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128: A Hierarchy of Health

Jan 17, 2023

When you decide it's time to start improving your health, what's the best first step? Is it improving your diet? Hitting the gym more often? Quitting smoking? Deciding where to start can be a bit overwhelming. The Who Cares guys discuss what has worked best for them and Dr. Troy Madsen turns to the research to rank what aspects of health he feels will give you the biggest bang for your buck when you're first starting out.

Episode Transcript

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: When you get to a place where you're ready to care about your health, sometimes it can be really, really overwhelming. Where should you start? There are a lot of different messages out there in the world, but if you could only do one thing . . . Because let's face it, we're not going to become a completely different person. We can only do one thing at a time. What should that one thing be? What's that first step?

So today, on the podcast, we're going to help you figure out that first step, whether you're just starting out, or maybe you've made some progress and you're wondering what is next. This is "Who Cares About Men's Health." We give you information, inspiration, and a different interpretation of men's health. We're just some guys trying to figure it out on our own as well, so we have these conversations about health hoping that they will be valuable to you as well.

So my name is Scot Singpiel. I bring the BS. The MD to my BS, Dr. Troy Madsen.

Troy: Hey, Scot. I'm here and I'm ready to talk about that one thing.

Scot: All right. We're calling it "The Hierarchy of Health." And also always sharing his experience, Mitch Sears. Welcome.

Mitch: Hey. Yeah, one thing? That's what we . . .? All right. Okay, I'm here.

Troy: One thing. Starting point.

Mitch: All right. Starting point, okay.

Scot: Probably is not going to be your only thing, but it's going to be your first thing, right?

Mitch: Sure. Okay.

Scot: All right. So I want to kind of be clear on this, and we want to be clear as we're talking about it, because one of the things we really try to do here is talk about stuff we know, like evidence-based. This is based on research. This is information we know. But then also we talk about our own experiences and how that manifests in the real world. So we're going to try to be sure that we're indicating what is what when Dr. Madsen goes through this hierarchy of health with us.

And another thing that I think is important to point out too that we've discovered through the process of this podcast is when we talk about health on this show, we're talking about it in terms of reducing a chance of disease, living a longer and more satisfying life, and just generally feeling better.

It's not becoming more athletic, or more ripped, or building muscle, or losing fat for aesthetic purposes, although that could be a side effect. But it's more about just being healthier.

So, Dr. Madsen, I'm going to throw out the things that we're going to talk about today and I want you to rank these in the most important order, and then we're going to talk about that a little bit.

So, first of all, one of the things we talk about is the Core Four. If you kind of focus on these things, it can go a long way. And that's your emotional health, your nutrition, your activity, and your sleep.

And then we haven't talked about this a lot, but really we should: other things that men tend to do that might not be healthy that you might want to evaluate, such as smoking, alcohol use, nagging health issues, and genetics.

So we're going to rank those. Do you have any to add to that list, Dr. Madsen?

Troy: I do.

Scot: You do?

Troy: Yes.

Scot: Oh, so there's another one, okay.

Troy: There's another one. Yep.

Scot: And where does it fall in the hierarchy? Is it towards the top?

Troy: It's about halfway down.

Scot: About halfway in.

Troy: Yes.

Scot: Any idea what that might be, Mitch?

Mitch: No, I have no idea. I'm just sitting here, I'm like, "That's it, right? Those are the eight things I need to be worried about." And now there's . . .

Troy: This list is so comprehensive, I know.

Mitch: . . . a ninth one.

Troy: Yeah, I'm going to make it nine. We're going to make it nine.

Scot: Well, what's awesome about this list is it really does kind of help narrow down what is the first thing you should do. So, without any further ado, Dr. Madsen, our hierarchy of health. If you want to take that first step to a healthier lifestyle and you're at square zero, what's the first thing? What would be the biggest impact for your dollar?

Troy: I know what you think it's going to be, and it's not going to be that.

Scot: Smoking.

Troy: Nope, it's not smoking. I'm going to say the number one thing. So let's say you're a total couch potato, you don't do anything, your diet is horrible. Let's say you smoke, you drink a lot alcohol, you know nothing about your genetics, and you have all kinds of nagging health issues. The number one thing I would say that will have the biggest impact on your health that is the most practical thing to do is activity.

Scot: Really?

