radiation and UVB radiation. Is there a specific type of radiation that causes that reaction?

Rowan Jacobsen: Yeah, for vitamin D, it’s all the UVB, which is particularly a narrow wavelength of UVB, about like 295 to 310, 315 nanometers. So yeah, there’s UVA, UVB, UVC. UVC gets filtered out by the atmosphere entirely, which is a good thing ’cause otherwise it would be really deadly. UVB is that next wavelength and then UVA has a very different size wavelength to it. And so we get both UVA and UVB on our skin. UVB is the one that can hit those molecules and break apart that bond and make vitamin D.

Brett McKay: What does our body do with vitamin D once it’s turned into vitamin D?

Rowan Jacobsen: So, most famously, it’s essential for bone mineralization. And this was discovered way back when kids were getting rickets in like… During the Industrial Revolution, suddenly, people who had always been outside farming were in these cities. The cities were really sooty, so even if you were outside in the city, you weren’t really getting any sunlight and the kids were working in factories. So suddenly, all the kids were getting rickets, which is when your bones are soft, too soft. They don’t get hard enough ’cause they don’t have enough calcium in them, and then you get these bowed legs. It’s bad. You don’t want to get rickets for sure. But a lot of kids were in the Industrial Revolution suddenly. And they figured out that that was because they weren’t getting proper bone mineralization.

They weren’t getting that calcium into their bones. And vitamin D does that. And that discovery was a huge health step forward because we were able to pretty much eliminate rickets famously because of cod liver oil. So cod liver oil is a good source of vitamin D. So they started giving the kids cod liver oil and that gave them just enough D to not get rickets. They also started putting babies in the sun. You know, like there’s these crazy photos from back in the day of these little cages hanging out the windows of tenement buildings, and you would put your baby in that cage for a little while just to get a little sunlight on the baby.

Brett McKay: That’s interesting. So people hear that, okay, I just need vitamin D. I don’t want to sit out in the sun ’cause I don’t want to get a sunburn. I don’t have time for that. I don’t want to get skin cancer. So I’ll just take a vitamin D supplement and that will take care of me and I’ll get all these benefits that come from vitamin D, one of them is just bone mineralization. And then there’s been these other health benefits that have been associated with vitamin D. So if you have elevated vitamin D levels, you have better metabolism, you reduce your cancer rates, things like that. So yeah, why not just take the vitamin D supplement?

Rowan Jacobsen: Yeah, right. And this is the message and the advice we’ve been receiving from dermatologists for a couple of decades now, is like, we know that sun exposure causes skin cancer. We know that it makes vitamin D, we know we need vitamin D. But no problem, avoid all sun exposure, and yeah, your body won’t make enough vitamin D, but you just take vitamin D pills to make up for that, and problem solved. So that was this overly simplistic understanding for a while. But to test it, what you have to do is do these trials where you get a lot of people so that you have some statistical power to get randomness out of there, and give half the people vitamin D pills and the other half just get a placebo and see what happens. And so now, some huge, huge trials have been done, multiple years, tens of thousands of people involved in the trials. And we have extremely strong definitive evidence that those vitamin D supplements do not help to improve any disease.

Just they totally failed in a way that… You know, science rarely gets results that are so definitive. Like there’s no question. They didn’t improve a single condition. Which was really surprising, because like you say, people who have high levels of vitamin D in their blood have lower rates of pretty much every disease you can think of. So we really did think, oh, vitamin D is not just for bones, it must be essential for all these other things in the human body and for preventing all these other diseases. So then these supplement trials, when they failed, then everyone had to kind of go back to the drawing board and say like, now wait a minute, how can it be that people who have naturally high levels of D in their blood have lower rates of all these diseases but if you artificially raise people’s amount of D in their blood with supplements, it doesn’t do anything? And you probably, you already know the answer.

Brett McKay: Right. Well, yeah, it’s the sunlight that’s doing it. Vitamin D is just a marker that you’re getting a sufficient amount of sunlight.

Rowan Jacobsen: Right, exactly. So it wasn’t causative, it was just correlation. The people with the lower rates of disease had a higher D because they were getting sun exposure, but now we know it wasn’t the D that was causing the lower rates of disease. It was something else about sun exposure.

Brett McKay: Okay. So people probably heard this idea that vitamin D improves a bunch of health conditions, but it turns out it’s not the vitamin D. There are other things going on, other pathways with the sunlight itself that creates those health effects. And we’re gonna talk about how the sunlight can improve those different facets of our health. That’s not to say that vitamin D is not important. You can get it from the sun or from a supplement. And as you said, we need vitamin D so we don’t get things like rickets. You don’t want rickets. So we need vitamin D for that.

Rowan Jacobsen: Yeah. And vitamin D is probably important in other ways. Like pretty much every cell in our body has vitamin D receptors in it, so they’re there for a reason. Like our cells are all doing things with D, but we only need so much probably. So you don’t wanna be vitamin D deficient. But this idea that really cranking up your level of D was gonna somehow chase all these diseases out of your body, that has turned out to be false. So D is important, but you probably get enough through sunlight, most of us. But it depends, like it depends where you’re living. So yeah, that’s only part of it. So could there be other things that sunlight is doing for you?

And now we have quite a bit of evidence that, yes, it turns out there’s dozens of different processes and pathways that are triggered by sunlight hitting skin that have lots and lots of different effects on the human body, and we’re really just learning about them. So this is the impasse. So now, the dermatologists are gonna have to readdress this whole formula that they gave to people. Like, don’t worry about the D, get the D through the supplement. Because it doesn’t work, and all those health benefits that we’re chasing, probably you need actual sunlight for that.

Brett McKay: Well, let’s talk about some of these health benefits that people are starting to see there’s a connection to sunlight. One of them is blood pressure. There’s a connection between increased amounts of sunlight exposure and decreased blood pressure. And there’s a guy, it’s a dermatologist who found this connection, a guy named Richard Weller. Tell us about him. What’s the connection between sunlight and blood pressure?

Rowan Jacobsen: So he’s a fascinating guy, a dermatologist in Scotland, but he does work in Ethiopia every year and has for decades. And he started questioning the conventional wisdom on sun exposure and vitamin D after doing all this work in Ethiopia. Where Ethiopia, like huge amount of sun ’cause it’s in the tropical zone, in the equatorial zone and it’s up at like 6,000 feet. So it gets a huge amount of sunlight. And he says he never treated a skin cancer there, never saw any ’cause he was treating people with very dark skin and they just weren’t coming down with skin cancers. So that was the first step where he started questioning some of the conventional wisdom. But then in terms of blood pressure that we had known for a long time in these observational studies that people living in areas that got more sun exposure had lower blood pressure. Like high latitudes, where you don’t get as much sunlight, higher blood pressure.

And everyone had sort said like, well, it’s probably just temperature, because your blood pressure is definitely lower in warmer temperature areas. So everyone kind of like chalked it up to temperature. But then, back, I don’t know, in the early 2000s, I think it was, some scientists discovered that… Actually it was earlier than that, scientists discovered that nitric oxide, which is a very simple molecule, is actually a really important signaling molecule in the body, and that nitric oxide will cause the muscles in blood vessels to relax and to dilate. So nitric oxide is a really potent vasodilator, so it will expand those blood vessels and lower blood pressure. And that was, a guy won a Nobel Prize for that back in the ’90s I think. But what people only realized more recently and what Richard Weller’s research helped to show was that our skin actually has these huge stores of nitrates in them, which is sort of a precursor to nitric oxide.

And when sunlight hits skin, it breaks up those nitrates into nitric oxide and sends them into the body and lowers blood pressure. And he did these experiments on his grad students. Like first they showed it in mice and they’re like, huh, it works. And then he did experiments on grad students where he shone UVA. He wanted to prove it wasn’t vitamin D that was responsible for this ’cause everybody chalks up everything about sunlight to vitamin D. So he used UVA instead of UVB ’cause UVA light does not create vitamin D. So he took his grad students and shone UVA light on their arms and he also put foil, like metal foil on half the students so that they were getting the heat of the UVA but not the actual beams of the UVA ’cause he wanted to prove that it wasn’t just heat either, ’cause we know heat can lower blood pressure.

And sure enough, the students who got the actual raise of UVA light, their blood pressure went down more than the students who just got the heat. And they’ve since done other studies looking at huge chunks of people in both the US and UK. And yeah, it’s now very clear that sun hitting skin produces nitric oxide, which lowers your blood pressure. And blood pressure is the number one risk factor for lost years of life and mortality worldwide. So anything that lowers blood pressure can be a pretty big deal.

Brett McKay: And that’s a cheap intervention. It’s free.

Rowan Jacobsen: Yeah, it is. It’s free. You know, it’s a cost benefit ratio ’cause when you’re exposing yourself to light, you are raising your risk of skin cancer. But skin cancer kills very few people. It’s a very, very small factor in mortality, and blood pressure and all the cardiovascular related diseases is number one cause of mortality in the world. So yeah, it’s probably a very good benefit for the risk.

Brett McKay: Yeah, we’re gonna talk more about the real risk of skin cancer later, but with these blood pressure experiments, it was UVA radiation that produces nitric oxide?

Rowan Jacobsen: Yeah, well, so he used UVA ’cause he wanted to prove it wasn’t related to vitamin D. But since then, I think they’ve found that UVB does it too. Like all the UV produces nitric oxide. So yeah, so the blood pressure lowering effect is, and I don’t even like dividing it up too much ’cause anytime we start to boil it down to this sort of human created simplicity, it reminds me of like fat carbs of protein. It’s like this human construct that turns out to be much simpler than the real thing.

Brett McKay: So sunlight can reduce blood pressure. There’s also been research showing that sunlight can strengthen immune function or improve immune function. Can you tell us about that research?

Rowan Jacobsen: Yeah, and that’s really fascinating to me. And that research was one of the main reasons the Australian authorities decided to revise their sun exposure recommendations. But this is, again, is something that’s been known for a while. We’ve got 20 or 30 years of research on this and it’s just… In science, department A is not necessarily talking to department B. So the immunologists were way down this path of researching sunlight’s effect on the immune system, and the dermatologists were just not ever getting the message on the other side of the campus. But anyway, so what we know is that we have a lot of immune cells in our skin, which makes sense ’cause the skin is the first barrier to the outer world. So the skin is constantly dealing with pathogens and cuts and all kinds of assaults to the body. So there’s constant immune action happening in the skin. And UV is another sort of minor assault that we get every day, that we’ve been getting every day for as long as humans have been humans.

So the skin has evolved to deal with it. So it gets a little dose of UV and then it heals that damage and healing that damage is basically an anti-inflammatory response. So the UV is a tiny bit of inflammation and it triggers an anti-inflammatory response in the skin. All these immune cells get created, they reduce inflammation, but then what’s really interesting, which is a more recent discovery, is those cells then migrate from the skin into the body through the lymph nodes and reduce inflammation throughout the body. So it’s the systemic anti-inflammatory response that’s triggered by a little bit of UV. And that’s important, because one thing we’re learning more and more is that a lot of the classic diseases of modern civilization have roots in inflammation. Like we sort of have a lot of chronic inflammation going on all the time. So something, and again, like you said before, a free intervention that can reduce inflammation could be a fantastic health benefit.

Brett McKay: And I feel like we intuitively understood this maybe a century ago. I love reading these old history books, biographies, and there’s always this instance where some famous guy gets sick as a kid and the doctor’s like, “Well, you need to take them out to the desert,” or “Go to the the ocean side and get lots of sun, because you got tuberculosis and that will help heal you.” And I think that just spending time in the sun probably did a lot that helped strengthen their immune system.

Rowan Jacobsen: Yeah, exactly. There was this whole age of heliotherapy where, like you said, tuberculosis, rickets of course, and some other diseases, psoriasis. People would be sent out into the sun, or they’d be sent up into the mountains in Switzerland to cure these diseases. And it worked. They didn’t quite understand why it worked, but it was somewhat successful. So sun was definitely considered by the leading doctors to be a benefit to health. And then that all started to flip in the ’30s and ’40s as everyone realized, they discovered the mechanisms by which UV can cause skin cancer. And then slowly, decade by decade, the message, that sort of the drumbeat got stronger and stronger, stay out of the sun so you don’t get skin cancer. And we’re kind of at this like peak moment of that.

Brett McKay: Another way sunlight can improve your immune function, you know, vitamin D, again, vitamin D plays a role in your immune system. If you get sunlight, you’re gonna increase your levels of vitamin D, which also contributes to your immune system.

Rowan Jacobsen: Exactly. And yeah, that’s an important point. All of these pathways are probably way more complicated than we think. It’s not gonna be one very simple step by step, like this, to this, to this. A whole lot of stuff happens when sun hits skin, and all these signaling molecules and hormones, they don’t necessarily just do one thing. In different situations they’ll do different things. You’ve got this very complex effect happening with nitric oxide, which can also be anti… It can be used to kill pathogens. So you’ve got nitric oxide, you’ve got vitamin D, you’ve got these direct effects on immune cells.

And one of the other things, like vitamin D, we’re all told to take vitamin D pills, that’s because everybody thought there was just one type of vitamin D, and most dermatologists today still think that. But one of the things we’ve learned in the past 10 years is that there are more probably like 20 different, slightly different versions of vitamin D that the body makes with sunlight. And they all have slightly different side chains on these molecules, but they all do slightly different things and we really don’t understand how that works. But we do know that a bunch of those non-canonical types of vitamin D, you can’t replace those with a pill that is going into the stomach and then to the liver. It just doesn’t work. It will not make these other flavors of vitamin D.

Brett McKay: Related to the immune system, there’s also been research showing that sunlight exposure can help with autoimmune diseases. So this is when your immune system goes haywire and starts attacking your body. So things like psoriasis is an autoimmune disease, arthritis, rheumatoid arthritis, MS is another disease like that. But sunlight seems to help with those conditions.

Rowan Jacobsen: Yeah, for sure. Again, it’s that anti-inflammatory effect. And it’s really strong with MS, which is a disease where the body’s immune system starts attacking the sheaths around the nerves that protect the nerves so that signals can be sent, electrical signals can be sent. The body mistakes the little sheaths around those nerves for an invader and starts attacking them. It’s just this classic but like overreaction of the immune system. And sun exposure really effectively slows down that process for MS. Like you look at the observational studies based on latitude and sun exposure and people living at high latitudes have usually several times the risk of MS compared to people living at lower latitudes. And prevalence is higher in winter than in summer, and it’s also, you can even track it with birth month where people born in spring, at the end of like a long winter, have higher rates than people born in early fall.

Same thing for psoriasis, type 1 diabetes, like you said, and some other autoimmune diseases. And there’s some clinical trials going on right now where they’re tracking this. Because basically this has mostly been observational studies, so you really, in order to prove it, to really have like the gold standard of evidence, you need to have some clinical trials where you’ve shown that it works. But we do know from some early clinical trials that just a little bit of narrow band UVB therapy, so using a light that only shines UVB in this very narrow wavelength that doesn’t cause skin cancer, it reduces all the biomarkers of inflammation in the blood of these patients that have MS and other things. So yeah, it looks good so far for that.

Brett McKay: That’s really interesting. What about insulin resistance, does sunlight affect that? That’s a big problem these days.

Rowan Jacobsen: Huge. Huge. Yeah. Insulin resistance, diabetes, all the… Like the metabolic syndrome stuff, where your body’s not metabolizing very actively, it’s just sort of slowed down, getting a little groggy and your cells aren’t accepting… They’re resisting insulin. Yes, sunlight has been shown in studies of both mice and observational studies of people to have a pretty solid impact on reducing risk of diabetes and insulin resistance. And in terms of why, like it’s probably some of those same things we’ve been talking about. I think there’s probably an inflammatory component to diabetes and insulin resistance as well, and so this probably reduces that a little bit. But then the other part of it, and I think you can apply this to a lot of things we’ve been talking about, if you wanna like pull back and think about big picture, there’s this really fascinating study a few years ago that looked at all the genes in the human body and when they were being expressed.

So then when they were being cranked up and when they were being kind of turned off, in terms of like month of the year. And what they found was that about a third of the genes in the body have a seasonal component. So they’re either being cranked up in summer or in winter. And generally, what they saw was that the inflammatory genes were being cranked up in winter and anti in summer. So winter, like evolutionary, the theory would be that in winter that’s when flu and all these other infectious diseases are on the rampage. We’re spending a lot of time cooped up together in spaces where we’re more likely to share diseases with each other. Summer is a low disease time, so it makes sense in winter to crank up your inflammatory genes to deal with all these pathogens and to basically try to just survive winter.

 And then summer, things are good, you’re out in the open air, you can reduce all that inflammation. But of course the signal for that is, one of them is sun hitting skin, sun hitting skin and sun hitting retinas. So if we are living our lives indoors and aren’t getting exposure outside, our bodies might be in a sense thinking that it’s biological winter all the time. So they’re acting like it’s biological winter, so they’re staying in this inflammatory state. So that would be the theory underlying why this would be the case, but it’s just a theory right now.

Brett McKay: We’re gonna take a quick break for a word from our sponsors. And now back to the show.

What about sun exposure and its connection to sleep and mood?

Rowan Jacobsen: That one is for sure, like no question and nobody even argues with this one. And it’s through different mechanisms. It’s probably partly through the skin, but a lot of it is through the eyes. But yeah, we know for sure that getting that hit of light in the morning is what sets your circadian rhythm, sets your biological clock, tells you that it’s morning, it’s time to crank up your system and be really active and high functioning. So if you’re outside in the morning and you’re getting a lot of bright light, then that melatonin that your body makes that’s for sleeping at night will quickly get reduced and you’ll get alert for your day, and then also you’re on the schedule where at night the body will know to turn up the melatonin so that you sleep well.

And when you don’t get that strong, diurnal change in light, then your circadian rhythms can get messed up. And you can’t get it being indoors, it’s interesting. I didn’t start paying attention to this until I was reading some of these researchers who specialize in this stuff. But even a cloudy day outside is way brighter than with your lights on indoors. Not even close, by like 50 times, 100 times, in terms of lumens. So you really need to be outside to get that signal that tells your body to wake up and sort of crank up the whole system and then the opposite at night.

Brett McKay: And the connection to the mood, people probably are aware of seasonal affective disorder. It happens during the winter. There’s less sunlight exposure, so people kind of get in the funk. You’re probably familiar with this, you live in Vermont.

Rowan Jacobsen: Totally.

Brett McKay: Vermont falls and winter. I remember we lived in Vermont, my wife and I, shortly after I graduated from law school, we were there in the fall. And I remember it was like 4 o’clock in the afternoon, it’s dark. I’m like, what? It’s 4 o’clock. Why is it…

Rowan Jacobsen: Yeah, it’s depressing.

Brett McKay: It got depressing.

Rowan Jacobsen: It does. And you can fight it, right? You go out, you ski, you do whatever you can to embrace the day. But it’s still, it’s not that natural an environment for human beings at some level. So you got to figure out ways to get around that. And yeah, people do. Yeah, their hormones are strongly affected by that. So again, you kind of go into hibernation mode. It’s kind of like what we were talking about earlier. All that darkness is a signal to the body to just shut down and endure. ‘Cause normally, in winter, food is often tight. Like before all our modern conveniences, you really did want to sort of put the system on minimal mode until things got better. So I think we still are dealing with that. So the best thing and the way to fight it is either, like you can have artificial lights that are bright enough that they can affect that SAD, or you go outside as much as possible or you go on vacation.

Brett McKay: Yeah. So yeah, I saw some research that sunlight can increase levels of serotonin, which is a feel good neurotransmitter, releases endorphins that can also help you feel high and euphoric.

Rowan Jacobsen: Totally.

Brett McKay: I mean, if anyone’s been to the beach or on a hot sunny day, you just feel good, you just feel so groovy whenever you catch some rays.

Rowan Jacobsen: Yeah, and it’s direct, like your skin and brain are producing endorphins, are producing dopamine. Dermatologists talk about how unfortunate it is that people get addicted to sunlight because of these things, but it’s like, well, there’s a reason. Your body isn’t just making those on a whim, there’s a reason. So you don’t want to get too much, but you do want to at least pay attention to those natural signals that we have.

Brett McKay: Okay, so I think we’ve talked a lot about the health benefits of sunlight. Increases vitamin D, but vitamin D, what we talked about is not necessarily connected to all these other health benefits, like reduced blood pressure, reduced metabolic syndrome, etcetera. That is from sunlight itself. Vitamin D is just a marker that you’re getting enough sunlight. And people might be hearing this thing, oh, okay, yeah, I’ll grant you that there’s all these health benefits that come with sunlight, but we know for a fact that it frequently causes skin cancer. So why risk the exposure to get those benefits? Just put on the sunscreen.