Troy: That's where I would start, and I'll tell you why, Scot. There was a study that came out recently, evidence-based. This looked at exactly those people, and it compared people who did nothing to people who had minimal activity, short bursts of energy, two minutes long, maybe three times a day, just taking the stairs instead of the elevator, shoveling snow, things like this. Not big activity. They found that people who engaged in these short bursts of activity had a 50% reduction in heart disease and cancer risk over about seven years.

Mitch: Wow.

Troy: Fascinating, I know. Major impact.

Mitch: Because we're not even talking the 30 minutes three times a week of activity.


Troy: No.

Mitch: We're talking just 10 minutes? What are you saying?

Troy: We're talking just take the stairs. That's all it was. So that's why I say that's your starting point. If you do nothing else, take the stairs, shovel the snow, do something to get your heart rate up for two minutes three times a day. That alone will have a dramatic impact. Fascinating study, really well-done study.

Scot: And just to be clear, more impact than quitting smoking, if everything else is equal?

Troy: I'm going to say yes. Quitting smoking is absolutely going to reduce your cancer risk. I can't say for sure that, in seven years, it will reduce your cancer risk by 50%. Maybe we'll find something out there that suggests that.

I'm looking at seven years. They were seeing this impact seven years, not a long time down the road, major impacts on health. And again, you're starting super low, and just adding something to it. But just adding that little bit makes a huge difference. So that's why I'm going to say activity over smoking because of the shorter-term benefits they saw in a lot of this risk reduction.

Mitch: Wow.

Scot:All right. And of course, we know activity has so many other impacts on the rest of our health, right? That activity . . .

Troy: Exactly.

Scot: . . . can help us feel emotionally better too. It can help us sleep better. I don't know if you're like me, but for me, if I get my activity in, I tend to find, and this is just me, that I will eat better. I don't know why, but I'm more likely to make better choices when I eat.

Troy: And that's why I put activity at the top, because I think a lot of these things follow when you get more active. Then you're going to be more motivated to quit smoking because then you can be more active. So I think it then kind of feeds into itself. So if I said start anywhere, just start with activity. And with the activity, start incredibly small. Just take the stairs. That's it.

Scot: Just start moving a little bit more.

Troy: Move a little bit more, yep.

Scot: Try to walk around the block.

Troy: That's right. Walk around the block.

Scot: All right.

Troy: Small amounts of activity.

Scot: All right. Well, already I'm surprised, Mitch.

Troy: That's what we do. We aim to surprise.

Mitch: You were so sure.

Troy: We aim to surprise on this podcast.

Scot: All right. Hierarchy of health, first thing is activity, and that's just adding in a limited amount of activity. What's the second thing then you might want to consider doing?

Troy: I've got to have smoking here, because you're exactly right. Yeah, smoking, huge health impact. If you can drop smoking, your risk of cancer is going to drop, your risk of lung disease, all kinds of health issues.

And again, if you're starting to get active, I think it makes it easier to quit smoking just because it gives you a little extra motivation, probably improves your mental health, maybe makes moving away from smoking a little bit easier. But that would be next on the list.

Scot: Mitch, I don't want to speak for you, but maybe . . .


Scot:. . . you can jump in. "No, please, Scot, speak for me." Maybe you could jump in here. So, to me, one of the things I love about the fact that activity was the first thing suggested and that some research showing that just even a small amount of activity, if you were getting none, can make such a huge difference in your health, that sounds a lot more achievable than quitting smoking.

Mitch: Oh, yeah.

Scot: Smoking, that's a major thing.

Troy: That's why I started with activity too. Sorry, Mitch.

Mitch: Sure. No, go ahead.

Troy: That's why I kind of put activity first, because I think it's a win, like, "I got that. I did it. I'm more active. Let's tackle smoking."

Scot: So part of it is mental. You get those little small wins.

Troy: Yeah.

Mitch:Having, I guess, both quit smoking and starting to do my activity on this podcast with both of them, training for the Who Cares 5k was . . . it was work and it was a big shift in my life. But we're not talking an addictive substance that I needed patches on my body and sucking down chocolate cinnamon bears, etc.

I think for me, at least, smoking was the kind of keystone. Once I was able to pull that out, it was easier for me to get exercise because my lungs didn't hurt. And it was easier to feel better, and my sleep went better. It was something that was really kind of holding me back with a lot.