And that’s the stance, we’ve talked about this throughout this conversation, that’s the stance the American Academy of Dermatology has taken, which says you should apply sunscreen every day on skin not covered by clothing if you will be outside. And I think this is interesting ’cause I’m 41, so if you’re my age, sunscreen really wasn’t a big thing when I was growing up. Maybe my mom would say, “Well, you’re gonna go to the water park all day, put on some sunscreen.” But I don’t remember putting sunscreen on that much when I was a kid. So when did this message to always wear sunscreen arise? What was behind it?

Rowan Jacobsen: Yeah, and so what was behind it was simply that one fact that we know that UV exposure triggers skin cancer, raises your risk of skin cancer. So based on that one thing is why we’ve been told to, continually to keep reducing our amount of sun exposure to basically zero now. Or let me add, skin cancer, also wrinkles, sunspots, like there’s this cosmetic stuff, the cosmetic damage that UV causes as well. But in terms of health, then skin cancer is the one thing that you have to worry about. And yeah, it’s interesting that the message has gotten more and more strident with each decade. And people have been using more and more sunscreen with each decade. But skin cancer rates are higher than ever. So the etiology is probably more complicated than they think, but it is definitely very well established that sun exposure causes skin cancer.

But in terms of what you wanna do about it, it’s not clear that a little bit of sun exposure is really that problematic. And there’s quite good evidence that there are more benefits than risks for that small amount of sun exposure. So then it’s a question of like, where do you set the… You know, the pendulum’s swung way far, as far as it could in one direction where, I don’t know, if you look at a lot of the recommendations in popular magazines and newspapers, the dermatologists are literally saying, even in winter, on a cloudy day, if you’re gonna be indoors all day, still put on sunscreen. There’s no science behind that. They’re just trying to get people into the habit of doing it. And I think the worry is that people aren’t very good at following directions. So if you want them to put on any sunscreen, you gotta tell them to put on a lot all of the time and hope that they’ll listen to you one out of every three times or something.

Brett McKay: In your articles, you talked about that the conversation about skin cancer is a lot nuanced. I think people hear cancer and they just think, okay, cancer equals death automatically. And they probably think melanoma when they think skin cancer. But there’s different types of skin cancer. Melanoma is the worst one you could get. But the stuff that’s often caused by sun damage, it’s like basal cell carcinoma. Those are actually pretty treatable. Like you can actually just go to a dermatologist and it’s like an outpatient surgery.

Rowan Jacobsen: Yeah, that’s correct. There’s three different kinds of cancers that are the main ones, basal cell carcinoma, squamous cell carcinoma, and melanoma. And basal cell carcinoma is by far the most common cancer in the world. It’s probably more common than every other cancer put together. That’s the one, you know, you always see these public service warnings, like one in every three people will get skin cancer. And that’s what they’re talking about, is basal cell carcinoma. It doesn’t actually really have any health impacts 99.9% of the time. That’s the one, yeah, you go in, you get a cutoff, you’re done. So in a way, it would be better if it wasn’t called cancer, ’cause like you were saying, that word really scares people. Richard Weller, the dermatologist we mentioned, he actually told me that when one of his patients comes in and he diagnoses a BCC on them, he then says, “Congratulations ’cause your life expectancy just went up.”

And what that means, that doesn’t mean BCCs are actually good for you. It means the people who are getting BCCs tend to be quite healthy, because it’s like your dad who’s playing golf in Florida every day. He’s getting sun exposure, he’s getting a lot of exercise, he’s getting BCCs, but he’s quite healthy. So yeah, Richard Weller says he cuts a lot of BCCs off a lot of very healthy old people. SCCs, squamous cell carcinomas, are a little bit more to worry about than BCCs. But again, usually it’s just cut it off, outpatient procedure, that’s it. Melanoma is the one that kills people and that’s the one you need to worry about, but it’s much, much less common than the other two. It’s like 1 to 2% of skin cancers are melanoma, and the rest are BCCs and SCCs. So there’s a little bit of a bait and switch that you see in the public messaging where people will say, skin cancer is incredibly common, one out of three people will get it.

And then they’ll say, melanoma kills 10% of the people who get it. And if you don’t look carefully, you’ll think that skin cancer is both extremely common and extremely deadly, but it’s not. There are some that are extremely common and are no big deal and there’s one, melanoma, that can be deadly, but it’s uncommon. And BCCs, definitely caused by sun exposure. The more sun exposure you get, the more BCCs you’ll get. Melanoma, it’s a different story. It’s not as simple as just chronic sun exposure. Melanoma tends to turn up in people who get intermittent sun exposure. People who have pale skin and basically go to Cancún on vacation and get fried, that’s kind of like the perfect formula for melanoma. And worst thing of all, probably for you and me, it’s mostly associated with sunburns in childhood and adolescence, so.

Brett McKay: I had some sunburns, some really bad ones.

Rowan Jacobsen: Me too. I grew up in Florida. And so a 13-year-old kid growing up in Florida is gonna get a fair amount of sun.

Brett McKay: Yeah, I had one, I had a few where like your skin just peels like paper.

Rowan Jacobsen: Yeah.

Brett McKay: It hurt. But then when it peels, that was kind of satisfying.

Rowan Jacobsen: And it’s just so weird. It’s kind of fun. But it’s not good for you. They definitely, like every researcher I’ve talked to across the board says, just don’t burn. Burns are bad.

Brett McKay: So one of the arguments you’re making in your articles and in your research is that this sunscreen absolutism that we have in the United States, where it’s like you gotta apply sunscreen, even if you just go outside for a little bit, just all the time, even in winter time. What it’s doing, yeah, we might be staving off these skin cancers like basal cell carcinoma, but those, it’s not gonna kill you. You can get just the surgery to take it off, but we’re missing out on those other health benefits that come from sun exposure. ‘Cause when you block the sun with sunscreen, you’re missing out on the vitamin D production, the reduction in blood pressure, immune system improvement, etcetera.

Rowan Jacobsen: Yeah, possibly. It depends on the sunscreen. And this is one of the interesting nuances here I think, is back when sunscreen was SPF 15 or whatever, it doesn’t block 100%. It blocks maybe like 90%. So there’s still about 10% getting through. And so maybe, like on a day at the beach, that might have actually been the perfect formula, where that sunscreen was letting you get a great amount of UV but was still preventing you from getting burned. So now of course we’ve got SPF 50 or even SPF 100 sunscreens, and the advice is even on a cloudy winter day, put it on. So there’s this real push to make sure that people never, never get any photons hitting their skin. So that’s probably gonna have to change. But I actually think sunscreen can be an ally in making sure you do get the right amount of sun. ‘Cause if it gets you outside without burning, it could actually be a benefit.

Brett McKay: Something you mentioned in one of your articles, this sunscreen absolutism. The dermatologists, they don’t discriminate on your melanin level. So even if you’re Black or Hispanic, where you have a lot of melanin and you don’t burn as easily, they still say, yeah, you gotta wear a SPF 50 sunscreen. And you’re like, well, that doesn’t make sense.

Rowan Jacobsen: Right. And this is the thing that’s gonna have to change I think, and I think probably pretty soon. That advice to always put on heavy duty sunscreen every day, indoors or outdoors, that’s probably not a bad recommendation for people with the very palest skin. Like people who have red hair, freckles, who evolved, their ancestors came from places at very high latitudes that were getting very little sunlight and kind of evolved skin to harvest whatever light they could get. Like people who never tan always burn, that advice makes sense for them, but not for everyone else. And the world is mostly populated by everyone else.

So people with really dark skin, on the other end of the spectrum, basically do not get skin cancers from sun exposure, do not have any of these risks. But also have, because they have more natural sunscreen basically, need more sun in order to produce vitamin D and some of these other compounds. So for them, the recommendations make no sense. And then there’s a bunch of people in the middle who have maybe more of like a Mediterranean skin tone, an Asian skin tone, who have a little bit more risk of skin cancer than people with super dark skin, but really very little. And also probably have a lot to gain from moderate sun exposure. And you don’t need, that’s the other thing we should probably talk about, you don’t need too much to get some of these benefits.

Brett McKay: We’ll talk about the daily recommended dose of sunlight here in a bit. So in America we have a very, you call it sunscreen absolutism. No matter what, how you spend your time, whether indoors or outdoors, whether you’re pale, dark, wear sunscreen, health officials in Australia have taken a different tack, they’ve gotten more nuanced with sunscreen use. And this is interesting ’cause Australia is a place that has notoriously high levels of UV exposure and skin cancer, but health officials in Australia are saying maybe you don’t use sunscreen all the time. So what are they recommending?

Rowan Jacobsen: Yeah, and it’s so funny, because probably the last place on earth, you would expect to be the first place to take the plunge on changing the recommendations would have been Australia. ‘Cause as you say, their skin cancer numbers are off the charts, the highest in the world, like more than twice as high as US or UK. And it’s because they have predominantly pale skin population in an extremely sunny place. So it’s a really bad match. So they get tons of skin cancer, but they also have some of the longest lived people on the planet. So right there, it tells you that maybe like sun exposure isn’t so bad for you, even if you do have pale skin.

So Australia, I think the reason that they ended up being the first ones to change, to go away from the zero sun policy is because they’ve had to deal with this. Like melanoma and skin cancer is in their face every day, they’ve had to like process it the most. So maybe they’re a little less scared of it in a sense. And I think it was more obvious to them, ’cause they do a lot of research on it. They have a lot of the top skin cancer researchers in the world. And they can see that a lot of people were clearly getting more harm than benefit from this zero sun policy. They’re also saying that there was a lot more vitamin D deficiency in Australia than they would ever expect for such a sunny place.

So they actually started worrying that people had taken the message to heart maybe too much. So they wanted to change their messaging so that it was no longer this one size fits all message that should only have applied to people with super pale skin. And they kind of broke up their messaging into three groups, people with pale skin, people with dark skin, and then people in the middle, and different recommendations for each one. Pale skin, yeah, still use your sunscreen all the time pretty much. But when the sun’s not so bright, try to at least get outside with sunscreen on to get whatever… They were focusing on D, but they know it’s this other stuff too, to get whatever sun you can.

Middle group, get small amounts, still use sunscreen anytime the sun is pretty bright. But yeah, work the edges of the day, the edges of the season and make sure you are getting some direct exposure. And then people with dark skin, they basically said like, you just should focus on getting lots of sun. You don’t need sunscreen except when you’re gonna be outside for an extended period on a bright day. So that was quite controversial. And they caught a little bit of hell for it, but I think they’ll turn out to be the first penguin in the water and then all the other penguins will start to join them.

Brett McKay: Are you seeing a shift happen amongst American dermatologists yet?

Rowan Jacobsen: No. So far, none. UK, yes. UK is starting to shift a little bit, Europe a little bit. America is gonna be last on this for whatever reason. It’s just kind of how we do things, I think.

Brett McKay: Yeah. So let’s talk about how we can get sun exposure without increasing the risk of skin cancer. ‘Cause some people might hear this news that, okay, sunlight is great for you. I’m just gonna get sun all the time and never wear sunscreen. That’s not what these health officials in Australia are advocating for. So based on the conversations you’ve had and the research you’ve done, how can we get sun exposure and get all these health benefits without increasing our chances of getting different types of skin cancer?

Rowan Jacobsen: Yeah. And this, I’m quite sympathetic with the dermatologists because, yeah, you tell people that 10 minutes of sun is good for them, and sure enough some of them will go out there and get six hours of sun. ‘Cause they’re like, if a little’s good, then a lot’s better, right? So that is definitely something worth worrying about. But I feel like you just have to give the straight information, right? And then hopefully it’s clear enough that people can follow it. So Australia, when they put out their new position statement, they actually have all these tables in the back. It’s worth looking at that document that they created.

And the tables show for places with different UV indexes, so that’s gonna depend on where you are in the globe and what season it is and the day, right? For your skin type and UV index, how many minutes of exposed sunlight do you need to get a healthy vitamin D dose? So those will translate to the US too. So those are worth checking out. But what it comes down to is, for most people on most days, you’re either gonna get it just walking about your day, or you can get it with 10 minutes or to 20 minutes of focused exposure.

Brett McKay: Yeah. And if you have darker skin, you might have to extend the amount of time you’re out there getting that sun exposure to get the benefits.

Rowan Jacobsen: Quite a bit. And the other part of it, though, is that in higher latitude places, like here in Vermont, we don’t get any UVB. All the UVB is filtered by the atmosphere like November through March, probably. There’s just too much atmosphere that the sun is coming through at that low angle. So we don’t get any UVB for four months of the year. And you can save, your body will save it up a little bit, but that’s where you see a lot of vitamin D deficiencies, is at higher latitude, colder places.

Brett McKay: All right. So those Australian tables are a good place to check to see how much sun exposure you should get each day and in each season, ’cause it’s gonna differ, and then when to use sunscreen. But in general, what are some good general guidelines for using sunscreen? Because you’re not… I mean, even though you’re against sunscreen absolutism, you’re not against sunscreen altogether. So when should people put on sunscreen?

Rowan Jacobsen: Anytime you think you might be out long enough to get a burn, and as I think you and I can both attest to, it’s easier to get a burn than you think. Like you think, oh, I’m not gonna get burned, and then you get burned. It’s easy to just get a little more than you think you’re gonna get. So it makes sense to play it cautious and use it anytime you know you’re gonna be out for a while. And unless it’s like, you know, if it’s winter, that’s a whole different deal.

Brett McKay: Yeah, all the dermatologists you’ve talked to who are sort of pro getting sunlight and not using sunscreen all the time, they all agreed you do not want to get sunburned. Like you want to avoid sunburn as much as possible ’cause that’s what caused all those problems.

Rowan Jacobsen: Yeah, that’s just your skin cells dying and freaking out, and yeah.

Brett McKay: Yeah. So for me, I work from home. I typically don’t wear sunscreen at all ’cause I’ll just go outside, get some sun when I’m doing my early morning walks, doing chores and errands. I will wear sunscreen when I’m gonna be out for a long time, especially if I’m gonna be at altitude. So like my wife and I just went backpacking, I slather on the sunscreen. It’s so easy to get sunburned when you’re up in the mountains at 10,000, 11,000, 12,000 feet, ’cause you don’t have the atmosphere filtering the radiation.

Rowan Jacobsen: Yeah, for sure.

Brett McKay: So constantly applying sunscreen then and then when I’m skiing, ’cause like the sun reflects off the snow, and it’s easy to get sunburned. And it’s hard there ’cause you think it’s cold, so you really can’t feel anything, but you go in and your cheeks are red, and you’re like, ah, didn’t put on enough sunscreen.

Rowan Jacobsen: Yeah, for sure. Yeah, totally. All those things. And yeah, also anytime it’s gonna help you get outside, because one of the criticisms that people get in these observational studies where it’s like, oh, these people who are getting all the sun exposure are healthier in all these ways, and they have better longevity, blah, blah, blah. And one criticism will be, well, but how can you tell it’s the sun exposure? Maybe there’s just things about being outside, they’re exercising. Like, in those studies, you always try to control for exercise, so you’re comparing people who are exercising the same amount. But still, there could be other things about being outside that are just good for you. So, I don’t see the problem in that if the answer is get outside, right? So if sunscreen is gonna help you spend less time indoors, then I think it’s all to the better.

Brett McKay: Is anyone exploring, I don’t know, special sunscreens or ways people can get the benefits of sunlight without raising their risk of skin cancer?

Rowan Jacobsen: What people are doing is there’s a lot of experiments using these narrowband UVB lamps that a couple of companies are making now. I think this is gonna become a big deal. So they were first used for psoriasis treatment I think, and they just produce a very narrow band of UV, somewhere around like 300, 310 nanometers. It’s been used in psoriasis patients for a long time, decades, and we know it does not cause skin cancer. It’s not the type of wavelength that damages DNA. But it does produce vitamin D, and it also seems to have these good immunological effects.

Like psoriasis is an autoimmune disease where your skin is being attacked by the immune system, and it definitely has an excellent effect on psoriasis. It seems to work for MS. It even worked for COVID, it seems like, maybe. So I think you’re gonna see a lot more people using UVB, so then there’s not even an issue with skin cancer. But I’m still not convinced that you get all the benefits from UVB lamps that you would get from sunlight.

Brett McKay: Here’s a controversial question. Tanning beds. Can you get the benefits of sunlight from a tanning bed?

Rowan Jacobsen: Yeah, that’s an interesting one. I don’t know the answer yet. That’s why I’m working on a book about all this. It’ll be out in a couple of years by the time I’ve done all the research, written the manuscript, and then gone through the production process. But I’ll definitely have a chapter on tanning beds in there. Right now, I don’t know enough. I do know, like tanning beds do raise your risk of skin cancer, so dermatologists are strongly anti-tanning bed. But they do definitely give you some of the benefits, especially the endorphins, for sure. They give you that hit of feeling good. They will improve your vitamin D a little bit. But again, because it’s not the same as sunlight, I’m somewhat skeptical of them, but I don’t know enough to say whether they’re just plain bad or whether they might have a use.

Brett McKay: Yeah, a few years ago here in Oklahoma, we had a winter where it was just gray every day for like two months. And I was getting pretty depressed. I was getting some seasonal affective disorder. I got brown skin. I’m swarthy. So I need a lot of sunlight to get the benefits. And my wife said, you should just go to a tanning bed. And I’m like, tan? I’ve never done that before. That’s like what they do on Jersey Shore. Like I’m not gonna… And so I did it, I did like the least amount. So I did the least amount of time. I think it was just like two minutes. I mean, it was really short. And I felt better afterwards.

Rowan Jacobsen: Totally, yeah. I have friends who do it, and same thing.

Brett McKay: Yeah, I’d be interested to see if instead of tanning bed salons, you have UVB light salons, where you stand in front of a UVB light instead of going to a tanning bed to get the health benefits of sunlight.

Rowan Jacobsen: Yeah, I’m curious too. And I suspect that the tanning beds are gonna go in that direction, whether it’s more than just the UVB or just the UVB. But I bet they’re gonna try to curate their wavelengths a little bit to try to maximize the good and avoid the bad. That’s just a guess.

Brett McKay: Well, Rowan, this has been a great conversation. Is there someplace people can go to learn more about your work?

Rowan Jacobsen: For me, it would be rowanjacobsen.com.

Brett McKay: Rowanjacobsen.com. And then look out for the book you’ve got coming out.

Rowan Jacobsen: Yeah, In Defense of Sunlight, 2026.

Brett McKay: 2026.

Rowan Jacobsen: I think that’s safe. Safe prediction.

Brett McKay: And in the meantime, if you’re listening, go out and get some sun. You’re a plant. That’s one of the cool takeaways. I forget, like we’re little plants. We need water and we need sun. So get some sun.

Rowan Jacobsen: We photosynthesize, yeah.

Brett McKay: Yeah. Well, Rowan Jacobsen, thanks for your time. It’s been a pleasure.

Rowan Jacobsen: Thanks. It was great being here.

Brett McKay: My guest today was Rowan Jacobsen. You can find more information about his work at his website, rowanjacobsen.com. Also check out our show notes at aom.is/sunlight, where you can find links to resources, and we delve deeper into this topic.

Well, that wraps up another edition of the AOM podcast. Make sure to check out our website at artofmanliness.com where you can find our podcast archives. And while you’re there, sign up for our newsletter. We got a daily option, and a weekly option. They’re both free. It’s the best way to stay on top of what’s going on at AOM. And if you haven’t done so already, I’d appreciate it if you take one minute to give us a rating on Apple Podcast or Spotify. It helps out a lot. And if you’ve done that already, thank you. Please consider sharing the show with a friend or family member who you think would get something out of it. As always, thank you for the continued support. Until next time, this is Brett McKay, reminding you to not only listen to AOM podcast, but put what you’ve heard into action.

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Note: This is a rebroadcast.

When men think about optimizing their hormones, they tend only to think about raising their testosterone. But while increasing T can be important, an ideal health profile also means having testosterone that’s in balance with your other hormones as well.

Today on the show, Dr. Kyle Gillett joins me to discuss both of those prongs of all-around hormone optimization. We start with a quick overview of the different hormones that affect male health. We then get into what qualifies as low testosterone and how to accurately test yours. We also discuss what causes low testosterone in individual men, and how its decline in the general male population may be linked to both birth control and the world wars. In the second half of our conversation, we discuss how to both raise testosterone and get rid of excess estrogen, including the use of some effective supplements you may never have heard of. We then get into the risks and benefits of taking TRT, before ending our discussion with what young men can do to prepare for a lifetime of optimal T and hormonal health.

Resources Related to the Podcast

• AoM series on testosterone, including How I Doubled My Testosterone Levels Naturally
• AoM Podcast #761: How Testosterone Makes Men, Men
• AoM Podcast #878: The Fitness Supplements That Actually Work 

Connect With Dr. Kyle Gillett

• Kyle on IG
• Gillett Health Podcast on Spotify and Apple
• Gillett Health on YouTube
• Gillett Health website

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Read the Transcript

Brett McKay: Brett McKay here and welcome to another edition of The Art of Manliness Podcast. When men think about optimizing their hormones, they tend only to think about raising their testosterone, but while increasing T can be important, an ideal health profile also means having testosterone that’s in balance with your other hormones as well. Today in the show, Dr. Kyle Gillette joins me to discuss both of those prongs of all around hormone optimization. We start with a quick overview of the different hormones that affect male health. We then get into what qualifies as low testosterone and how to accurately test yours. We also discuss what causes low testosterone in individual men and how it’s decline in the general male population may be linked to both birth control and the world wars. In the second half of our conversation, we discuss how to both raise testosterone and get rid of excess estrogen, including the use of some effective supplements you may never heard of. We then get into the risk and benefits of taking TRT before ending our discussion with what young men can do to prepare for a lifetime of optimal T in hormonal health. After the show is over checkout our show notes at aom.is/optimalt.

All right, Dr. Kyle Gillette, welcome to the show.

Dr. Kyle Gillette: Thank you. My pleasure.

Brett McKay: So you are a medical doctor. You do family practice, you specialize in obesity but also hormone optimization, helping people have healthy hormones so they live a flourishing life. And today I’d like to talk about hormones, particularly male hormones. I think when most people think about male hormone optimization, they think about testosterone and which is obvious why you do that. And we’re gonna dig deep into testosterone today. But are there other hormones that affect male health that people often overlook?

Dr. Kyle Gillette: There certainly are. So even testosterone in and of itself, there’s nothing unique about it compared to other androgens. There’s just one androgen receptor. Testosterone just happens to be the most well-known androgen. So there’s DHEA, which is a very weak androgen. It’s produced by the adrenal glands, which are small glands above the kidney. There’s DHT, which is dihydrotestosterone. This is a very strong androgen. You don’t have as much of it as testosterone, but it’s vitally important for what’s called secondary sexual characteristic development, like the deepening of the voice, growing facial hair, those secondary sexual characteristics which are vital.

Brett McKay: And also I think people often overlook estrogen plays a role in male health.

Dr. Kyle Gillette: Certainly, testosterone aromatizes and directly converts to estrogen. So the way to think about estrogen is the more estrogen the better for your health because it prevents things like heart attacks at a correct ratio to where you feel good.

Brett McKay: Okay, so we gotta have some estrogen in there at the right balance. And then there’s another hormone called SHBG. What does that do?

Dr. Kyle Gillette: So SHBG is also known as androgen binding globulin. It’s a protein, it’s made in many places, the liver makes most of it, but the testes also make some of it. And SHBG stands for sex hormone binding globulin, it most strongly binds DHT and then it binds testosterone, relatively strongly, DHEA weaker than that. And then estradiol, which is your main estrogen, even weaker than that. So think of this as regulating all of the hormones and keeping them more stable. The higher the SHBG, the more stable the level will be. Men produce a lot of testosterone during sleep. So the level is generally much higher in the morning. But if you have a very low SHBG you’ll crash and you can actually have deficient levels of testosterone in the evening routinely. But normal levels in the morning if you don’t have enough SHBG, the most common cause of an SHBG deficiency is insulin resistance, which is often due to too many calories or too many carbohydrates and sugar.

Brett McKay: So what’s interesting about all those hormones is they interact with each other. It’s a complex system so if you raise the level on one, one might go down or up. So I think a lot of guys they get too focused on, well I gotta increase this one thing or reduce this one thing. Well, if you do that you’re gonna have these cascading effects that might not be optimal.

Dr. Kyle Gillette: Correct. I actually heard an advertisement from a TRT clinic this morning and it said new studies shows that men with low testosterone are more prone to cardiovascular disease and early death and diseases of aging. And I thought to myself, this is odd because they are implying that you need testosterone replacement to prevent this. But of course that is a logical fallacy because just replacing the testosterone without figuring out what’s actually causing it in the first place, not that TRT is wrong, but you need to figure out what the cause of it is and then address it.

Brett McKay: Okay. And I hope we can talk about TRT ’cause I know a lot of guys are thinking about doing it or maybe they are doing it and they might have questions about that. Let’s talk about testosterone. So there’s two ways to measure testosterone or two measurements of testosterone that I read about. One is total testosterone and free testosterone. So first, what’s the difference between the two and as a clinician is there a particular number you focus on?

Dr. Kyle Gillette: Yeah, so total testosterone is a total amount of testosterone, whether it’s bound or unbound, when testosterones bound it in general does not bind the androgen receptor, which is on the X chromosome. And total testosterone includes a testosterone bound to albumin, which is the main protein in the blood and also SHBG which we talked about earlier. But free testosterone or any free androgen is what is going to be what is actually binding to the receptor. And then it takes it into the nucleus of the cell and then it binds to DNA to cause what’s called gene transcription. So the androgen receptor gene that’s on the X chromosome is then mostly activated by free testosterone. Oddly enough, sometimes I make the analogy of plumbing. So you have a pipe that’s your bloodstream that takes testosterone everywhere and then you have different types of cells. For example, a muscle cell or a brain cell or a germ cell in the testicle or a somatic cell in the testicle, which we don’t have to get into. But anyway, the free testosterone level can be very different in the bloodstream, which is where we measure it on a blood test versus inside the cell. So it is possible to have symptoms of low testosterone because you don’t have enough androgen in the cell but have a normal level in the blood. It’s rare but it’s possible.

And the opposite is possible, to have a low level in the blood but still have enough inside the cell that’s free to be causing normal gene transcription.

Brett McKay: Okay. So just to recap there, total testosterone is made up of bound and unbound testosterone. Bound testosterone could be bound to albumin or SHBG. And then when it’s bound to those things it can’t attach to the antigen receptor in the cell and so it can’t be… Can’t effect have those changes on the cell. Free testosterone, unbound testosterone is free testosterone. So as a clinician, when you do a blood test on a patient, what number is more important to you? Which one are you gonna be focusing on more? Is it the free or the total?

Dr. Kyle Gillette: I think both are equally important. For athletic purposes, for muscle building purposes. Usually that’s more correlated with free testosterone level. However, symptoms and how you feel is usually correlated more with total. Insurance companies and academic societies usually put more weight into total testosterone, partly because free testosterones are often measured inaccurately so often it’s more accurate to calculate your free testosterone using your total testosterone and your SHBG and then you estimate what your free testosterone is. Some societies say low testosterone is often best treated if you one, have symptoms. And then two, also have a testosterone below about 400. That’s what the urologists say. Most other societies go by 300 and I tend to agree with the level of 400 with a caveat if you have significant symptoms and with a second caveat, if you cannot improve that naturally in any way after identifying the root cause.

Brett McKay: Okay. I wanna dig more into diagnosing low testosterone because there’s lots of commercials out there. You just mentioned one or these businesses popping up where you can just go in, get a blood test and like, hey, you got low T, here’s testosterone and maybe they don’t. So you mentioned two things you look at to diagnose low testosterone, you’re gonna do blood work and if it’s below 400, coupled with if the patient is reporting symptoms of low testosterone, we’ll talk about the symptoms of low testosterone here in a bit, but let’s talk about blood work. ‘Cause I think a lot of guys out there, they think it’s a panacea, if you just take a test, you take the test and it says, oh well, your T is at 400. They’re like, well I got low T. Why isn’t one blood test alone sufficient to diagnose low testosterone?

Dr. Kyle Gillette: Yeah, in general testosterone levels can have what’s called outliers. It’s the statistical phenomenon. But it’s especially true of testosterone where you could check it one time and your testosterone that morning could be low because the last two nights you’ve had poor sleep and poor diet and other lifestyle factors. Males that are generally seeking a TRT prescription know those very well because there’s various things that you can do to artificially make your testosterone level look low that morning. So in general, the recommendation is to recheck it two to three times after a good night of sleep and normal diet and whatever you’re doing normally not after you’ve dieted down to 7% body fat to do an ultramarathon or body building show, then your testosterone is certainly going to be low. But when you’re at a healthy body fat and there’s not an artificial something else that is going to make your testosterone look low. There’s a runner, his name is Nick Bare and he also is doing a body building show and I saw that he got his total testosterone checked and he’s a healthy guy. I’m not sure what his baseline testosterone is and his total testosterone was right at 100 before his body building show.

So that was obviously secondary to the caloric deficit. That wouldn’t necessarily count as a testosterone reading that you could put stock in assessing TRT or not. But for most people they probably won’t be in a scenario like that. But it is important to get at least two readings. If you’ve been sick before, then maybe just postpone the blood test by a week. That way you get an accurate reading.

Brett McKay: Let’s move on to the symptoms. So you do the blood test, what symptoms are you looking for to diagnose low testosterone?

Dr. Kyle Gillette: Yeah, could be through any system. So it could be anything from depression, anxiety to low libido is certainly classic. Low muscle mass is not really one that we look for. Testosterone levels that are naturally produced are not as correlated as people would think with body composition and muscle mass and athletic performance. So it’s not uncommon to see a pretty high level athlete have a total testosterone of let’s say 450 and let’s say someone that has very low muscle mass and maybe even 20%, 22% body fats have a total testosterone of 1000 and there’s not as much correlation. But other things that you would look for seriously is, for example, erectile dysfunction, sexual health in general, sperm production. So if there’s a patient that is having even sub-fertility, just a little bit of trouble getting pregnant, that individual should certainly have a test of his testosterone as well.

Brett McKay: So with low libido, how does a guy know if he has low libido? Because that seems like it’d be pretty subjective.

Dr. Kyle Gillette: Yeah, libido obviously has a lot of psychosocial factors as well. It’s usually taken at a patient’s word and a lot of times when you’re testing these patients, you’ve known the patients for a while, sometimes you haven’t. But if they’re telling you that it’s low relative to what it usually is and no other factors have changed, for example, you know they’ve been married to the same person for five years, they’re not actively going through problems in the marriage, there’s not something else that would be affecting the libido. So that would usually come up in the social history. When you do a history and physical on a patient, it is important to dig into the social history to make sure there’s not something else that is affecting the libido.

Brett McKay: So besides the low libido, maybe the lack of drive, what are the consequences of suboptimal male hormone levels like chronically? Is it gonna affect your cardiovascular system? Is it gonna affect cancer? Does it affect things like that?

Dr. Kyle Gillette: It will. If someone is significantly hypogonadal for a long time, they’re at much higher risk of osteoporosis, which leads to bone fractures and even mortality as well. They’re at higher risk of neurodegenerative disease, likely largely due to low estrogen. If you don’t have a lot of testosterone, you’re probably not converting a lot of it to estrogen and if you’re not doing that then you’re also at risk of cardiovascular disease. Estrogen is very cardioprotective and helps with the production of good cholesterol to help take cholesterol out of the plaque. So they’ve done studies and you look at one group of people that have true hypogonadism, which is generally two levels under 264 or so, and then one group you give TRT and then one group you don’t give TRT, you would think that the group that you give TRT would’ve a shorter lifespan ’cause androgens do cause excess production of “bad cholesterol.” They do increase a particle called ApoB, which is the most important one to watch for cardiovascular risk. But the group that you give TRT actually has less heart attacks and strokes.

Brett McKay: Right, because what you were saying before, the testosterone creates estrogen and then the estrogen protects the heart. So let’s talk about the causes of low testosterone. What can be behind low T?

Dr. Kyle Gillette: Most commonly, metabolic syndrome. So excess calories, excess carbs, insulin resistance, high fasting insulin leads to the liver not producing SHBG. So you might be producing a decent amount of testosterone but it’s being metabolized so fast that it’s difficult to use. That’s most common. The second most common I think is sleep apnea or obstructive sleep apnea. Obviously that kind of goes hand in hand with metabolic syndrome but often it goes hand in hand with PTSD. I saw a study on young men that had just gotten out of the military and they had been diagnosed with PTSD and they tested them all for sleep apnea and something like 80% of them had sleep apnea and they were all under under a BMI of 25. So there’s certainly a lot of stress component as well. The limbic system includes places like the hypothalamus and the amygdala and downstream to that is the hippocampus and the amygdala, downstream of those is the hypothalamus and that’s some of the places of the brain that are involved in sleep regulation and breathing.

So the theory is that apneic episodes don’t just come from having a huge neck and excess body fat, but there are other factors like trauma at play. And when you have a patient with severe sleep apnea, they have a score called a AHI score and if that score is very high, like 100 or 200, you almost always see deficient testosterone levels.

Brett McKay: Okay, so having metabolic syndrome, being overweight, sleep apnea, any other causes of low testosterone?

Dr. Kyle Gillette: Yeah, so theoretically xenoestrogens could be a cause of low testosterone. These are things like phthalates. These are also things like bisphenol A, also known as BPA, you might see BPA free on water bottles from time to time. These do bind various estrogen receptors and are likely suppressive. By suppressive, I just mean they shut down the production of the hormones that lead to testosterone production to some degree. Heat damage is also kind of an honorable mention. Some people might be familiar with what varicose veins are. Varicocele is where there’s varicose veins in the scrotum and some people with varicocele can have venous cooling very well. The testes wanna be about 91 to 92 degrees where the body is 98.6 degrees. So if you can’t keep your testes at 91 or 92, then you’re going to have less testosterone production and less sperm production. And in the more severe cases you’ll have atrophy, which is shrinking because, think about them as factories. If you’re not using the factory, they start to shut down.

Brett McKay: And besides these lifestyle factors and environmental factors, you could also have just an issue with your pituitary system, right? You might have a tumor or something in pituitary gland that’s dysregulating the release of hormones.

Dr. Kyle Gillette: Correct. I suppose that would be likely one of the more common less modifiable risk factors. There’s not a lot that you can do about that. You can take supplements like vitamin B6 or like vitamin E, but a lot of times pituitary microadenomas or even macroadenomas, basically it’s a small tumor in the brainstem. The pituitary gland is where you make a lot of different hormones like growth hormone and like LH and FSH. But LH is the main hormone that’s produced there that leads to testosterone release. So there’s two different types of hypogonadism. There’s primary and secondary. So primary is where the testes are not functioning. And then secondary, think about it, it’s two steps instead of one step. So the LH can be low in secondary hypogonadism and if your LH is very low and a hormone like prolactin or IGF-1 is very high, then that might be a sign of a pituitary micro adenoma. In which case you need MRI.

Brett McKay: And LH, that’s Luteinizing Hormone, correct?

Dr. Kyle Gillette: Correct. LH is Luteinizing Hormone. FSH is follicle stimulating hormone. They do crosstalk to some degree, but LH mostly helps with testosterone production and mostly binds to the Leydig cell in the testicle. And FSH mostly binds in the seminiferous tubules and helps with spermatogenesis.

Brett McKay: So I mean listeners have probably heard reports that T levels in men have been declining in the past few decades. Do we know what’s causing this sort of general decline? Is it just all these lifestyle, like people are getting fatter, there’s not sleeping, they’re stressed, and the stuff in the environment is that kind of what we’ve decided is the cause of the lower T levels?

Dr. Kyle Gillette: The various causes that we’ve already discussed are likely the primary causes of what is causing declining testosterone levels. But I think there is another factor, and a lot of that has to do with what I’d call epigenetic drift. Some people might call it natural selection, I might call it unnatural selection, where individuals with higher testosterone levels are no longer being selected for as early. And also a lot of individuals are having kids later on in life, for example, in their 30s or even 40s, when you might have very different maternal and paternal hormone profiles. That’s one of the reasons why I recommend if men are taking medications like Finasteride or Dutasteride, that they stop their Finasteride 90 days before attempting conception and they stop Dutasteride, depending on what dose they are, usually six months before conception. By the way, spermatogenesis takes about 60 days or two months. That way they have enough time to wash out before they start producing the sperm in the germ cells so that they wouldn’t pass down any epigenetic changes to potential offspring.

Brett McKay: Okay, so maybe this is… The idea is that… Again, this is theoretical, right? The testosterone increases aggression and risk taking behaviors and that’s not as adaptive in our safe high tech modern landscape. So men with lower testosterone might be more successful these days and women choose those men for their partners and then when they have children, the men pass down his genes and then his children have lower testosterone too. And that just perpetuates, just lower testosterone in the male population overall. Also, this idea of selection, I’ve heard that, I read this somewhere, correct me if I’m wrong on this, that women on birth control, they’re not attracted to higher testosterone men. Is that true?

Dr. Kyle Gillette: Yeah, that is one of the major players of what I would call unnatural selection. Another interesting unnatural selection, I suppose, if you look at, not very recently, but the World Wars, certainly in World War I and World War II or in the Korean War or Vietnam War, but especially wars that… Even if a war has a draft, the individual that has higher testosterone and also more sensitive androgen receptors, so this is probably true throughout all of human history, you would… And this obviously cannot be proven scientifically, but theoretically that individual would be more likely to volunteer to go to the front line or to very risky positions. And if that male passes away at age 18 or age 19, then that is likely a fecundity rate of zero. So no offspring from that individual and then you start to have genetic drift.

Brett McKay: Okay, so again, this is theoretical, what you’re saying is that men with very high testosterone, they’re gonna take more risk and in doing so, that may take them out of the gene pool by taking those risks. And there’s more opportunity for that sort of risk taking during big global conflicts like the world wars, right? More high T men die, they lose the chance to reproduce and pass on their genes. And then that just contributes to the declining testosterone in men in general. And that’s gonna have echoes through the generations. And on top of that, we have selection factors going on in the mating market as well.

Dr. Kyle Gillette: Yes. And it’s not like it’s an be all end all. All or nothing. You select for high testosterone or you select for low testosterone. There’s a lot more psychosocial factors at play, but we are certainly seeing that there’s likely a decline in testosterone even a bit more than could be accounted for by just metabolic syndrome and sleep apnea. Maybe things like heat damage to the testicle, maybe things like xenoestrogens are playing some part in this, but we’ll probably never know. But it’s very fun to speculate about it.

Brett McKay: Well, the heat damage to the testicle, what would… Causes like keeping your laptop on your lap, sitting down a lot, would that cause heat damage?

Dr. Kyle Gillette: Probably not significantly enough, but if you already had a Varicocele and you already spent an hour in the jacuzzi, keeping your really hot laptop and phone directly over your scrotum is certainly not gonna help. I suppose someone could prove this at some point. They’ve actually done a lot of studies where they look at the scrotal temperature and they’ve randomized two groups of usually, college students and one group they have wear basically like a sock around their scrotum that has something really warm in it. So they warm up the scrotum artificially to 98 degrees instead of 91 or 92 degrees. And in the individuals that don’t have varicocele, they can still overcome that heat damage because their venous pooling mechanism is so good at buffering that heat damage. So that did not affect their testosterone production and it did not affect their spermatogenesis. However, in individuals that already have impaired venous cooling, for example, with varicocele or varicose veins then it did.

Brett McKay: We’re gonna take a quick break for a word from our sponsors. And now back to the show. Let’s talk about optimal levels of testosterone. So below 400, and if you’re experiencing low testosterone symptoms, that’s not good. Is there an optimal level, as like a level that guys should reach for or is it gonna differ from man to man?

Dr. Kyle Gillette: It certainly differs, but that’s kind of an easy answer. So I’ll get into it more than that. A lot of times people have told me that I say individualized, I say that word a lot because health is individualized. We are all unique, we have different genetics, we have different epigenetics and we have different growth and development past that as well. But for most men, an optimal testosterone level is between about 500 and as high as you can go naturally. So there is some individuals with a total testosterone of 1500, they almost always have really high SHBG. So a lot of times their free testosterones only 20 or 25, between about 550 and whatever you can produce top in endogenously naturally without medication.

Brett McKay: But you also said it could be lower. I mean you mentioned there are athletes who are at 450 and they’re healthy. So if you get a blood test and it’s below 500 a little bit, you probably… I mean, I guess you shouldn’t worry too much about it if you’re not experiencing any symptoms.

Dr. Kyle Gillette: Correct.

Brett McKay: Okay, that’s good to know. So let’s say a patient comes to you reporting symptoms of low T, you do a series of blood tests that show yeah, that your T levels are low, they’re below 400. What’s your first line of attack in helping this patient get his T levels up?