But at the same time, if the activity really does give you that much more benefit, it was a whole lot easier for me to start being more active in my day-to-day than it was to quit smoking. Not to say it's impossible. I don't want to sound like whatever. It's just hard. It's really hard, especially if you've tried it before.

Scot: And let's take this moment to celebrate, Mitch. How long have you been cigarette free?

Mitch: Oh, the math . . . I think we're three.

Scot: That's so incredible.

Mitch: Three years now.

Scot: Yeah, that's so awesome.

Troy: All you have to do is just think how long has the pandemic been going on and then you just add about four months to that.

Mitch: I made it through.

Troy:Right before the pandemic, yeah.

Scot: Mitch, another question about smoking and activity for you. Did you find when you were trying to quit smoking that doing something like getting out and walking helped manage any of the addiction at all, took your mind off it for like a couple seconds? I can only imagine you're constantly thinking, "I want a cigarette," and you're constantly playing this game of "How can I distract myself for another five minutes to not want a cigarette?"

Mitch: So, in my case, one of the things that I did try doing is . . . not only did I do the cessation aids, which I highly recommend. If you've tried quitting smoking before and it didn't quite work, talk with your doctor, get the patches, get the gum. Not that it's easy, but it made it for me, someone who had to do it seven, eight times to actually stick to it, man, that stuff really, really helped.

But yeah, there was something about . . . During that time period, I started taking walks. For me, when we talk about nicotine addiction, it is not just the cigarette. We know the cigarette is bad. We know it's bad for our health. But it was also a time to take a break from everything and go outside and sit for 5, 10 minutes, and then come back inside and just kind of reset.

And when you suddenly lose that cigarette, you've got to make sure you're still doing those types of things. So if that break from the every day, and if that getting outside, walking around a little bit is a part of why it's so hard to quit, I just started walking around the block.

This was before I started jogging. This was before I whatever. But I would go out the front door, I would just do one lap, come back in, and it helped a lot actually, surprisingly.

Scot: Incidentally, it should be mentioned, people trying to quit and not being successful multiple times is the norm. If you're in that situation, if it's been six times, try seven times.

All right. The health hierarchy, Dr. Madsen. We've hit starting with some activity. Then we've moved to smoking, quitting it, or at least reducing maybe as a first step so it's not quite overwhelming, if you can just even reduce it. What's number three?

Troy: So number three is going to be nutrition. And here, we're just going to keep it really simple. Ideally, in terms of science, you're going to switch to where you're eating the Mediterranean diet. Lots of great science there. But let's just keep it really simple and let's just say you look at your diet, and you say, "My diet is not good at all." Start with just stopping drinking soda. That would be my number one recommendation on diet.

And in terms of evidence, tons of evidence showing you reduce that sugar intake, just so much sugar in sodas, you're going to see big benefits very shortly in terms of weight loss, and certainly in the long term, in terms of cancer, risk of heart disease, those things.

Scot: Also, a lot of sugar in your body is not good for your organs, from what I understand.

Troy: Yeah, exactly.

Scot: It's just really hard on them. It's like this sugar bath, which isn't a great thing for your organs.

Troy: Yeah, exactly. And again, if you're looking to go all in on that in terms of really switching your diet, then work toward the Mediterranean diet. Increase your fruits, vegetable intake, legumes, nuts, whole grains, those sorts of things. That's the ideal, but again, we're starting just saying, "Hey, I've got to start somewhere." I would say start with sodas. Try and reduce, and that's a quick way to get your sugar intake down a lot.

Scot: And if sodas aren't the issue, I think . . . So there's been some debate on the show, I remember. But one of my takeaways about nutrition is this debate of "Do you deny yourself or do you add? Do you subtract or do you add?" Do you try to eliminate the stuff that you think is bad, or is it better just to go, "You know what? Every meal, I'm going to try to eat a serving of vegetables. I'm not going to change anything else. I'm just going to add a serving of vegetables"?

I mean, I don't know. Some people might do better at subtracting. Some people might do better at adding. But that would be another maybe next step. How can you add in some of those healthy things Dr. Madsen talked about just even once a day? Again, don't overwhelm yourself.

All right. The hierarchy of health. We started with activity, we moved to smoking, and then working on your nutrition, especially if you're drinking soda to get rid of that, or add in something healthy. What's the next one?