Dr. Kyle Gillette: First thing to look at would be LH and FSH. If those are really low, then I’m worried about the pituitary or the brain. If those are really high, then I’m worried about the health of the testicles. If they’re in between, then I look for another pathology like diabetes, metabolic syndrome, insulin resistance, sleep apnea, etcetera. I also look at prolactin and IGF-1, make sure you assess their tumor risk. And then I also look at estradiol. If it’s a very high estradiol, then estradiol is likely what is suppressing the production of LH from the pituitary. So you have estradiol, which is your main estrogen, which is causing less testosterone production. And in that case, I look at things like alcohol consumption that can up-regulate aromatase or consumption of excess calories or fat that can up-regulate aromatase, which converts testosterone to estrogen by the way. So those are the first things.

Brett McKay: Beyond that, what are you looking at?

Dr. Kyle Gillette: Beyond that, I’d like to, if pertinent, do an exam, make sure, especially if this individual is developing, if they’re an adolescent or whatnot, you need to make sure that they’re through all the tanner stages. Basically tanner stages one to five, five is done, when you’re essentially adult growth and development to make sure that they don’t have some unusual or unlikely syndrome. And then after that I’d like to look at their fasting insulin, their A1C, see if there’s something that I can correct. I look at their cortisol. If their cortisol is high, then there’s a lot of lifestyle factors and also supplements that can help control cortisol like Ashwagandha or Emodin. I look at their prolactin. So if their prolactin is just a little bit high, then maybe I do start them on some Vitamin B6 or some Vitamin E. If their estrogen is high, maybe I start them on some Calcium D-glucarate that helps with estrogen glucuronidation and metabolism. It basically helps you excrete it through your stool and then repeat labs in one, two, maybe even three months and see if we can improve those things along with, as always, diet and exercise.

Brett McKay: Okay. So it sounds like the first line of attack, if it’s not a pituitary problem, you’re gonna be primarily doing lifestyle changes, right? Quitting drinking, getting better sleep, diet, exercise to help get that insulin sensitivity back online. So yeah, lifestyle stuff would be the first line of attack and then will it take maybe one to two months before you start seeing results from that?

Dr. Kyle Gillette: Yeah, often it does. A lot of times you feel better the first week and a lot of times your testosterone production recovers very quickly. But occasionally, I use medications as well. So some people utilize a short course of HCG, which essentially binds the LH receptor, takes the place of LH and occasionally, I’ll utilize very short courses. By very short, I mean, a week or maybe two weeks of selective estrogen receptor modifiers or sometimes longer in the right patient, especially very young patients that you’re trying to stimulate endogenous production, these are often patients that desire fertility within the near to mid near future.

Brett McKay: Besides diet, exercise, sleep, managing stress, you mentioned a few supplements that you recommend men taking to optimize male hormones. Are there ones that you recommend for just any guy who… Maybe they don’t have any problems with testosterone but they just want to feel good? Are there ones that you like and that are safe?

Dr. Kyle Gillette: Creatine 5g-10g a day would be a great start. L-carnitine would be a consideration, especially if they’re interested in athletic performance optimization or body composition optimization, L-carnitine would be reasonable. Consider checking a TMAO to make sure that it doesn’t convert to that in too high of a rate. Another reasonable addition if someone has high estradiol would be Calcium D-glucarate to make sure that they’re binding up extra estrogen and excreting it.

Brett McKay: I’ve heard that Boron can impact testosterone. How does boron increase T levels?

Dr. Kyle Gillette: Boron works okay for people with really high SHBGs. It increases free testosterone by decreasing SHBG. The effect wears off to some degree if you take Boron for a very long period of time. If you have very low levels or you’re insufficient or deficient in Boron, it works extremely well and a lot of people consume Dates or Raisins because they tend to be relatively high in Boron.

Brett McKay: There’s another something I’ve been hearing about lately, Tongkat ali, I think that’s how you pronounce it. What’s going on with that one?

Dr. Kyle Gillette: Tongkat ali is also known as Longjack. So Tongkat’s active ingredients are Eurypeptides, one of which is Eurycomanone. And Tongkat is helpful because it upregulates a couple different enzymes in the steroidogenesis pathway. There’s been plenty of human study on it, with mixed results and it looks like the cause of the mixed results is, sometimes people have great activity of those enzymes. So that’s not the rate limiting step in testosterone production. So think of it as a signal, think of your testicles as a factory. Tongkat is a signal to that factory to ramp up production, but if your factory is already operating at maximum capacity or it’s limited by something else, then that’s not going to improve your testosterone level. Tongkat works on very similar enzymes that are also upregulated by insulin and IGF-1. So in general, if you’re in a caloric deficit or if you’re trying to lose weight or body fat, Tongkat will work better. If you have a low fasting insulin or a lower end IGF-1, Tongkat will also likely work better. And I’ve seen this anecdotally as well.

Brett McKay: A couple years ago, I remember ZMA was a big supplement that was pushed for increasing testosterone levels. Anything to that?

Dr. Kyle Gillette: ZMA is very reasonable to add if you have a low alk phos. So if you look at your CMP, which is your metabolic panel, there’ll be an enzyme called alkaline phosphatase. Alkaline phosphatase along with GGT are two intracellular enzymes. And the lower these two are the more likely you are to have insufficient levels of Zinc and magnesium. That’s why when I have input to various companies designing a supplement to optimize testosterone, I almost always put in Zinc, Magnesium and Vitamin D. You just wanna make sure these aren’t the right limiting step. Think about trying to optimize your testosterone is like trying to get into a fraternity. You’re not just making best friends with one of the people and then just hoping that nobody else will blackball you. You wanna make sure that you address each individual because if you… Let’s say you forget your Vitamin D and forget your Zinc, you’re deficient in Zinc, you’re deficient in Vitamin D, those two things will hold you back.

Brett McKay: Once you start down this path of increasing your testosterone or getting them optimized, is there any benefit to getting them higher? So let’s say you started off at 400, you had low T symptoms and then through lifestyle changes and maybe taking some supplements, you bump it up to like a 700. Are you gonna get any more benefit from testosterone by getting it up to 800 or 900?

Dr. Kyle Gillette: Past about 600, there’s little to no benefit, other than bragging rights.

Brett McKay: At what point would you have a patient go on testosterone replacement therapy?

Dr. Kyle Gillette: At any point when the risks outweigh the benefits and they understand both the risks and the benefits in their own terms.

Brett McKay: So what are the risk of TRT?

Dr. Kyle Gillette: Yeah, one of the risks is it causes more fluid retention and swelling. One of the risks is if you hyper convert to estrogen, estrogen will then bind to the liver and cause more SHBG and platelet production. And if your platelets go very high past a certain point, we know that people on oral estrogen, the blood clot risk is associated with how high their platelets and SHBG go. It’s likely the same for TRT. So if you go on TRT and you go into a huge bulk and you start consuming a bunch of alcohol and your platelets skyrocket, then it is gonna increase your blood clot risk. So TRT is not in and of itself going to improve health, it’s just going to be a tool to help you achieve a lot of your goals. Another risk of testosterone is if people have heard of medications called statins. Those work by decreasing the activity of an enzyme called HMG-CoA reductase. Any androgen including testosterone increases the activity of this enzyme. So often people’s cholesterol and it’s not actually cholesterol, they are lipoproteins, but people’s “bad cholesterol” gets worse. That’s why we watch that ApoB number very closely because we know that ApoB is the particle that is going to lead to plaque formation in areas like the coronary artery.

Brett McKay: And I guess the benefits of TRT is that you’ll mitigate those symptoms of low testosterone?

Dr. Kyle Gillette: Correct. And there’s of course other benefits as well like the benefits of estrogen, that we discussed earlier, being it’s cardioprotective benefit. And one of the main benefits of testosterone in a lot of individuals that I see start is they might have a… Let’s say they have an A1C of 5.7 or 5.8, which is technically pre-diabetes. You’re very unlikely to get diabetes on testosterone compared to if you are not on TRT. So a lot of individuals, perhaps they’re, I wouldn’t say doomed, but very likely to get diabetes and TRT can make a huge difference, especially when combined with other insulin sensitizing medications to prevent that.

Brett McKay: Do you keep people on TRT indefinitely? Is it like once you start to keep doing it or are there periods where you’re like, “Well, we’re gonna take you off and see what happens” or well how does that work?

Dr. Kyle Gillette: Most individuals are on indefinitely, but not everyone. Occasionally there’ll be a patient that is profoundly hypogonadal and the benefit of testosterone at that time is just huge. Let’s say it’s a patient who has a BMI of 40 and they weigh 400 pounds and they also don’t have a huge amount of lean body mass to lose in proportion. Everybody who weighs 400 pounds is gonna have a lot of lean body mass, but just less relative to your average person and they wanna maintain as much of that as possible. They need that tool in order to exercise, even if it’s somewhat of a placebo tool, that still helps. So if it gets them having a very healthy lifestyle, they go on that medication, perhaps they go on another medication like a GLP-1 for a short period of time and then they don’t really know what their baseline testosterone is. So maybe after two years they’ve learned those lifestyle interventions. They very slowly are ready to come off of every medication and then you can use a medication like HCG to help restore natural production. Perhaps one week of a medication like Enclomiphene or Novedex or even Raloxifene. And then you see what their natural production capability is. You give them a few weeks and perhaps they restore to a total testosterone of 600s, which is likely quite good in that situation or perhaps they go down to 100s again.

But a lot of people would want that chance to go back to producing their testosterone naturally. And in some cases it does work. I would say 90% of people that start on testosterone are going to remain on it indefinitely. But I would also say that 90% of people that go on testosterone can very likely regain at least their previous level of testosterone if they were to want to come off.

Brett McKay: Well, here’s a question. With female hormone therapy, you might start taking it during menopause to help with symptoms, but at a certain point, once menopause is over, I think you’re supposed to get off those hormones. Does something like that happen for men? I mean, you might do TRT throughout your 50s and 60s and then at a certain point you’re in your 70s and you’re like, Well I don’t need to do this anymore. Or are there 80-year-old or 90-year-old guys taking TRT?

Dr. Kyle Gillette: There are 80 or 90-year-old guys taking TRT. Occasionally, you’ll do a dose adjustment. It just kind of depends on the situation, but a lot of times when males reach that age, they are less likely to have as much benefit and they are more likely to have slightly more harm. So it’s a moving target over time where you get out the scale and you’re weighing the risks and the benefits and at that point when a patient’s already on TRT, you also weigh the risks of how difficult it would be to come off, which is not extremely difficult. But it is difficult because there’s medication regimens that you have to go with and even with those medications often there is a short period of time when you don’t feel great.

Brett McKay: So we’ve been talking about optimizing male hormones in grown men, but let’s say we got some dads and moms out there listening and they’ve got boys who are about to start or are in the middle of puberty. What can they do for their sons? What can young guys do to make sure they set themselves up for a lifetime of male hormone optimization?

Dr. Kyle Gillette: First and foremost, no huge dirty bulk in early adolescence. What I mean by that is, I mean, let’s say there’s somebody that’s trying to put on weight for football or whatever other reason, can’t think of any reasons where it would be worth it, but they’re putting on weight and also putting on fat. Adipose tissue in fat, adipose tissue is fat, that is going to increase the conversion to estrogen and estrogen is gonna close the growth plates of the bone. So that’s gonna prevent you from reaching full stature, both in height and other areas of your skeletal developments as well. So that’s a great initial recommendation. Thinking about gut health and fiber consumption is also very important. That’s gonna prevent, again from over, it’s called intrahepatic circulation of estrogen. Estrogen is not necessarily the enemy. In fact, a little bit of estrogen is neat to what’s called priming the pituitary in order to fully kickstart adolescence.

And that’s one of the reasons why boys with very high body masses have higher estrogens. The pituitary gets primed too early and something called precocious puberty is happening, which is too early of puberty. So that’s another thing to consider. In addition to that, you wanna have a reasonable balance between cardiovascular exercise and resistance training. You certainly want to do both because adolescents can be thought of as your free endogenous steroids of, I’ll say cycle, just because people understand it. But your free endogenous steroid boost where you know you are going to be one, super sensitive to all the androgens that are released, probably most people remember puberty and you’ll also be having a lot of androgen around, regardless of what you do, even if your health hasn’t been great. So when that endogenous steroid burst happens, that is the perfect time to take advantage of those lifestyle tools to build up very high bone mineral density and very high lean body mass without putting on excess body fat.

Brett McKay: I imagine young people getting plenty of sleep is important too.

Dr. Kyle Gillette: Yes, extremely important. And that might be one of the most common causes of suboptimal hormone profiles in adolescents.

Brett McKay: What about supplementation? Is supplementation something you encourage in young people to optimize their hormones or is you just focus on the diet and exercise?

Dr. Kyle Gillette: With the oversight of a doctor, I do encourage supplementation, if it makes sense. For example, let’s say there’s a young person and they get a stool test and the beta-glucuronidase enzyme is very high. We know that that individual is just recycling their estrogen over and over again, that makes something like a Calcium D-glucarate or with the oversight of the doctor maybe even a very low dose of an aromatase inhibitor, a very reasonable addition. And then if you get blood tests, you can actually check the hormones to make sure that they’re increasing at the correct rates, that your DHT is optimal, your testosterone’s optimal, your estradiol is optimal, your IGF-1 is optimal, and then you can tweak a supplement. Supplements are just like medications, they have pharmacologic effects so they have an effect on the body and the body metabolizes them.

So things like Creatine can be very reasonable. Creatine does not affect the development of the kidneys. I did a podcast with my good friend James O’Hara recently. We get a lot of questions from pediatricians because the AAP, which is a society of pediatricians, still recommends no Creatine supplementation whatsoever up to the age of 18. So not even, not even a 17-year-old. So I just kind of thought that was… And it’s been 15 years. So they’re gonna update their recommendation within the next couple years whenever they have a joint meeting. But that’s definitely a vestige of times past when we thought that Creatine was harmful to healthy kidneys. You just check a Cystatin C because Creatine makes your creatinine blood marker look abnormally high. Falsely high. So Creatine can make sense in a lot of kids as well. And then if there is a kid that has really low insulin IGF-1, sometimes Tongkat makes sense in that individual.

And then in some kids that do have optimal hormone profiles, let’s say there’s an athlete and he’s developing or she’s developing and they have very high testosterone, very high IGF-1, that’s great, you know that Myostatin levels are gonna be really high after you have that burst of androgen during adolescence. Myostatin is gonna stop the muscle from developing and cause you to start putting more fat into the tissue. I think that Myostatin inhibitors, week ones like Fortetropin, which comes from fertilized egg yolks or Epicatechin. CocoaVia is a good source of Epicatechin. Different cocoa powders have a lot of Epicatechin. Green tea has EGCG, which is another Epicatechin. Basically, those take down the levels of Myostatin. Those are also very reasonable to take for the right patient.

Brett McKay: What about, should parents be sweating about xenoestrogens in their kids? Like, make sure they get certain types of deodorants or cosmetic products and avoiding plastics?

Dr. Kyle Gillette: Bisphenol A and phthalates. Yes. That’s kind of where I personally draw the line, where if you are worried about every single thing, we live in an unnatural environment, more so than ever. So those are usually the ones that I say to avoid. If you live in an area that more likely has contaminants and microplastics, a lot of times I do recommend testing your water. There are a lot of services that do this. I personally used MyTapScore to test both the water, from the tap and the water through my Berkey filter. If you have young children. And that seems like a very reasonable time to use a water filter if you don’t know what the contents of your water is. And then as far as foods, of course, avoiding ultra processed foods, I think, it was ultra processed mac and cheese that got a bad name for having high phthalates. I assume they fixed that by now, but I actually don’t know. So a lot of times it’s the same recommendations as any other whole food diet. And then know your sources, try to avoid contaminants at very high levels and use the Pareto principle, try to do right most of the time and you’ll get most the benefit even if you’re just doing it some of the time.

Brett McKay: Well Kyle, this has been a great conversation. Where can people go to learn more about your work?

Dr. Kyle Gillette: My hub is on Instagram, kylegillettmd, and it’s Gillett Health on all other platforms. I do have a podcast that we fairly recently have, I guess, gotten pretty good audio and video of, but that’s on YouTube, Spotify and Apple Podcasts. We have a clinically, I guess, a clinical grade podcast. And then we have a layman’s podcast that we’re gonna call After Hours, which should provide good entertainment.

Brett McKay: Fantastic. Well, Dr. Kyle Gillett, thanks for your time. It’s been a pleasure.

Dr. Kyle Gillette: Thank you.

Brett McKay: My guest today was Dr. Kyle Gillett. You can find more information about his work at his website, gilletthealth.com. Also, check out his podcast, Gillett Health podcast and check out our show notes at aom.is/optimalt where you’ll find links to resources where we delve deeper into this topic.

Well, that wraps up another edition of The AOM podcast. Make sure to check out our website at artofmanliness.com, where you can find our podcast archives as well as thousands of articles that we’ve written over the years about pretty much anything you think of. And if you’d like to enjoy ad-free episodes of the AOM podcast, you can do so on Stitcher Premium. Head over to stitcherpremium.com, sign up, use code MANLINESS at checkout for a free month trial. Once you’re signed up, download the Stitcher app on Android or iOS and you can start enjoying ad-free episodes of the AOM podcast. And if you haven’t done so already, I’d appreciate if you take one minute to give us a review on Apple podcast or Spotify, it helps out a lot, and if you’ve done already, thank you. Please consider sharing the show with a friend or family member who you think could get something out of it. As always, thank you for the continued support. And until next time, it’s Brett McKay, reminding you to not only listen to the AOM podcast, but put what you’ve heard into action.

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Do you sometimes walk to another room in your house to get something, but then can’t remember what it was you wanted? Do you sometimes forget about an appointment or struggle to remember someone’s name?

You may have chalked these lapses in memory up to getting older. And age can indeed play a role in the diminishing power of memory. But as my guest will tell us, there are other factors at play as well.

Charan Ranganath is a neuroscientist, a psychologist, and the author of Why We Remember: Unlocking Memory’s Power to Hold on to What Matters. Today on the show, Charan explains how factors like how we direct our attention, take photos, and move through something called “event boundaries” all affect our memory, and how our current context in life impacts which memories we’re able to recall from the past. We also talk about how to reverse engineer these factors to improve your memory.

Resources Related to the Podcast

• AoM Article: 10 Ways to Improve Your Memory
• AoM Podcast #546: How to Get a Memory Like a Steel Trap
• AoM Podcast #750: The Surprising Benefits of Forgetting
• Reminiscence bump

Connect With Charan Ranganath

• Charan’s website
• Charan on IG
• Charan’s faculty page

Listen to the Podcast! (And don’t forget to leave us a review!)

Listen to the episode on a separate page.

Download this episode.

Subscribe to the podcast in the media player of your choice.

Read the Transcript

Brett McKay: Brett McKay here and welcome to another edition of the Art of Manliness podcast. Do you sometimes walk into another room in your house to get something, but then can’t remember what it was you wanted? Do you sometimes forget about an appointment or struggle to remember someone’s name? You may have chalked these lapses in memory up to getting older. And age can indeed play a role in the diminishing power of memory. But as my guest will tell us, there are other factors at play as well. Charan Ranganath is a neuroscientist, psychologist, and the author of Why We Remember, Unlocking Memory’s Power to Hold on to What Matters. Today on the show, Charan explains how factors like how we direct our attention, take photos, and move through something called event boundaries all affect our memory, and how our current context in life impacts which memories we’re able to recall from the past. We also talk about how to reverse engineer these factors to improve your memory. After the show’s over, check out our show notes at awim.is/memory. Charan Ranganath, welcome to the show.

Charan Raghunath: Thank you very much, Brett. Great to be here.

Brett McKay: So you are a neuroscientist and you’ve spent your career, 20 plus years, researching memory. And we’re gonna talk today about why we remember some things, why we forget other stuff and what we can do to improve our memory. But after I read your book, one of the big takeaways I got from it was that memory is more than just an archive of our past, that actually memory shapes our day-to-day lives. So how does memory influence our lives beyond just being able to recall events?

Charan Raghunath: So one just very kind of simple example would be let’s say you wake up in a hotel room, your first question as you wake up as you’re a little disoriented and probably without even thinking about it you’re having this moment of, where am I? And just to situate yourself in time and space, it’s like you can look around you know where you are in the room, but, where is this room? It could be in like a prison somewhere or it could be in like a resort, who knows, and so you have to rely on memory just to get to that point to dig you out of that hole and tell you exactly where you are. So let’s take a slightly more complex example now like let’s say for instance you are trying to choose which restaurant you wanna go to and you have like a usual restaurant that’s pretty good but then lately they changed the menu and, you know, the last time you went there you had a terrible meal.