Troy: So I would say the next one is something we've talked a lot about this past year, and that is emotional health. I think you're going to get benefits to your emotional health as you do these other things, but the more you are able to improve your emotional health, that will then feed back into these other things you've already been working on and, I think, make you a lot more successful.

And of course, there are the health benefits simply to improving your emotional health, reducing symptoms of depression. But that then feeds into more activity, better diet, and you're getting all the health benefits from those things as well.

Scot: I want to try to nail down what does that even mean then, improving your emotional health? What's a concrete thing a listener can do?

Troy: Well, certainly if you are suffering from severe depression or anxiety, I think it's worth talking to your primary care provider, being referred to a mental health professional. If you feel like maybe you're not at that point, there are certainly online resources. We've talked a lot on our show about mindfulness and resilience and working on those sorts of things as well.

So I think it's looking at your outlook on life, looking at your general mood throughout the day, those sorts of things, and just saying, "Hey, where am I right now? Do I feel like things can be better? Okay, great. Do I need to get some additional help for this from outside individuals, or is this something where we can engage in practices like we've talked about, like gratitude journaling or . . ."

Scot: Box breathing.

Troy: Box breathing, yeah, exactly. Those kinds of strategies where maybe you don't feel like you're at the point where you need to go see a mental health professional.

Scot: Mitch, do you have some thoughts on this? As I look at this list, you've overcome most of these.

Troy: I know. It's remarkable.

Mitch: Overcome. It is all a process, and I'm still working on it all.

Scot: I know you are.

Mitch: So emotional health. See, that's just kind of it too. I don't know if I am the everyman with that particular situation. We have found some stuff with . . . We'll talk about it more this season, a recent ADHD diagnosis that I got in adulthood, a generalized anxiety disorder, etc. I was at a much different place than I think the average person, just kind of not feeling super great, or wishing they had a more positive outlook, etc.

But I can tell you that the first step, the very first step is always either talking to someone you really trust about what's going on in your mind, or talking to a doctor. That's what started my whole line down it. I was at a physical checkup getting my yearly physical, and I'm just like, "I'm not feeling right. My thoughts are not what I want them to be. I'm tired all the time, etc." And they at least were able to give me resources and a direction to start.

I really think that's where you need to start, is talking to at least someone in your life, get some perspective, whatever, someone you trust. Or number two, talk to a doctor and the doctor should be able to help you in the right direction.

Scot: And on the podcast, we do talk about all of these things we discussed, the Core Four, and even stuff like smoking or alcohol use. They're all interrelated, right? They all point back to emotional health in one way, shape, or form. For example, too much alcohol will make me anxious the next day.

So I think when you start improving some of these other things, some of that emotional health might start to improve. I have not found myself quite in the same situation as you, Mitch, where things such as just taking a 10-minute break during the day and just not consuming any media . . . That maybe can be another one, right? Try to eliminate social media. That made a huge difference for me. I limit it a lot more than I used to. Or just taking a break and just being there with your thoughts and just being in the quiet can reset you for a little bit later.

Troy, do you have anything you'd like to add to that? Are we ready to move on to the next in the health hierarchy?

Troy: Well, I'm so excited for the next one. I don't know. This is the wildcard. We're at the halfway point. This is the one you didn't suggest that I'm just going to throw in. And this is one we just had an episode on: health screenings. So this is one where this is definitely going to make a difference on your health.

We talked about colonoscopies. Certainly, if you're a woman listening to this show, mammograms. Prostate cancer screening, something to discuss with your primary care provider. There has been a little bit of controversy in terms of prostate cancer screening and we have talked about that on the show as well. But I would say health screenings.

And one of my wake-up calls was a cholesterol screen. To see my numbers in my 20s really was a wake-up call, and then led me to make a lot of these other changes we've made.

So it can certainly help to prevent disease, it can identify early disease in terms of cancer risk, and it can also potentially prompt you to make additional changes to avoid future disease.

Scot: Motivate you, which is another big part of this equation. A lot of us know the things we need to do, but sometimes we're just not motivated to do them until we get that little wake-up call, like you did with your cholesterol. I did with my fasting glucose.

Mitch: Sure. And that's one of the big things for me that really kind of changed the game, is not just talking on the podcast. I think that was a huge part for me. Just talking about my health was a big first step for me. But actually calling the number and being like, "Hey, what do I need to do to get a PCP? What do I need to do to get a primary care person?"