Brett McKay: So you can use memory to basically say, you know what, I’m going to go to someplace different this time. And then we can take something like a big choice. So I decided to go into research in cognitive neuroscience, but my training was in clinical psychology. And I actually had the chance to do a clinical internship in which I could have been on a career path to make lots of money in a clinical career. And when I look back on that decision, what I asked myself was essentially, what are the kinds of moments that I feel most comfortable in, that I’m happiest about? When I thought about the instances in which I was in the clinic, I thought, okay, I have to be dressed up well. I have to be there early in the morning. I have to be on when people say there’s a lot of pressure because if I don’t get things right, bad things can happen.

Charan Raghunath: Versus the times that I could remember from being in research where I was like staying up late, drinking beers and eating pizza in the lab while we were working late for a conference or something like that. And the people that I hung out with in the lab versus the more kind of formal environment in the clinic. And it was just a no-brainer. And so these hard life decisions are very very complicated we’re making them based on insufficient information and so we rely on memory to give us that data that we need to make these decisions about our future.

Brett McKay: And as we’ll see in this conversation too, memory is connected to a lot of other things in our lives that we might not think are connected to memory. The ability to imagine things, that’s connected to memory. How we situate ourselves, not only in place, like that example you gave, you wake up in a hotel room, you’re like, “Where the heck am I?” But also in time. But let’s get to this question. I think a lot of people might have this. Why do we remember some things, but not others? And then the follow-up question is, what can that answer tell us about how memory works?

Charan Raghunath: When we look at the design of the brain, what you see over and over and over again, whatever system you look at, is that the brain is optimizing to make the most of a little bit of information. And so what I mean by that is if we see the world, we’re not literally looking at everything. We’re only grabbing little bits and pieces of the world with our eyes by just moving our eyes and focusing in different places and then assembling that into a meaningful picture. So we know that even our ability to perceive the world is limited and our ability to hold things in attention is limited. So what makes things memorable and what makes things grab our attention, there’s a high relationship between them. They’re often things that are biologically important. So something that you’ll probably find this, I imagine yourself, Brett, if you look back on things in your life, you probably remember the first things that will come to mind will be the highs and lows, right?

Things that are very emotionally, there were exciting or times where you were scared or times where you felt intense desire. And these are biologically important moments where there are chemicals in the brain that promote plasticity that are released during these moments. So that right off the bat tells you something about why some events are memorable is because they’re biologically important. Other events that would be also important would be things that are new or things that are surprising. So we often remember these events that really surprise us because they stick out. And some of that is related to a phenomenon I’ll get into with regards to interference. But some of it is also when we’re surprised or when we’re in a brand new place that we’ve never been to before. Again, there’s these release of neuromodulators, these chemicals in our brain that promote plasticity. So those are some of the key factors. And another key factor, as I mentioned is the fact that memories compete with each other.

And this is a phenomenon called interference. So I think intuitively, we might think of memory as being like I store a bunch of files in my hard disk. And more or less, if I store 10 files or if I store 20 files, it doesn’t make a difference. But that’s not how memory works. In human memory, the memories are competing with each other. And so if I’m trying to remember, Brett, let’s say, your name, I meet you sometime in person. We go into the real world as opposed to the virtual world. I meet you, we have a beer or something like that. Then later on, I meet someone named Britt. Well, remembering Britt is going to be complicated because I’ve just learned about Brett and there’s going to be this interference between them. So the way that memories can survive that competition is if there’s something distinctive that makes this memory different from something else.

So if I had something about your name and I could tie it with something interesting about you that I learned and make that all into one big story, for instance, then now all of a sudden you’re very, very different from Britt because Britt is just sound that I heard. And this is the way in which memories can stick around is if we’re attending to something that allows us to capture what’s unique about this moment in time. So the sights, the sounds, the smells, emotions, something that you think about that’s unique.

Brett McKay: Does our brain store memories in a specific part of the brain?

Charan Raghunath: Well, this is a very tough question to answer because essentially it comes down to what is the memory. And so there’s many different ways memory can be manifest. One is your ability to just know, call upon facts, general knowledge that you have about the world. And that’s called semantic memory. And then there’s your ability to remember specific events in your life, like episodic memory. So, I know that Def Leppard was a British metal band that played very melodic songs in the 1980s, but that’s different than my memory for seeing them in the round during the Hysteria tour, which was a little bit after they had peaked. But nonetheless, that’s an episodic memory from one point in time. And so those kinds of memories differ from each other. Now, the hippocampus is an area of the brain that’s known to be very important for forming new episodic memories. And it doesn’t do it by itself, but what it does is it ties together all of these different parts of the brain that are processing the different kinds of aspects of the semantics of your world. Does that make sense? Am I kind of getting too…

Brett McKay: No, that’s making sense so far, yeah.

Charan Raghunath: Yeah. So a lot of what people think of when they think of the memory loss, for instance, that you see in the earliest stages of Alzheimer’s disease, that’s related in part to the loss of the hippocampus, because what happens is people start to lose this ability to form new episodic memories. They still have knowledge of who they are, all the people they know in those early stages, but they lose this ability to form new episodic memories. And so that’s why the hippocampus is such a big player in memories, ’cause it plays this role in just arbitrarily saying, in some ways, the hippocampus, I mean, if we were to pretend the hippocampus is a person instead of a brain area, you could say, well, it’s being deliberately dumb. It’s not thinking about why things should go together. It’s just saying, “Hey, I happened to see Brett in the pub while the song was playing in the background all at the same moment in time.” And that’s what the memory is. It’s just this random coincidence of factors.

Brett McKay: Okay, so the hippocampus is involved in episodic memories.

Charan Raghunath: Mm-hmm.

Brett McKay: Something that you’ve researched a lot and found, and it’s been groundbreaking, is the role the prefrontal cortex plays in memory. People might be familiar with the idea that the prefrontal cortex can be used as short-term memory, it’s sort of used as… The analogy is the prefrontal cortex is like RAM. It’s like working memory. So if you need to temporarily remember something, prefrontal cortex can take that for longer-term memories. You go to the hippocampus. What your research has found is no, the prefrontal cortex actually plays a bigger role in those long-term memories. What role does the prefrontal cortex play?

Charan Raghunath: Yeah, I think that I’m really glad you brought up that RAM analogy because I think that was very popular for a long time in psychology that we used to think of humans as being like computers in this very kind of straightforward way, but we’re not. What the prefrontal cortex seems to be about is it’s kind of a, again, I’m gonna use these analogies just to keep things simple, although I hope people with a more scientific background won’t get mad at me for this. But a lot of people use the term executive to describe what the prefrontal cortex does. And what that means is, you know, an executive who’s running a company really has no useful skills. You’re not gonna trust them with the accounting. You’re not gonna trust them to like handle the mailroom or anything like that. But their job is really to oversee everything coordinated towards a common goal.

And that’s what the prefrontal cortex is all about. So for a long time, people used to think, oh, the prefrontal cortex doesn’t do anything because people could lose a prefrontal cortex and they would still walk and talk and have all the knowledge they did before, but they couldn’t function in the real world because they had no ability to use that information to get their goals achieved. And so you brought up this idea of short-term memory. And so part of the idea of being able to hold a phone number, say, in short-term memory, like if I give you a phone number or if I say, “Hey, here’s your temporary password. I need you to reset it so that you can get back into your bank account.” You’re keeping that information in mind. But to do that, you have to keep yourself from being distracted. There’s a kid crying in the background or maybe you’re getting a text alert on your phone and you have to suppress those distractions to focus on what’s relevant.

And that’s where the prefrontal cortex comes in. But that same ability is also what allows you to be present in the moment and focus on what’s important, like where I put my keys or where I put my phone, as opposed to the things that may be less important but could grab your attention, like the sound of a dog barking or a kettle whistling or something. Things that you need to take care of, but they’re not necessarily related to these other long-term goals.

Brett McKay: And so this idea that the prefrontal cortex directs our attention to stuff that we wanna remember. And if we’re distracted, we might not remember that thing. That explains like why we forget, like, where did I put my keys? Where did I put my wallet? Because you just, you weren’t, your prefrontal cortex kind of checked out when you just dropped them on the counter and you weren’t paying attention. So it was just like, “Yeah, we’re not gonna remember that.”

Charan Raghunath: That’s exactly right. Yeah, yeah, that’s exactly right. And so, and sometimes what happens is our prefrontal cortex isn’t checking out, but it’s actually, sometimes we intentionally do it. We switch from one task to another. We’ll go, “Oh, yeah,” I’m gonna be like, I’m walking in the door, I’ve got my keys, but then I just decide habitually to check my email or something. And so the prefrontal cortex is saying, “Okay, let’s shift gears. Now my goal is to check email.” And so the next time when you go back to your keys, you’re already a step behind because your prefrontal cortex has to use all these resources just to shift back from the email task back to whatever it was you were doing when you opened the door. And so as a result, our resources become too depleted, spread too thin, and we can’t focus in on what we need. So sometimes the prefrontal cortex is there, but we misdirect it because we have bad habits.

Brett McKay: Right. Or it could just be overwhelmed I think you highlighted some research how constantly using social media that can inhibit memory because your prefrontal cortex has got all this information just… You’re blasting it and it then it can’t remember stuff you actually wanna remember.

Charan Raghunath: That’s exactly right. Yeah. So you can be blasted both by switching between these things. And again, a lot of this is under our control, so to speak, meaning that we don’t have to check social media all the time. Like right now, if I was being sloppy, I would be checking social media in between points in our conversation, which would be horrible for my ability to remember our conversation later on, which is why I turned off all my alerts and I went into focus mode for this conversation because otherwise I’d be having this conversation and then somebody would say, “Hey, what did you do today?” And I’d be like, “I was on this amazing podcast, but I can’t remember anything about it.”

Brett McKay: Yeah. And this might explain like why as you get older, I mean, there’s a couple of things going on as you get older, why your memory feels like it’s not as sharp. But I just think as you get older into your 30s and your 40s and your 50s, you have a lot more going on in your life, a lot more stuff to keep track of, keeping track of your kid’s schedule, your work schedule, things that need to be done on the house. And so, yeah, you’re probably gonna forget that your glasses are on top of your head because you got so much going on.

Charan Raghunath: That’s a very good point. So as we get older, there’s a bunch of things that happen. So one is, that we have a lot of stresses, we have a lot of pressures, and we have a lot of competing things and deadlines and so forth. And so when we’re under stress, the natural response of the brain is to down-regulate the prefrontal cortex. You wanna go into more of a responsive mode rather than a mode of planning and deliberation. And so we’re now compromised because of that stress. But then on top of it, as we get older, on average, the prefrontal cortex shrinks a little bit. It’s not functioning as efficiently as it should. And then we’re maybe having some health issues. Maybe we just got over a bout of COVID. Maybe you’re not sleeping as well as you used to. And so all of these factors can compromise the frontal cortex even more. So one of the things I think a lot about is how modern life is just optimized to deplete our mental resources and put us in the state of perpetual amnesia.

Brett McKay: Okay, so the prefrontal cortex plays a role in memory by directing where we place our attention. And then when we don’t give something sufficient attention, we can’t remember it. So, if we got a lot going on in our lives, we tend to be forgetful because there’s just too many things to pay attention to. It overwhelms the prefrontal cortex. And then when you’re multitasking, you’re task switching a lot, you can’t give any one task enough attention to remember what’s going on with it and do it well. And then all these things, it can cause stress and that can deplete the strength of the prefrontal cortex as well as other things like lack of sleep. Something related to this is how the use of smartphone cameras affects how we remember an experience. What does the research say there?

Charan Raghunath: So, on average, the research shows pretty significantly that when we use cameras to document our lives, we actually have a paradoxically lower memory for those events. And I think people have this intuitive idea that if I take a picture of this event, I will remember it. And in theory, that could be true. But what often happens is people don’t go back to the pictures, right, ’cause we collect gobs and gobs of pictures and then on top of it, we’re mindlessly documenting these things. And you can see this with the rise of Instagram walls everywhere, right? So it becomes no longer about the experience, but about the picture. And so what happens is, is that people tend to have a poor memory for these experiences when they’ve been focused on taking the pictures and posting them now it doesn’t have to be that way so you could be more selective in the way that you take pictures and use the camera as a tool for grounding you in the moment and say, “What’s really going on here? What’s interesting here?” And then selectively take pictures that are planting cues in your mind for later on being able to remember them. Because that’s what a lot of memory is, is if you have the right cues, some distinctive thing that you’re seeing or smelling or hearing, that’s what allows you to go back and revisit that moment. And so we can be mindful about picture taking.

One study found that if people are in that kind of condition, you can actually improve memory. Another way you can do it is by actually going back to those pictures. So we can think of, like, an Instagram story or a Snapchat post as being a metaphor for how photos actually have this amnesia quality, where you post something, and then two days, it disappears. And this is what I think we often do with our photos. But if you actually. One of the things I do like is what’s called Facebook memories, where they put on a photo that you haven’t seen in years, but you posted it a while back, and that’s now a cue to recall that memory.

And the act of recalling that memory now makes it more accessible later on, so that way you can remember it again. So the act of remembering makes it more memorable.

Brett McKay: Okay, so if you’re going to take pictures, I think going back to what we were saying about the role of the prefrontal cortex in memory, if you’re just focused on taking the perfect picture and thinking, “Oh, this would be great for Instagram, and what are my friends gonna think about?” The way you’re directing your attention, you’re putting it on the picture taking itself. I mean, you’re not really present. You’re not there. And because of that, you’re not gonna remember the experience as much. But you could, if you direct your attention differently, even while taking a picture, that can enhance your memory if you wanted to.

Charan Raghunath: Yes, I would say that if you… You can use your prefrontal cortex. Say, if my goal is to have a memorable experience, I can actually, first of all, think about what’s in front of me, think about the sights and the sounds and the smells and so forth, and immerse myself in it. Immerse myself in this moment. But then when I do take pictures, you can actually ask yourself, what would be a good reminder of this moment? What are the points in this moment that I want to remember? What are the points in this moment that I don’t want to document? I think lots of times we just take pictures without ever even thinking, is this the memory that I want to be calling back? Because ultimately, once we start taking these pictures, those pictures will have a disproportionate effect on what we remember. So how many times have you taken a vacation and you take pictures, and the events that you remember later on are those events that you photographed and the ones that you didn’t photograph get thrown to the side? Has this ever happened to you?

Brett McKay: Yeah, no, for sure.

Charan Raghunath: So, yeah, so that’s I think part of it is the camera can be a tool. And again, if you use your frontal cortex to say, “What do I want out of this experience?” The camera can be a tool to get it, as opposed to a distraction that just takes you away from what you want.

Brett McKay: So going back to this idea of episodic memory, this is sort of remembering events in our lives that happened to us. Why is it that we have a harder time with episodic memory as we get older? So I think we mentioned some things, right? You have just a lot going on in your life. There’s stress. Your prefrontal cortex shrinks as you get older. But, I mean, I’ve noticed this in my own life, and I think you talk about this in the book. I can remember stuff from when I was middle school through age 30. Like, very vividly. I remember college. I remember traveling internationally. I remember high school football. But then after age 30ish, things are kind of like… I kind of remember doing that, but it’s not as in much detail as those teenage years. What’s going on there?

Charan Raghunath: Well, this is something that’s very, very common. In fact, memory researchers have a name for it, which is the reminiscence bump. And the idea behind the reminiscence bump is that if you just plot the number of memories that people will report if you ask them about different times of their lives, and you just make a little graph out of it, there’s a big bump in the graph from the years between the ages of 18 to 30, and there’s a number of reasons for that. And one big reason is that that’s when our sense of who we are is actually emerging. And so the experiences that we have during that time period are very tied to our sense of identity. And that’s the time when we’re forming our tastes in music in food, and we’re finding the friendships that help define us and so forth.

And so we tend to call upon those memories more as a result. And as I was saying, the memories that you call upon the most will be strengthened each time you call upon them.

Brett McKay: Another theory as to why we remember more from our youth is that memory is enhanced when we encounter something novel. And when we’re young, we’ve got a lot of novel things. There’s a lot of first, we do a lot of new things. And so when the brain encounters that, its memory camera is like, “Oh, hey, this is novel. This might be important. We’re going to take a lot of footage of this.” So then when you look back on it, there’s a lot of memory footage to unspool. But as adults we tend to get into a routine, we experience less novelty. Each day, I mean, even year, is just a lot like the last one. So the memory camera just, like, turns off. It’s like, “Well, I’ve seen this before. No need to capture it.”

So when we look back, there’s not a lot of memory footage to unspool. So if you want more memories in adulthood, you’re gonna have to do more novel things. More memorable things. We’re going to take a quick break for a word from our sponsors.

And now back to the show. How can understanding how episodic memory works help us understand why it is when we go into the kitchen for something, we forget why we went into the kitchen. What’s going on there?

Charan Raghunath: This is one of my favorite topics and actually something that we’re studying a lot in my lab right now. Even though our lives are continuous, what happens is we tend to remember our lives as a series of events. Like, I went to the kitchen, I went to someone’s 21st birthday party, blah, blah, blah. And so what we think happens is that as we go about our day, you’re creating a little story in your head. That’s okay. So my job right now is to talk to Brett and answer this question. I’m keeping your question in mind. I’m thinking of all these ways of answering it. But then we move on to another question, and I flush that information out. I focus on the new question you’re asking.

And that time, when I pivot from question one to question two is what we would call an event boundary. It means that one event is over, another has begun. And what we can see when we scan people’s brains is at those moments, there’s almost a tectonic shift in the patterns of brain activity, where you see this change in patterns as people’s story about the world changes in a moment.

And so what’s interesting is, is that even the act of just moving from one room to another can give you that. So if I take a few steps right now, if I were just stand up, take a few steps to my right, I’d be in my room. And then one more step, and I’m crossing into the hallway. And even though it’s just another step, I would psychologically feel like I’m in a new place. And that change in your spatial context is enough to create an event boundary. And because context is so important for memory, that is episodic memories are so tied to a time and a place that in the time it takes me to go to the kitchen, now I’ve shifted across two or three rooms. And now when I go back and try to remember why I went to the kitchen, I have to engage in this act of mental time travel to recall what I was doing back in that time period when I was in my room.

Brett McKay: And that’s why it’s often helpful if you go back to the room you were in originally, you’ll remember why you went to the kitchen.

Charan Raghunath: That’s right. Yeah, that’s right. So then what happens is, for me personally, I’ll go to the kitchen, I’ll say, “Oh, what was I here for?” Then I’ll just grab some food and eat it. And then I come back to my office, and I’m like, “Oh, my God, I left my phone in there.” I realized, okay, over the course of the past year, I probably consumed thousands of calories because of these damn event boundaries.

Brett McKay: As I read about that idea about event boundaries, it made me wonder if this can help explain. Whenever I read stuff on a digital device, like my smartphone with the Kindle app, I don’t remember as much as when I’m reading from a paperback book.

And I think it’s it could be because when you’re on a device, it could be on the Kindle app, and then immediately I can swipe over to Instagram or my email. That event boundary when I’m reading on my phone, it’s just really porous. I’m switching back and forth between events, so I’m. I’m remembering less about each. But with a book, like a paperback book, there’s a clear event boundary in its pages. When I’m reading, I’m reading. I’m just in the book, it’s just one event.

And I’ve noticed that whenever I read a paperback book, I remember it more. I can find things, and I can remember where some quote that I highlighted is. I know which part of the book it’s in, but I don’t have that experience when I’m reading on the Kindle app.

Charan Raghunath: Yeah. So there’s definitely physical aspects of holding a book that are different than the way we interact with a Kindle, for instance. And so that can lead our reading experience change, which is going to change memorability. So one of the things that you mentioned is just the fact that if you’re using a device that has more than just a reading app on it, it’s just so tempting to think of other things. So, when you pick up that device, your brain is considering all the possible tasks you could do on that device. And so it’s almost like you’re at a buffet.

I don’t know about you, but if I ever go to a buffet, I’m eating one thing, but I’m thinking about all the other things I could be eating, right? So, again, I’m never really there. And with a book, on the other hand, you have no choice. You’re sort of stuck with it.

And also with a book, there’s a way in which there’s a spatial sense of where the plot is, because, essentially, there’s a physical place for each word on this book. But on the screen, it’s a little different, because every page appears on the same screen, so it gives you a little bit more distinctiveness.

And all these factors put together, I believe, make it easier. I think you brought this up in your example. If I’m reading page 100, I often have to think back to what happened in page 70 in order to be able to understand what’s happening in page 100, and that’s easier to do, I think. At least it feels more natural with a physical book because it’s on a different page.

So I can think about it in a way that actually takes me back to a different place in a different time. And what we found is that actually there’s a little burst of activity and a pattern of activity in the hippocampus that tells us that people are mentally time traveling back at these points where you can make a connection between the current part of a story and a previous part of the story.

Brett McKay: That’s really interesting.

Charan Raghunath: And so I think that act of being able to link things together and build them into a bigger narrative is just mentally easier with a physical book.

Brett McKay: Okay. So if you feel like your brains kind of like, “I’m not remembering as much,” few things you can do there. Don’t blast your prefrontal cortex as much. Maybe turn off the fire hose of social media. Don’t tasks switch so much? Take care of your prefrontal cortex. Sleep, reduce stress, eat right. That can help out a lot.

I thought it was really interesting. You have this chapter about the role that imagination plays in memory. What’s the connection between the two?

Charan Raghunath: So, I loved writing this chapter. It was just so much fun because it allowed me. One of the things about writing this book that was so much fun is I got to take a beginner’s mind and start to look at things that I’d seen and different things that I had read and put it together in a new way. And so there’s a very old idea going back to a researcher named Bartlett in 1930, where he argued that we don’t replay the past, but we really create what he called an imaginative construction. And by that, he means that we don’t play the past. We actually imagine how the past could have been. It’s like, instead of replaying it, we stage a play in our mind of how it could have gone out.

And so we do get some details, but then we use imagination to fill in the blanks and add meaning to our past. And likewise, he suggested this. And then, in neuroscience, this idea really took off about 15 years ago, that we actually use memory to supplement imagination. That is, when we imagine things, they’re not coming out of thin air. They’re based on this combination of all these semantic knowledge that we have and then all these little episodic memories, these random bits of experience that we’ve had at different moments in our life that allow us to anticipate and imagine things that have never happened before. And it’s sort of the root of creativity.

Brett McKay: So this raises an interesting question. If memory is us just imagining how things might have gone, how do we know if what we’re remembering actually happened, that we’re not just imagining it?

Charan Raghunath: This is one of the coolest things about science, when somebody comes up with a problem that nobody had previously realized was a problem. And so my old advisor, Marcia Johnson, just came out with this as a young researcher in the seventies. She just said, “How do we tell the difference between imagination and things that we’ve actually experienced, because it’s all in our heads. A memory for something that happened and a memory for something we just thought about are both just mental experiences.”

And so the way that we have to do it is, again, surprise. You have to use your prefrontal cortex to do a little bit of extra detective work. And so what that involves is saying, “Okay, when I remember this thing, what are the bits and pieces that are coming to mind? Are they things that I can see or are they things that I can hear? Or something that gives me some grounding in that past event? Or is it just stuff that I thought about?” So, I don’t know about you, but for me, I have these issues where I ask myself, did I send that email? Or did I just think about sending the email? Did I take my medicine today? Or did I just think about it and then get distracted?

And I have to actually ask myself, okay, can I feel myself pushing the send button? Can I visualize myself or can I taste like putting the medicine in my mouth and drinking the water? And if so, do I bring back a sense of today versus some other day? And so those kinds of sensory experiences ground us in things that we’ve actually experienced in the real world, but the information that we think about could very easily be imagined.

Brett McKay: And then also, whenever we’re doing that imagining memory thing going on, like, other stuff might mix in as we’re trying to recall a memory of our childhood, there might be something that we picked up, like we read a book or something or we saw a movie, and we unintentionally spliced that into the childhood memory, and it might turn into something that it actually… That’s not how it happened.

Charan Raghunath: Yeah. And often, I mean, we need this because it’s this less is more principle that we’re using schemas as the scaffold for our episodic memories so we don’t have to keep rebuilding our memories from scratch. If I went to a cafe every Monday and met up with a different friend, if I formed a blank memory of that every time, I would be wasting enormous amounts of resources when instead, I could just take all my knowledge about what generally happens in cafes and then tack onto that the specific details of what I did this week versus what I did last week.

Now, the problem is that our schemas allow us to fill in those blanks, but sometimes we fill them in incorrectly. And then what’s worse is when we recall those events and we fill in the blanks incorrectly. Now, that new information can creep into our old memory because the memories get transformed every time we recall them. And so that’s why often people’s, when they tell the story of something that happened in their childhood over and over and over again, or your parents probably do this, what happens is that they get more and more of these little errors that start accumulating.

Brett McKay: Does this idea explain why sometimes people confess to crimes they didn’t commit?

Charan Raghunath: Yes, because what you can typically do in these interrogation situations, and there’s actually manuals that… There’s a manual called The Read Manual that talks about an interrogation method, which relies on this, where what they do is they ask a person to… So, first of all, you start off with somebody who’s an authority figure, like a police person. You put the defendant under stress, and then you give them some misinformation, like somebody else has ratted you out. We already know that you did this. So now there’s a little bit of a seed of doubt planted in the person’s mind, and they’re stressed out, so they’re not applying this kind of critical thinking that the prefrontal cortex would normally let them do.

And then you ask them, “Okay, well, if you don’t remember, just imagine how it could have played out.” And so now they think about it, and if they have a vivid imagination, they might actually be able to come up with a very vivid mental picture of how the crime could have played out. And the next day you ask them, and now they remember something, but they don’t remember what happened. They remember what they imagined. And so if you do this across multiple days while a person is stressed out, sleep deprived, in case of it’s some interrogation of somebody abroad, like what the CIA does with their enhanced interrogation tactics, maybe they’re being tortured. And so as a result of all this, people can develop quite a rich false memory for things that never happened.

And this has been simulated in the lab by Julia Shaw and Elizabeth Loftus, and this has been shown to happen in real life.

Brett McKay: Okay, so memory can be squidgy because our imagination plays a role in recalling memory. Here’s another thing I’ve noticed in my life, and it goes to the squidginess of memory. Sometimes you’re talking to a friend, and you’d be talking about when you were in high school or in college, and you say something like, “Oh, yeah, I remember you were really for the war in Iraq. And I remember how adamant you were.” And the person, your friend says, “Actually, no, I wasn’t I mean, I might have said some things, but I actually wasn’t.” You’re like, “No. You seem pretty adamant about that at the time.” Do we sometimes change our memories in order to match how we see ourselves today? So maybe we thought something in the past, but then our politics has changed or our beliefs have changed, but we update the way we remember things so that it matches how we think of ourselves today. Does that make sense, what I’m asking?

Charan Raghunath: Absolutely. And the answer is yes. So our ability to recall anything in a given moment is based on who we are and how we feel and our mental context at a given moment. So just as if you hear the right song or if you’re in the right place, you can access a memory for a particular moment that matched up with that. It can kind of send you back in time. Likewise, when we’re searching for information, the goals that we have and the beliefs that we carry with us affect what we can pull out and what we can’t.

So it can be something like more unconscious. So, for instance, it could be something along the lines of you’re having a fight with your partner, and so now all of a sudden, you pull up all these things recently that they did to piss you off, and it’s just so easy to come up with them. Then you make up, and then a week later, you can’t remember what you even thought about, let alone all those other memories that popped up.

  And so what changed was your mental context, this emotion, this intense emotion that you felt. And this also works for beliefs, too. So we have certain beliefs, and we tend to find memories that are consistent with our beliefs. If my belief is the past used to be great, and I was so cool when I was in high school, then I’ll remember all these great things that happened in high school, but I won’t remember all the negative things that happened in high school.

And then finally, we view the world through a particular perspective, and so we can actually access other information. We change this perspective. So, for instance, two people who are members of different political parties might watch the same presidential debate and come away with memories of completely different experiences of who won and who lost based on little one liners and so forth and the talking points that they selectively remember.

But people can switch perspectives and, say, well, what if I was instead of being a Republican? What if I was a Democrat or vice versa? They can start to pull up these exceptions that they might have normally missed. Just like you can probably pull up information about the positive aspects of your relationship with your partner when you’re not fighting with them.

Brett McKay: Okay, so that’s interesting. So how do you manage that? Are there any tips on how to make sure you’re remembering things correctly and you’re not messing things up just so it updates and matches your current state?

Charan Raghunath: Yes. I think one factor to keep in mind is just, first of all, how much you’re going to search for information in memory that confirms your beliefs. So on average, people tend to think of them, recall memories that are more positive and that make themselves look better than they really were. So if I recall some experience from some time in my life, I might actually think of it, think of an experience that’s going to be more positive, but I’ll also remember myself in a way that’s maybe been more of a positive role than it actually transpired.

So being aware of these biases, I think, is the first step. Another step is allowing ourselves the time to think critically. And again, what often happens is we’re under stress. You shut down the prefrontal cortex, you move on to the next thing very quickly, and it makes us very susceptible to misinformation. It makes us very susceptible to manipulation. But likewise, I think one thing we can do to help ourselves is surround ourselves by diverse perspectives and give ourselves a chance to remember things from other perspectives and think that maybe the way I see the world now is just one view of how the world could be.

Brett McKay: What’s one thing that people can start doing today to get more out of their memory?

Charan Raghunath: Oh, so much. What I would say is, probably the one thing that I would say is be comfortable with discomfort. And what I mean by that, and I don’t mean like that necessarily. Be a man. Man up. I know we’re in the Art of Manliness, but what I do mean is that I think we often assume that memory should be effortless. Things should just easily come to mind, and we should be able to memorize things easily.

And you look at the kid who gets straight A’s and you’re like, “Oh, that person’s smart. That person’s doing great in school.” But really the person who’s getting straight A’s is not learning. In theory, if you’re learning, it means that you’re actually struggling and you’re failing to recall things sometimes, and that you can get the most learning by pushing yourself and exposing the weaknesses in your memory so that you can then capture those weaknesses and fix them.

Likewise, if you want to be more creative, you need to expose yourself to sources of memories that are very idiosyncratic and weird. If you just kind of expose yourself to gobs and gobs of the same media, whether it’s reading material or music or people who you interact with, and they’re all from the same demographic group, same culture, same beliefs, you might as well be ChatGPT. You’re not going to be that creative or interesting. And if you want to be accurate and you don’t want to be remembering things in a way that’s basically making you susceptible for manipulation, you need to surround yourself with sources of information and people who have different beliefs, again, so that you can really constantly challenge yourself to challenge your view of how the past transpired.

And all of those things can be uncomfortable, but they can also be sources of curiosity. And curiosity is a major driver of learning and has enormous effects on the brain, as we’ve shown in our lab.

Brett McKay: Well, Charan, this has been a great conversation. Where can people go to learn more about the book and your work?

Charan Raghunath: Well, you can definitely read my book Why We Remember. You can also go to my website, charanranganath.com, to get on our mailing list for more information. And you can find me on Instagram, where we post periodically, including some tips about memory from time to time. And that’s @thememorydoc.

Brett McKay: Fantastic. Well, Charan Ranganath, thanks so much for your time. It’s been a pleasure.

Charan Raghunath: Thanks for having me, Brett. This has been fun.

Brett McKay: My guest here is Charan Ranganath. He’s the author of the book Why We Remember. It’s available on Amazon.com and bookstores everywhere. You can find more information about his work at his website, charanranganath.com. Also check out our show notes at aom.is/memory where you find links to resources where we delve deeper into this topic.

Well, that wraps up another edition of the AOM podcast. Make sure to check out our website at artofmanliness.com where you find our podcast archives. And while you’re there, sign up for a newsletter. We got a daily and a weekly option. They’re both free. It’s the best way to stay on top of what’s going on at AOM. And if you haven’t done so already, I’d appreciate if you take one minute to give us a review on Apple podcast or Spotify. It helps out a lot. And if you’ve done that already, thank you. Please consider sharing the show with a friend or family member who you think would get something out of it. As always, thank you for the continued support. Until next time, it’s Brett McKay reminding you not to only listen to AOM podcast but put what you’ve heard into action.

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If you read most first aid guides, the last step in treating someone who’s gotten injured or sick is always: get the victim to professional medical help.

But what if you found yourself in a situation where hospitals were overcrowded, inaccessible, or non-functional? What if you found yourself in a grid-down, long-term disaster, and you were the highest medical resource available?

Dr. Joe Alton is an expert in what would come after the step where most first aid guides leave off. He’s a retired surgeon and the co-author of The Survival Medicine Handbook: The Essential Guide for When Help is NOT on the Way. Today on the show, Joe argues that every family should have a medical asset and how to prepare to be a civilian medic. We discuss the different levels of first aid kits to consider creating, from an individual kit all the way up to a community field hospital. And we talk about the health-related skills you might need in a long-term grid-down disaster, from burying a dead body, to closing a wound with super glue, to making an improvised dental filling, to even protecting yourself from the radiation of nuclear fallout.

Resources Related to the Podcast

• AoM Article: How to Use a Tourniquet to Control Major Bleeding
• AoM Article: The Complete Guide to Making a DIY First Aid Kit
• AoM Article: How to Suture a Wound
• AoM Article: What Every Man Should Keep in His Car
• AoM Article: Improvised Ways to Close a Wound
• AoM Podcast #869: The Survival Myths That Can Get You Killed With Alone Winner Jim Baird

Connect With Joe Alton

• Doom and Bloom website
• Doom and Bloom on YouTube
• Doom and Bloom on FB

Listen to the Podcast! (And don’t forget to leave us a review!)

Listen to the episode on a separate page.

Download this episode.

Subscribe to the podcast in the media player of your choice.

Read the Transcript

Brett McKay: Brett McKay here and welcome to another edition of the Art of Manliness podcast. If you read most first aid guides, the last step in treating someone who’s gotten injured or sick is always get the victim to professional medical help. But what if you found yourself in a situation where hospitals were overcrowded, inaccessible, or non-functional? What if you found yourself in a grid-down, long-term disaster and you were the highest medical resource available? Dr. Joe Alton is an expert in what would come after the step where most first aid guides leave off. He’s a retired surgeon and the co-author of The Survival Medicine Handbook: The Essential Guide for When Help is NOT on the Way. Today on the show, Joe argues that every family should have a medical asset and how to prepare to be a civilian medic. We discuss the different levels of first aid kits to consider creating from an individual kit all the way up to a community field hospital. And we talk about the health-related skills you might need in a long-term grid-down disaster from burying a dead body, to closing a wound with superglue, to making an improvised dental filling, to even protecting yourself from the radiation of nuclear fallout. After the show is over, check out our show notes at aom.is/medic.

All right, Joe Alton, welcome to the show.

Joe Alton: Hey, thanks for having me. I really appreciate it, Brett.

Brett McKay: So you are a retired obstetrician and pelvic surgeon, and you’ve stayed busy in your retirement by helping families prepare medically for long-term disasters. How’d you end up doing that?

Joe Alton: Well, Brett, I was exposed to disaster medicine very early in my career as a volunteer DMAT member, Disaster Medical Assistance Team member for the aftermath of Hurricane Andrew down here in South Florida in 1992. And that led me, like many Floridians honestly are now, to become what you would call a hurricane prepper. And that means instead of the three days worth of food and supplies the average American has on hand, we’d have a couple of weeks worth. But I really have to say, it was Hurricane Katrina in 2005 that opened my eyes to medical preparedness, serious medical preparedness. I mean, it was then that I saw what happens when the ambulance isn’t just around the corner. And that’s not because we didn’t have hundreds of medical personnel converging on the Gulf Coast. I knew it was going to be a big disaster. So that was going on even before the storm was completely through. But the providers and the technology were just not able to get to victims due to all the flooding. I figured that any number of disasters could actually do that. An earthquake, for example, could make roads impassable and people couldn’t get to you, for example.

Really, any disaster with enough casualties can overwhelm the existing infrastructure. If there’s a three car wreck in a two ambulance town, I mean, you could have a bad outcome. So I figured if I can teach the average person how to deal with injuries and illness and put some supplies in their hands, well, then maybe some tragic outcomes might be avoided. So my mission became to place a medically prepared person in every family before a disaster occurs.

Brett McKay: All right. So you co-authored a book called The Survival Medicine Handbook. And this is a tome of a book. It is, I think it was 700 pages. You co-authored this book with your wife, who’s also a nurse practitioner and a midwife. And your goal is, again, it’s a comprehensive guide to medicine in a situation where it’s a grid down situation. You might not have immediate medical access. And so how to manage things you might encounter in that period. I’m sure a lot of people have read first aid books on, say wilderness first aid or maybe prepper first aid, but you argue that those books will only get you so far in a long-term disaster scenario. How so?

Joe Alton: Well, there are a lot of books on first aid, even for wilderness settings. And many of them are really quite good, but they fail to take into account that in a true survival, long-term survival scenario, there’s no access to medical medicine, modern medicine, rather, for the foreseeable future. And that becomes a problem when every chapter of your first aid book or your medical book ends with, and get to the hospital or, and seek a qualified medical professional. Because in real terms, no such thing exists when the medical infrastructure is collapsed. And so our entire book is pretty unique in that it assumes that some disaster has happened and you no longer have the option of accessing modern medical care, maybe for the long run. And the book addresses the average citizen in plain English, as if they were the last line of defense when it comes to your family’s wellbeing in a disaster. That’s because it’s a real possibility.

Brett McKay: So a lot of the first aid books out there are geared towards taking care of the situation so you can get to medical help. But in a long-term disaster, professional medical help may not be available. So what considerations do you have to think about to deal with that situation?

Joe Alton: Well, let’s take an injury for an example. I mean, what is the difference between today and in a grid down situation when it comes to encountering somebody who’s sick and injured? Let’s say even in the normal times, let’s say they broke their leg in a car accident. What do you want to do? You want to stabilize that person, do what you can for them and get them to the nearest medical asset. That makes sense. So you’re not a doctor after all. And once you ship the patient off, your responsibility has been discharged and you’re on your merry way. But what if that’s not an option? I mean, grid down, your responsibility extends from the point of injury to full recovery. Will you be able to provide daily wound care for this person? Would you be able to identify if a wound infection is occurring? Would you have a plan of action to rehab that person and get them on their feet again, make them productive as a group member as they most certainly would have to be in an off-grid disasters type setting. I mean, you have to do this and that’s the difference. You have to be ready to be the highest medical asset left and be effective in that role.

Brett McKay: And another thing we’re going to talk about in detail later on in a bit, another thing you have to think about as the medical asset in your family is you have to think about preventative medicine. It’s just basic things you don’t have to think about because we live in the 21st century, sanitation, hygiene, things like that to prevent sicknesses.

Joe Alton: You’re absolutely right. The important thing to know is that you can prevent headaches and heartaches as the family medic if you have a plan to enforce sanitation and water disinfection and food preparation, things like that. And these are sort of part of your job description.

Brett McKay: As part of the medical asset. So one of the things you talk about in the intro of the book in the first few chapters is before you start thinking about buying medical gear, I know guys love that. It’s the one thing I think a lot of guys love about survival or prepping is buying gear. It’s fun. But you say before you even do that, there’s two things you probably need to think about in order to become a medical asset. One is establish a community, put yourself in a strong community and then two, get your personal health in order. So first, how can being part of a robust community help with medical care or healthcare in a long-term survival situation?

Joe Alton: Well, I mean, as a community, let’s take some examples from TV. Have you seen the show, Alone?

Brett McKay: Yes.

Joe Alton: Well, there you go. In Alone, they drop you off alone with some supplies, probably as much as a person might be able to reasonably carry a fair distance. And they plop you off into the off-gridest of off-grid locations. And that person has to find water. They have to make it drinkable. They have to find food. They have to cook it properly. They have to make a shelter. They have to worry about personal protection. They have to deal with injuries and other medical issues that occur along the way. I mean, how much easier would it be to have a group of like-minded individuals with that common goal of surviving? I mean, these guys survive and they survive for an extraordinary amount of time in my opinion, but it’s not for a normal lifetime. I mean, they’re there for 90 days. And when at the end of the 90 days, they look pretty ragged. I mean, a person can survive alone for a time, but you can see on Alone, on the show Alone, that it’s a pretty miserable existence. So that’s something that I think is so important to have people that can thrive.

And how about skills? I mean, I have medical skills, but I have very few tactical skills. For example, I probably couldn’t take a part in AR-15. I probably wouldn’t be very good in a firefight, but there probably are people that would be. And having people with skills that can complement each other would make for the possibility of the existence that could make a village.

Brett McKay: Yeah. Now we had an Alone contestant, a winner on the podcast a while back ago, Jim Baird.

Joe Alton: Oh, yeah.

Brett McKay: Him and his brother won. And one of the big takeaways from that conversation I had with him and also watching the season that he was on, on Alone, it was amazing to see how little tiny injuries could just devastate you. That actually ended people’s time on the show. You just, you sprang an ankle and then you’re done. Even having another person there, it wasn’t enough. You needed to have maybe two or three more people because that one person couldn’t do, you’re basically working for two people now and they just didn’t have the energy for it.

Joe Alton: Yep. [chuckle]

Brett McKay: Yeah. Okay. So have a community. What about personal health? What parts of your personal health should you have in order in order to be ready medically for a long-term grid down scenario?

Joe Alton: Well, what I hope people are doing now, I mean, eating a healthy diet, exercising, staying away as much as possible from addictive substances that wouldn’t be around in a grid down situation, like maybe alcohol or tobacco on top of that. And this is something that people are surprised to hear me say is that you should be using the high-tech available today to fix issues that would be a problem off the grid. I mean, if you have a bum knee, that’s not going to be very helpful off the grid and would certainly not increase your chances of survival. So see an orthopedic surgeon now, get it fixed. You have terrible vision, consider a LASIK procedure. For example, I had classic near sightedness blind as a bat. I got it done probably 30 years ago, probably one of the first people to get it. And now I have the eyes of an eagle, a very old eagle now, I’ll admit, but still.

Brett McKay: Okay. So yeah, get your health in order. So you’re ready for that scenario. So you talk about becoming a medical asset in your family. And when you’re a medical asset, it means you take on different responsibilities. You’re not just providing first aid, but there’s other roles you take on. We mentioned one of them. You’re sort of the chief sanitation officer of your family. Any other responsibilities that a medical asset needs to take on in order to take care of the healthcare of their family?

Joe Alton: Well, Brett, I mean, of course you’re the chief medical officer, but you’re gonna have to deal with a lot of other things too. You’re gonna have to deal with dental issues as well. Now, I’m not talking about a week without power due to a storm. I’m talking about a long-term scenario, a few months off the grid. And you’re going to wind up facing as many patients on a daily basis with dental problems as medical problems. And you’ll even have to extract a tooth now and then. 90% of dental emergencies in the past were treated that way. I’m not talking about Roman times. I’m talking about the early to mid 20th century. And you’re going to be responsible also for making sure we talked a little bit about water disinfecting. You got to make sure water is disinfected properly. Foods prepared and cooked thoroughly. Human waste is disposed of safely. These are things that are part of your job description. You’re also the chaplain. You may not have to deal with bullet wounds on a daily basis. I hope, at least I hope not, but you’re going to see anxiety and depression on a daily basis of some major disaster hits.

You need not only to be sympathetic and understanding, but you’re going to also have to be confidential as well. Nothing loses the trust of a group than a non-confidential medic, somebody that doesn’t keep people’s private things to themselves. Well, one other thing, you also actually going to be the quartermaster who decides when your limited supplies of medical items are dispensed. It’s not a committee decision. It should be the medic.

Brett McKay: You also have in here medical archivists. So you got to keep track of people’s issues.

Joe Alton: Yes, that’s right. That’s another thing. And that’s something you should probably do now. If you knew who was going to be in your extended family or in a mutual assistance group, you should probably interview them beforehand and keep everything of course, confidential, as I mentioned, and you should definitely learn what their medical issues are, what their family history is, what vices they might have. I mean, are they heavy smokers or do they drink a lot? And you should try to sort of steer them in the direction of getting healthier. And the fact that you would know what medicines, let’s say a person is on, would help you sort of encourage them to get more of these medicines, stockpile some of them so that you don’t have somebody with very high blood pressure showing up at your retreat with their last three days of blood pressure medicine and that’s it.

Brett McKay: Okay. So let’s get into skills and gear here. Do you recommend people like just a lay as an average citizen, take any sort of formal intensive training to get ready for a grid down disaster scenario when it comes to healthcare?

Joe Alton: I think a good start is just go through your municipality and see what courses that they have available. Many times they have free courses available for first responders or CERT members, Community Emergency Response Team members, other people that will be willing to volunteer in disaster settings. Sometimes they’ll have stop the bleed courses. Seek these out. And like I said, they might even be free. And there are, of course, a lot of wilderness first aid courses out there, a lot of companies that put forth these kinds of courses. You can find them online. I’m sure your experience may vary with them, I have to say. But all of these courses do prepare you to do what you need to do, stabilize and transport victims in normal times, but not so much for long-term care. So therefore, what I recommend to people is that when you take each class, think about what you would do if transport to a modern medical facility was not an option. What would you do with that particular individual, that particular sickness or that particular injury? And that’s the key is to have the right mindset and a plan of action in situations where you’re not going to be able to take that person to a higher medical asset.

Brett McKay: One of the most useful things that I’ve done, I really enjoyed it, too. I need to go back and do it again. I took like a first aid CPR certification class. It was done at one of the community colleges here in town. It was a couple hours, I believe. But not only did you do the CPR, but they just went over like basic first aid, what to do about burns, head injuries, big wounds. And I remember I learned a lot. But what I realized is that knowledge and like we actually practice some skills, like how to how to bandage things and things like that. But I realized that stuff, that knowledge and those skills, they degrade if you don’t use them. Like you have to constantly refresh yourself on it.

Joe Alton: You’re absolutely right. We teach wound care class and wound closure class. And I teach people how to suture close simple wounds and things like that. And more importantly, when to close a simple wound and when to leave it open and provide open wound care. And I always make sure I give people extra sutures to take home and they keep their instruments so that they can practice. Now, whether they all do or not, that depends. But you have to develop muscle memory for just about any of these things. And the more you do it, the more effective you’ll be at.

Brett McKay: Okay. So take some sort of class that’s out there. You can find different things out there, but as you do kind of keep in mind, well, how can I take this further and how would I apply this in a long-term grid down situation?

Joe Alton: It’s a mindset.

Brett McKay: Yeah. Let’s talk about medical supplies now. And you’ve got, I love this section because I love checklists. You have these checklists for different medical kits. You think people should start building up so they’re ready for that long-term situation. The first kit is an individual first aid kit. What are some of the things that you would recommend people keep in this individual first aid kit? So every person in your house or your group is going to have one of these, correct?

Joe Alton: Right. Ideally, you would want everybody in the group to have it. In the military now, everybody carries, every infantryman, for example, carries an IFAK kit and the medic carries a more advanced kit that allows him to put an IV in and things like that. But these guys will carry things like a tourniquet to stop bleeding, maybe a burn gel and dressings, elastic wraps to wrap orthopedic injuries, things like that. And I think that that would be a good start for a first aid kit. We have a number of kits on our store that we designed that are very compact, but they manage to deal with a number of different issues that are most commonly seen. So an individual first aid kit, I think for every member of the family would be good, especially in situations where you have to be on the road. So it just depends on the situation. Does your 10-year-old have to carry a first aid kit to school? No, probably not. But in a true long-term disaster situation, which is what I write about, this is something that everybody should have.

Brett McKay: Yeah. This is good just to have if you go on a hike or backpacking trip. I always carry one and it’s got things, band-aids, got Benadryl in there. We got pain relievers, so Tylenol, Advil.

Joe Alton: Right. Moleskine, things like that.

Brett McKay: Moleskine, things like that. And you also have, I thought it was in raw honey packets. What’s the raw honey packets for?

Joe Alton: Raw honey has actually very strong and actually accepted medically antibacterial properties. And so you can use raw honey for a number of things. And of course you can use it to treat hypoglycemia, low blood sugar cases, but you can also put it on burns and other injuries and it actually would have an antibacterial effect.

Brett McKay: That’s interesting. Alright, so that’s the first kit. Start building up a basic individual first aid kit. The next one is the vehicle kit. What’s the vehicle kit for and what kind of stuff are you keeping in that?

Joe Alton: Well, the vehicle kit is more extensive and it really allows you to carry things that you might not be able to carry. Like in other words, a sturdy pair of boots if you found yourself stranded in a blizzard or something like that. And you have to actually go somewhere, although of course it might be better to stay in the car. It has changes of clothes, it would have foldable, multi-tool, shovels, tow ropes, flares, rock saw, things that would help you in situations where you’re in your vehicle. And also it has more of every item.

And the reason why is because you’re not physically carrying this. And so you have the ability to deal with not only things, but do you deal possibly with multiples of things, more than one injury?

Brett McKay: Yeah, we got an article on the site about what to keep in your car. And people are like, that’s kind of a lot of stuff. Like, when would you ever use that? It can come in handy. So my dad, I remember it was this probably 30 years ago. He was driving from Oklahoma City to Albuquerque on I-40 and in the middle of the Texas panhandle. He got stuck in a blizzard, and he was in his car, I think, for a while. I mean, I think it was like a day, but it was well stocked. He had blankets and he had some stuff. And so he was able to ride it out until he’s able to get towed out.

Joe Alton: It’s something that can be a serious thing if you have to make the right decisions. There’s one guy who got stranded. He decided he was going to go for help, and they found him the next morning and he did not make it.

Brett McKay: All right, so the third kit is the family kit. You’re going to keep this at your home, or if you got a retreat somewhere, you’re going to keep it there. And this thing is massive. This was a lot of fun to look through because it’s so big. You break it up into different modules. So what sorts of modules do we have in this family kit?

Joe Alton: Well, of course, we talked about dental situations, so a dental module would be there. You would have, depending on the makeup of your group, you would have maybe a module for a delivery of a baby. You might have your surgical modules with the ability to do more extensive things like sewing some tendons together, things like that. A lot of daily wound care items, because this is something that you can easily do if you are able to stay in place.

Eye care modules, things like that, in case there’s foreign objects. And a lot of people, when they do activities of daily survival that they’re not really accustomed to, they can injure themselves. And so you could be chopping wood and you wind up getting a splinter in your eye. So we have the ability to deal with foreign objects that could get caught in your eye. Just a lot of different things. We’re beginning to get to kits that have hundreds of items. And indeed some of our biggest kits in our entire line will have hundreds of items in them.

Brett McKay: Yeah. One potential module you might have, if you’ve got small kids, a pediatric module. So you have… Make sure you have medications for them.

Joe Alton: Yes, exactly. So you have all sorts of stuff in these situations. You want to have maybe growth diaries, and then you can identify basically how well your young people are doing by, if they’re growing in a normal fashion. And so that’s something that they might have. You have a lot of different sized things, like a CPR mask for an infant would be different than a CPR mask for an adult, and blood pressure cuffs, things like that. So there are a lot of items that are sort of size differential.

Brett McKay: So the fourth kit is… This is if you’re going all in, you want to actually have a field hospital. What sorts of items are in this kit?

Joe Alton: Oh, boy, that’s… I got about 10 pages of…

Brett McKay: I’m looking at it right now.

Joe Alton: And each page has 50 items each. So, I mean, you would have everything from, gosh, biohazard suits to operating tables to… I mean, we’re talking about a real mash unit kind of deal.

Brett McKay: When would you want to do that? I mean, you have a question in the book that you try to answer, which is, how much is enough? When do you know? Well, yeah, maybe I’m good at the family kit and I don’t need to go field hospital.

Joe Alton: Well, I think that it’s probably very few people that will reach the point where field hospital is what they’re going to wind up being responsible for. So I think that people really just need to get the items that are going to be able to deal with the most common issues that they’ll expect to be confronted with. And what we have here, I mean we’re talking about medical…

I’m looking through my list right here because I don’t remember all 500 things that are on here, but we’re talking about automatic portable defibrillators, and we’re talking about oxygen concentrators and things like that. Things that you would need if you had… You would have to have some solar power, for example, to get enough power to, let’s say, do some oxygen concentration. These are some of these items that you’re going to need a little power. And if you’re ready to put together a field hospital, you will have taken power into account. So at least if it’s solar power.

Brett McKay: Another point you make, kind of a broader mindset point you have to take when it comes to medical care in a long term disaster scenario, is that you have to adjust your expectations of what’s possible in this situation. I think today we take it for granted. It’s like, well, if something happens to me, I just go to the doctor and I’ve got medicine. Or if even like a serious thing happens. It’s not so serious. There’s things we can do. I mean, I guess what I’ve read is that people are surviving gunshot wounds more often because our skill and technology has gotten better.

One of the points you make is that in a long term situation, long term disaster situation, the best you can do is maybe just make people feel comfortable and you might not be able to cure them. You have to be okay with that.

Joe Alton: We have to be very, very realistic about what can be done and what can’t be done. In an off grid situation, you can expect a gunshot wound to the abdomen or a gunshot wound to the chest to probably have a 70% death rate. And it’s a terrible thing to say and certainly not the case today with modern medical facilities, but it’s what’s going to happen. And if it’s not the actual trauma from the injury itself, it’s the chances for infection.

Again, remember, your skin is your armor, and so once you have breached that armor, you have that chance of infection.

Brett McKay: That brings up a point I want to talk about. In the book, you talk about how you can plant a garden with herbs and plants that have medicinal purposes. But what do you do about prescription medicines like antibiotics for infection? Is it possible to stockpile antibiotics?

Joe Alton: There are some companies that are beginning to offer, “emergency antibiotic packs” with a televisit, as long as you fill out an application and do a televisit. So these are becoming more popular. They’re just popping up now. And I believe that there’ll be a thriving industry in this probably in the next few years, or at least until the state medical boards get a hold of them.

Brett McKay: What about special medications like insulin? Say someone’s diabetic, is that tough to stop…

Joe Alton: Brett, insulin like that are basic insulins like regular and NPH are actually over the counter in most states these days. You can get them as you need them.

Brett McKay: We’re going to take a quick break for your word from our sponsors.

And now back to the show. We’ve talked about supplies, we’ve talked about getting some training, hoping we can talk about some specific skills here in a bit. But I want to turn to this idea of hygiene and sanitation, because if anyone’s read any history book about war, war up until the 20th century, really, most of the casualties came from poor sanitation. Men were dying of dysentery, cholera, things like that. In a grid down scenario, there might be a situation where you no longer have flushing toilets. So you have to think about human waste. So what do you do about human waste in a grid down scenario?

Joe Alton: Well, human waste should always be buried if you don’t have a toilet. Now, if you have a toilet, you have two gallons of water. Even if it’s wastewater, you can actually flush that toilet, if it’s the typical configuration of the toilet in your home today, by flushing two gallons of water into the toilet, and it will actually flush. But if you’re out, let’s say you’re on the road, you’ve been driven from your home, you’re on the road, human waste, you’re in a retreat in the forest somewhere. Human waste should be buried no closer than 200ft away from the main water source to prevent contamination.

And the medic, if you’re in a community, let’s say you’re the medic for an actual community, that you should have an idea of how to put together a community latrine. And so the dimensions would depend on the length of time, of course, that’s needed, and the number of people in your group. If you had a small group, an 18 inch wide by about 24 inch deep, several feet long, that probably would work pretty well. A longer trench in some kind of partition sheet. If your group is big enough to have more than one person using it at a time, and you keep the dirt from the trench that you dug in a nearby pile with a shovel, and that covers up the waste after each use. So that’s something that would be good for dealing with human waste.

But you’re absolutely right about the importance of sanitation. In the past, entire populations succumbed to diseases that cause diarrhea, leading to severe dehydration. You mentioned cholera and dysentery. Those can be very, very lethal. I mean, more soldiers in the civil war died of these issues than from bullets or shrapnel. So, again, this is probably the third or fourth time we’ve mentioned already, but the medicine has to strictly enforce water disinfection, proper food preparation, waste removal, and more, or infection’s gonna run rampant among other people.

Brett McKay: So here’s something I’m sure people may have thought about if they’ve kind of do these hypotheticals in the head of, like, a long term disaster scenario where you’re not gonna have access to the comforts of modern life for a long, long time. What if someone dies? What are you supposed to do with the body? ‘Cause, like 200 years ago, when someone died in your family, you knew what to do today, you call the funeral home and they take care of everything, so what are you supposed to do?

Joe Alton: This is something that most people have absolutely no idea what to do, and you have to figure out what to do with the body. The body should be placed in a body bag. These are currently commercially available, by the way, and some of them actually have handles to facilitate transport. But if you don’t have these, you can found items like plastic sheeting, bedsheets from abandoned homes. These are things that you can use. Choosing a place to bury them is important. I mean, it should be at least 200 to 250 meters. That’s about 800ft from any water that might possibly be used by the living. That’s very important.

But the funny thing is that if you can properly dispose of the dead body and in that type of location, it doesn’t have the ability… It doesn’t really cause major contamination of the environment. So that’s something that’s important to know.

Current grave guidelines suggest a depth of about five or 6ft. That’s 1.5 meters, and preferably that amount of space above the water table. In some places, that’s really difficult to achieve. Down here, our water table is like 6 inches below the ground. That’s why you see in this area, the older crypts are either concrete and they bury them in the ground, but they’re buried in concrete. Or if you go to places like New Orleans, you see that everybody’s buried above the ground.

Now, you also use something called quicklime, and that’s calcium oxide. It’s been used in burials for centuries, but people think that it’s being used to speed the decomposition of the body, but it actually preserves tissue, which is funny. So why is it useful? Because it actually eliminates odors that attracts flies and animals. And there’s actually a formula for that. 1 kg or 2.2 pounds of lime per 10 kilograms of body weight.

Brett McKay: So you mentioned dental issues. You might not think that you have to take care of a dental problem in a long term situation, but you would. I mean, what are some of the dental issues you think are treatable in a long term disaster scenario?

Joe Alton: Well, the grand majority of dental issues can be dealt with by extraction, as I mentioned earlier, including dental decay. You also need to learn how to fasten loose crowns, replace loose fillings, lost fillings, broken teeth, knocked out teeth, tooth abscesses, gum inflammation. These are all things that you can easily deal with, with the right materials, but you can definitely take care of dental decay. Lost fillings you could put together with clove oil, two drops of clove oil and zinc oxide powder will put together a hardening filling material, material type of cement that will last for a pretty good long time. And you can use it to fasten a loose crown. And of course, you need to have extractors. There are extractors for different types of teeth. And there are probably as many different types of extractors as there are different types of teeth.

Brett McKay: And of course, with dental care, an ounce of prevention is worth a pound of cures. You gotta take care of your teeth. Even in a grid down scenario, brush your teeth, floss, and avoid all the sugary foods. Don’t eat too much of that raw honey. Save that for the…

Joe Alton: Right. Save that for the hypoglycemic patients.

Brett McKay: So in this book, you cover lots of different medical care skills that you think someone might need to know in a long term situation. What do you think are, let’s say, five skills you recommend people prioritize learning, either because, they’ll be especially common or because they’re not the kind of things you’ll have time to consult a textbook or your book to figure out how to do it in an emergency.

Joe Alton: Oh, boy. Well, I have like 40 that I’d like you to know. But if I had to pick five, of course there’s a sexy, sensational stuff like how to stop bleeding. That is, of course, always very important. And there’s a whole stop the bleed apparatus nationally that will help you learn that. But we, of course, we talk about it in detail, and we also describe all the different tourniquets and things like that in our book. And they’re good. There are pros and cons.

You can also expect to deal with a lot of orthopedic issues, ankle sprains and things like that. Of course, there’s going to be respiratory infections. That’s going to be very, very common. Open wounds. You need to deal also how to deal with significant problems. I think the ability to use a flexible splint to treat a bunch of different issues, I think that’s a big skill. The use of cravat or bandana or triangular bandage. We have videos to show you how to use that in seven different ways for different things. I think those are good skills to have because they handle different issues. So I think that’s important.

And of course, as we mentioned before, maybe the most important skill to obtain is how to enforce preventative strategies against injuries and illnesses. And to do that, you have to actually get the knack of observing simple things, such as whether your people are dressed for the weather and enforcing the use of hand and eye protection during work sessions. I mentioned you can really save yourself a lot of headaches as a medic and maybe heartaches if you can keep these people protecting themselves and adequately dressed for the weather. I think that’s important.

Of course you want to be able to treat burns and you want to treat open wounds, and you want to be able to close a wound if you absolutely have to. But more importantly, you need to know when to close a wound and when to not close a wound because you can lock in some bacteria and could cause some major issues.

Brett McKay: Okay, so we got know how to stop a bleed, know how to use different splints for orthopedic bone breaks, sprains and things like that, knowing how to do preventative medicine, and then how to deal with wounds. On the wound issue, like how do you know if you should leave a wound open or close?

Joe Alton: Well, if a wound is obviously dirty, in which a lot of wounds will be, if you happen to be on the road and in a situation where you know you’re not in a controlled environment, your wound is going to be dirty. And so if it’s an animal bite, for example, it’s going to be dirty. And these days, in the emergency room, they’ll actually close some of these wounds, but off the grid, you should definitely not close them. You should treat them as an open wound and just make sure that you keep them clean.

And we talk about, in detail, the ability to perform that daily wound care. And that’s why I think that’s a very important thing to be able to know. And you have to be able to identify when a wound is not getting better and when you may need to break out that last course of antibiotics that you’ve been saving, because in the end, that could save a life.

Brett McKay: Can you superglue a wound shut? I’ve seen that. If you decide you can shut this wound, can you superglue it?

Joe Alton: Yes. I’ll tell you exactly how. Take superglue, and I want you to use the gel version of it. It’s much easier to handle than the liquid version. So take superglue gel and hold the skin together, the cut edges of the skin together, and apply a line of superglue gel on top of that, holding it together, wait for it to dry, and then take a second layer, put a line over the first layer, and then go around and around in an ever widening oval for a couple of layers, then hold that together and let that dry, and then do it one more time on top, and even a little wide, a more widened oval. And if you do that and allow that to dry properly between, then you should do okay… It should be okay.

And the good news is that we’ll have an even less chance of infection than if you close it almost any other way because of the sealing of the superglue. Now, if you don’t hold the skin together properly, you’re going to put superglue in between the two cut edges, and they’re not going to close. It’s something that you just have to do. You might practice on, make a cut in a pool noodle and try to practice with that until you get that right.

Brett McKay: In regards to tourniquet, I know tourniquet use can be controversial. People have really strong opinions about it. Anything people should take into account when they think, well, maybe I need to use a tourniquet here?

Joe Alton: Well, I’ll tell you that the committee on Tactical Combat Casualty Care has stated recently that if you know that you’re dealing with heavy bleeding, that the use of a tourniquet should be your first course of action. Normally they recommend direct pressure with your hands and with either gloved hands or a hand with a barrier between the wound and the hand, but some sort of cloth or something like that. But they’re saying if you know you’re dealing with arterial bleeding or the bleeding is just of a volume that is serious, then use that tourniquet as the first course of action.

And that is a departure from previous eras. And in World War I, they actually called it The Devil’s Instrument because a lot of people just left it on too long and wound up causing nerve damage or even amputation. But you can definitely keep a tourniquet on for a period of time, at least two hours without permanent damage.

Brett McKay: I mean, okay, so the idea of a tourniquet, you’re supposed to put that on there so you can get to professional medical help. What do you do if you have severe bleeding in a long term situation?

Joe Alton: What I would say is you would transport that person to where the bulk of your medical supplies are. And there is a way to transition from a tourniquet to a, let’s say a compression bandage that you can actually do. Now, in normal times, you want to just get that person to the hospital. But if you don’t have the ability to get somebody to a hospital, then you might just have to transition that tourniquet to a pressure dressing by itself. And if you do, then you want to use on the actual wound itself something called a hemostatic dressing. And a hemostatic dressing is impregnated with material like kaolin or chitosan. And this is a blood clotting material. And so what you do is you apply it directly on the bleeding vessel, and you hold it in place for three full minutes, and it actually will stop the bleeding, even arterial bleeding, if you apply pressure and do it for the right amount of time.

I actually was talking to somebody who was a follower of our website, and he was a purchaser for the Navy in Hampton Yards, and he talked about a study that they did in which they basically hung up a pig and they shot it with a 9 millimeter and severed its artery, its femoral artery. And so they used the quick clot material, which is a brand of hemostatic dressing, held the pressure on it, and it stopped the bleeding. And then what they did is they shot the other leg, and they took the dressing out, the hemostatic dressing out, and then put the hemostatic dressing in the second wound and actually stopped it the second time around.

So it is something that, if you know how to use these things, when you have the right materials, the right hemostatic dressings, you can actually stop the bleeding in, at least from the standpoint of the emergent bleeding.

Brett McKay: Related to this idea of bleeding like gunshot wounds, are there any special things you got to think about there?

Joe Alton: Gunshot wounds, of course, are going to be difficult to treat off the grid. You have to remember that there’s things that happen when there is a projectile that enters the body and it forms a permanent channel, which is where the bullet actually went, physically went through. That’s called permanent cavitation, but it also forms something called temporary cavitation. And temporary cavitation is a shockwave that occurs as a result of the bullet passing through with speed through the body. And so if you shot me just under my liver, for example, I would have a channel that went through the area just under my liver, but there would be liver damage, and I could bleed to death as a result of the temporary shockwave that went through and disrupted liver tissue.

Brett McKay: Okay, I’m sure everyone’s thought about this at one point. What do you do in the case of a nuclear disaster? Because I think people have heard about radiation sickness. Are there things you can do to mitigate that?

Joe Alton: Well, nuclear disasters, believe it or not, if you’re not standing at ground zero, you actually have a pretty good shot at surviving. In Hiroshima, they lost more than 100,000 people total to the bomb. But it was a city that included the military that was there at the time, had swelled to 450,000 people at the time of detonation. So you have a shot to survive this. In the early going, your goal is to prevent exposure, and you want to prevent exposure over 100 rads, let’s say. Rad is the amount of radiation that’s absorbed by a living thing. So you might want to have a radiation dosimeter, and that gauge is radiation absorbed. And it’s widely available online. You can find it anywhere. This item predicts the likelihood that you’re going to develop it. But there are three basic, different ways to decreasing the total dose of radiation.

One, limit time spent in the open. Radiation damage is dependent on the length of exposure. So leave areas where high levels are detected and no adequate shelter is available. That’s important. The activity of radioactive particles decreases over time, which is great. After 24 hours, the levels have dropped a 10th of their previous value or less. Then you want to increase the distance from the radiation source. A lot of this is common sense. Radiation disperses over distance. And the effects will be decreased in proportion.

Nuclear reactor meltdowns common evacuation patterns include a complete 10-mile circle. Or if you looked at the pattern, it looks like a keyhole or an old timey keyhole comprising of, let’s say, a two mile circle and an additional three miles radiation radiating from the direction of the prevailing winds. So that’s something that’s important to know.

And then shielding, shielding, shielding, shielding. Shield your people to decrease radiation where they are. In many cases, they’re going to have to shelter in place, and the shielding is going to decrease exposure exponentially. So it’s important to know how to construct a barrier between your people and the radioactive source. And denser materials will give greater protection. Now, let me talk about halving thickness for a second. When I say halving thickness, I’m saying H-A-L-V-I-N-G. Shielding effectiveness is measured in terms of this. This is the thickness of a particular material that will reduce gamma radiation, the most dangerous kind, by one half. And when you multiply halving thicknesses, you multiply your protection. So let’s say the halving thickness of concrete is 2.4 inches or 6 cm. So a barrier of 2.4 inches of concrete is going to drop between you and the radiation.

It’s going to drop the exposure by half. If you double that and make it 4.8 inches, it drops it to 1/4th, one half times one half. Tripling it drops it to 1/8th. And 10 halving thicknesses drops the total radiation exposure to one in 1024th. So if you’re in a concrete bunker that’s 24 inches thick, you are 10 halving thicknesses thick. And so you’re exposed to only 1/1024th of the outside environment. So that’s something that’s important. Now, treating radiation thickness. You treat them as you would burn patients. But once you’ve received four to 500 rads, however, there’s not too much that can be done. You either survive or you won’t.

Brett McKay: And there’s like a medication you take for your thyroid?

Joe Alton: Yes. Well, that’s a also protective thing. For one thing only. And that is thyroid cancer. And you would take… An adult would take 130 milligrams of potassium iodide once a day or 65 milligrams a day if you’re a child. And it’s very useful to prevent thyroid cancer down the road, then the people that are getting thyroid cancer from Chernobyl, those people were children when they were exposed. So if you have a limited amount of this, the brand is called Thyrosafe. We have it on our store. And this is something that you would only give… If you had limited amount, only give it to the kids.

Brett McKay: Gotcha. Well, Joe, this has been a great conversation. Where can people go to learn more about the book and your work?

Joe Alton: Well, we’ve written several books. The main one now is called The Survival Medicine Handbook: The Essential Guide for When Help is NOT on the Way. And it’s now in its fourth edition. You can find it in black and white on Amazon, in color and spiral bound versions at our site, at store.doomandbloom.net, along with an entire line of medical and dental kits for the serious medic in times of trouble. Now, our website at doomandbloom.net now has over 1500, 1500 articles, videos, podcasts and more on medical preparedness. We also have a YouTube channel called Dr. Bones, Nurse Amy. That’s a nickname of mine, Dr. Bones, that has about 300 videos. You also find my articles on the newsstand in Backwoods Survival Guide, Off Grid Recall, Backwoods Home, Prepper’s Survival Guide and other magazines in the homesteading and survival genres.

Oh, and on Facebook we have survival medicine, Dr. Bones, Nurse Amy groups. We have a group that’s 8000 strong there. You’ll get all my articles and videos on that too. Also have presence on PrepperNet and [0:47:03.0] ____.

Brett McKay: Fantastic. Well, Joe Alton, thanks for your time. It’s been a pleasure.

Joe Alton: Same here, Brett. Thank you so much for having me.

Brett McKay: My guest today was doctor Joe Alton. He’s the co author of the book The Survival Medicine Handbook. It’s available on Amazon.com. You can find more information about his work at his website, doomandbloom.net. Also check out our show notes at aom.is/medic, where you can find links to resources where you can delve deeper into this topic.

Well, that wraps up another edition of the AOM podcast. Make sure to check out our website at artofmanliness.com where you find our podcast archives as well as thousands of articles that we’ve written over the years about pretty much anything you think of. And if you haven’t done so already, I’d appreciate it if you take one minute to give us a review on Apple podcast or Spotify. It helps out a lot. And if you’ve done that already, thank you. Please consider sharing the show with a friend or family member who you think would get something out of it. As always, thank you for the continued support. And until next time it’s Brett McKay reminding you to not only listen to AOM podcast, but put what you’ve heard into action.

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Every year in the United States alone, nearly a million people have a stroke. Strokes can strike at any age, but the chances of suffering a stroke increase as you get older. The most common age range for strokes is the 70s.

A stroke occurs when blood supply to part of the brain is blocked or obstructed. The blockage causes brain cells to die. On average, 1.9 million brain cells die every minute that a stroke goes untreated. That’s why being able to recognize a stroke in someone is such a vital skill to have. The sooner you recognize that someone is having a stroke, the sooner you can get that person treated and potentially save their life and reduce the chances of long-term disability. 

To recognize a stroke, just remember the acronym: BE FAST

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An important part of manhood has always been about having the competence to be effective in the world — having the breadth of skills, the savoir-faire, to handle any situation you find yourself in. With that in mind, each Sunday we’ll be republishing one of the illustrated guides from our archives, so you can hone your manly know-how week by week.

Burns are one of the most painful and most common injuries, from minor burns caused by soaking up a few too many rays on the beach to serious burns caused by close contact with fire. Burn injuries are classified as belonging to one of three categories: first-, second-, and third-degree. First-degree burns are the most superficial, only affecting the top layer of skin, leaving it red and painful, but typically healing within a few days. Second-degree burns are more painful, because they extend into the second layer of skin. They are often associated with the formation of painful blisters and take a week or more to heal. Third-degree burns are the most serious, classified by their size (anything larger than 2 inches across) and severity. They extend through the second layer of skin to cause blisters and leave your epidermis looking white or black.

For third-degree burns, always seek medical attention immediately. The same goes for any burn caused by electrical contact or chemical burns, and all burns affecting the face, hands, joints, or genital area.

For minor burns, however, simple at-home remedies are usually sufficient and only require the few basic steps and supplies outlined above.

Illustration by Ted Slampyak

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We’re big proponents of getting outdoors here at AoM. 

Spending regular time in nature comes with a whole host of benefits. It reduces stress, fights depression, improves focus, and can even speed up recovery from injuries and illness. 

Spending time outdoors is also just good for a man’s soul. The wild can induce awe and wonder, which keeps us humble and grounded.

So, how much time in nature do you need to get these benefits?

In The Comfort Crisis, Michael Easter (check out our podcast interview with him about the book) highlighted research from Dr. Rachel Hopman, a professor of psychology at the University of Utah, that provides a prescription for spending time in nature to improve our health and well-being. 

Hopman based her prescription on the idea of a “nature pyramid,” first developed by Tanya Denckla Cobb at the University of Virginia. Hopman simplified the nature pyramid idea into an easy-to-remember rule: 20-5-3.

The 20-5-3 Rule for Spending Time in Nature

The 20-5-3 Rule translates into the following guidelines for spending sufficient time in nature:

• 20 minutes in green space, three times a week
• 5 hours in a semi-wild environment, once a month
• 3 days completely off-grid, annually

Let’s delve further into how to fulfill each segment of this formula and the benefits of doing so:

Your Weekly Dose: 20 Minutes X 3

According to Hopman’s research, you can start to get the health-boosting benefits of nature by spending 20 minutes in a green space at least three times a week. These short outdoor jaunts can lower cortisol levels, boost cognition, and improve mental health.

Here’s the good news about this component of the 20-5-3 Rule: your thrice-weekly jaunts in green space don’t have to take place in a wilderness area to reap the benefits. You can spend your 20-minute allotments in any natural environment nearby — a pocket park, a community garden, or even a tree-lined street. So, even if you live in a city, getting in an every-other-day dose of nature is very doable. 

That being said, the more leafy and bucolic and the less cement-covered and civilized the setting of your outdoor interludes, the better they’ll make you feel.

Regardless of where you take your thrice-weekly dips into nature, put your smartphone away when you engage in them; Hopman found “that people who used their cell phone on the walk saw none of [the] benefits.”

Use your lunch break for a walk through a local park or stroll around your neighborhood after dinner (the benefits of an after-dinner walk extend beyond the nature exposure!). Make it a daily part of your routine, and start reaping the benefits of vitamin N.

Monthly Immersion: 5 Hours in Semi-Wild Nature

Think of your thrice-weekly 20-minute green space doses as the bottom of the nature pyramid. To start ratcheting up the benefits of nature, Hopman’s research suggests that we should aim to get 5 hours a month in semi-wild nature — a place with minimal urban intrusions. As mentioned above, the wilder the space you spend time in, the greater the effect it has on your health and psyche, so the aim as you move up the nature pyramid is to get a progressively deeper connection with the great outdoors. The higher the level of nature exposure, the happier and less stressed people feel. 

To get your more immersive monthly dose of nature, take a hike in a state or national park, spend the day at the beach, or go fishing at a local lake. 

Annual Reset: 3 Days Off the Grid

This is the top of the nature pyramid. Once a year, go somewhere off-grid — with few signs of human civilization and hardly any human contact — and spend three solid days there. 

Research has shown that spending three days off the grid can relax the brain and boost creativity. Military vets with PTSD who spent four days in the wilds saw a 29% reduction in symptoms. 

Spending this much time in the wild is like rebooting your brain to its factory settings. 

An annual backpacking trip can get you your yearly three-day nature reset. 

You can also do dispersed camping. 

If you don’t want to rough it, find a cabin in the woods on VRBO or Airbnb and spend the weekend there. Look for a listing that doesn’t have wifi or cell service. Force yourself to unplug.

The 20-5-3 Rule provides an excellent, motivating rubric for thinking about how much time you need to spend in the great outdoors. But don’t get too hung up on the specific numbers; after all, the last thing you want to do is to turn spending time in nature into another chore to mark off your to-do list. Just remember two overarching principles: 1) the more time you spend in nature, the better, and 2) the wilder the nature, the better. And then just get out there as much as you can!

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When you really stop to think about it, it’s an astonishing fact that we spend a third of our lives asleep. And part of that time, we’re dreaming. What goes on during this unconscious state that consumes so much of our lives, and how can we use our dreams to improve our waking hours?

Here to unpack the mysterious world of dreams is Alice Robb, the author of Why We Dream: The Transformative Power of Our Nightly Journey. Today on the show, Alice first shares some background on the nature of dreams, why their content is often stress-inducing, and how they can influence our waking hours, from impacting our emotional health to helping us be more creative. We then turn to how to get more out of our dreams, including the benefits of keeping a dream journal and talking about your dreams with others. We also get into the world of lucid dreaming and some tips for how you can start controlling your dreams.

Resources Related to the Podcast

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An important part of manhood has always been about having the competence to be effective in the world — having the breadth of skills, the savoir-faire, to handle any situation you find yourself in. With that in mind, each Sunday we’ll be republishing one of the illustrated guides from our archives, so you can hone your manly know-how week by week.

In a frigid environment, your skin and the tissue just below can start to freeze and crystallize in as little as a few minutes. This condition is called frostbite, and it’s no minor matter, but rather a serious injury which can permanently affect your appendages. Knowing how to properly treat it can mean the difference between a sore hand and an amputated one.

Your first course of action should always be to call 911 or to get yourself to a hospital. The damage may run deeper than you can visually assess. In the meantime, follow the steps above to do your best to ensure that no lasting tissue damage occurs.

Illustrated by Ted Slampyak

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Over the holidays, the McKays took a first-ever trip to Hawaii. While on this week-long vacation, I loosened up my usual diet. I didn’t track my macros like I usually do. We ate out every night, and always followed these big dinners with dessert. 

Yet, when I got home and weighed myself, I found that I hadn’t gained any weight. Instead, I had lost two pounds.

It reminded me of an observation strength coach Dan John made in our interview about fat loss. John’s noticed the same paradox with his clients that I experienced: people often come back from vacation lighter than when they left, even when they stay at buffet-heavy, all-inclusive resorts and feel like they ate and indulged more while on the trip. 

John thinks this paradox comes down to the fact that while you’re on vacation, you often:

Move more. I think this was the biggest factor in my vacation weight loss. When you’re on vacation, you frequently do much more physical activity than you do back home, walking many sightseeing miles across a city, strolling for hours through museums, or trekking the vast landscape that is Disney World. I spent each day in Hawaii swimming, boogie boarding, and hiking; even though I didn’t do any dedicated workouts while I was away, I was probably 10X more active than I am in my usual sedentary routine.

As Dr. James Levine shared in our podcast about non-exercise activity thermogenesis, or NEAT, research shows you can manage your weight simply by moving your body more outside the gym. Match an increase in calories with an increase in NEAT, and you won’t gain weight. Make your caloric expenditure from NEAT exceed your caloric intake, and you’ll lose weight.

Feel less stressed. I found that, even though I was much more active on my trip, my appetite was actually reduced. Though the meals I ate were bigger and richer than usual, I had less of a propensity to snack, so while it felt like I was eating more than usual, I’m really not sure whether my caloric intake went up significantly or not. 

This decrease in hunger may have to do with the way physical activity has been shown to regulate appetite, to the increase in the quality of my sleep (see below), or to the significant reduction in stress I experienced in waking up and going to sleep to the sound of the ocean’s waves. Stress increases cortisol, and cortisol makes you hungry. Less stress = less hunger. A reduction in stress can also provide a healthifying boost to your metabolism overall.

Sleep more. Being sleep deprived has been shown to have a negative effect on weight. When you don’t get adequate sleep, the hormones that make you feel hungry go up, while those that help you feel satiated go down. This leads to an increase in appetite, and you particularly crave high-carb food, as your body looks to sugar for energy to fight its fatigue. Additionally, insulin sensitivity drops and cortisol rises, making your body more apt to hang on to fat. 

Getting sufficient sleep helps regulate hunger hormones and improves your metabolism, and you’re likely to get more sleep on vacation. 

I’m not sure my quantity of sleep improved while I was in Hawaii because a (cursed, cursed) rooster woke us up each day at 5:30 a.m. But I do think all the physical activity greatly increased my sleep pressure each day, which significantly deepened my sleep. 

As Dr. Levine also noted in our conversation, sleep and NEAT create a virtuous cycle: when you move more during the day, you get better sleep at night, and when you get better sleep at night, you have the energy to move more during the day.

What’s great about recognizing the vacation weight loss paradox is that you can apply it to losing weight outside of vacation. It shows that you can lose weight without giving a lot of attention to and getting really strict with your diet (though, of course, dietary changes will enhance your results). Increase your sleep and physical activity while reducing your stress, and it’s possible to trim down naturally.

While it may be easier to improve your stress, sleep, and movement while away, these are all habits that you can readily implement in your normal day-to-day routine at home; while you may have to wait to enjoy beaches, museums, and amusement rides until your next trip, you can start living the vacation lifestyle, and reaping its pound-shedding rewards, right now. 

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