And just being able to have my primary contact with my health not be the instacare or the emergency room, to have it be someone who I see on a regular basis, who checks in, who I have enough of a relationship with that I can ask those "oh, one more thing that I'm curious about or I wonder about." They're the people that have the know-how and the specialty to help you, right?

And if you're just kind of struggling on your own, getting that first set of screenings and starting that relationship with a PCP can really help with a lot of these.

Troy: Exactly. And that's a big part of that, too. It's the screenings and then it's having a primary care provider who you can go to with those questions and go to with emotional health issues. Certainly, they can have resources to quit smoking, all those things as well.

Scot: The health hierarchy on "Who Cares About Men's Health." What is the next one if you could only work on one thing? We're getting pretty deep now.

Troy: I know. This is getting tough here at the end. I feel like it's getting a little bit tougher to kind of slice these and rank them. But I'm going to say reducing alcohol use.

So if you're at a moderate or high-risk range in terms of alcohol use, reducing that. Alcohol use increases your future risk of cancer. It becomes a little tricky because, certainly, you've heard of studies where alcohol use at . . . A low range of alcohol use can reduce your risk of heart disease.

That being said, multiple societies have stated if you don't drink, don't start drinking alcohol to reduce your risk of heart disease. More and more of these studies are saying, "Well, it reduces your heart disease risk, but even at a low level increases your risk of cancer."

But bottom line is if you're drinking at a moderate to heavy range, work on reducing that at least down to a low level.

Scot: That surprises me alcohol is so low. I thought it would be right up there with smoking. Why is it so mid to low pack?

Troy: Great question, Scot. It became tough to rank these and that's probably why.

Scot: So the difference between these at this point might be just really negligible.

Troy: I don't know. It's tough. Clearly, smoking is a no-brainer. I feel activity is a no-brainer because so much follows. I feel emotional health, once you address that, is going to help all those other things. So we kind of hit the big guns there.

I put alcohol down a little bit lower on the list. There certainly is cancer risk associated with alcohol. There's no question there are long-term risks associated with moderate to heavy use.

Scot: Yeah, like liver disease. What are some of the other diseases alcohol moderate to high use can cause? Potentially ending up in the ER with you because of trauma?

Troy: Yeah, exactly. That's probably the number one thing I see, is just the trauma associated with alcohol use.

Scot: It can really impact somebody's emotional health.

Troy: Yeah, exactly. And that again becomes a challenge because there's so much interplay here, and a big piece of emotional health may be alcohol use. It may be as you address your emotional health that your alcohol use reduces.

And we had one guest on the show who talked specifically about that, who talked about his alcohol use and how he then was able to address a lot of the underlying issues with anxiety and PTSD, a lot of what he experienced working for the fire department. And then he found that his alcohol use reduction followed.

So maybe that's why I put it a little bit lower, because I feel like if you're addressing some of these issues, sometimes the alcohol use is used to cope with anxiety or frustrations with your health. And as these other things improve, I think in many cases, not all, but in many cases, the alcohol use, the reduction may follow.

Scot: I do know if I'm more active and I'm watching my nutrition, I tend to use less because I'm full and I don't want to. And I'm also like, "Hey, I'm engaged in some activity doing some healthy things, so I'm going to just kind of . . ." Not quit, but I'm just a little bit more moderate in my usage, I would say.

Troy: Yeah, exactly. I mean, you talked about how you go out on your back porch and you drink your tea now instead of drinking a beer, and you're engaging mindfulness there.

Scot: I also always had a rule . . . well, I didn't always have a rule. I developed a rule that I cannot have that after-work drink or whatever until I've eaten a meal. Eat first. And a lot of times, then when I'm done, I don't feel like the beer, which is what I tend to want to drink.

Troy: Exactly.

Scot: One more thing I think that's worth bringing up. Even though we're building this hierarchy, I think it can be adjustable depending on what your main issue is that you need to deal with. Maybe nutrition moves up higher because you have a lot of body weight that you need to lose that is threatening your health. That and activity would be the two things.

So I think keep in mind that maybe this is flexible depending on the person's situation. And that's where a conversation with your doctor might occur.

Troy: Exactly.

Scot: All right, Troy. What's next on the hierarchy?

Troy: I put this low on the list because it's something I just am so bad at, so I just wanted to make it so it's not a high priority. It's sleep.

Scot: To make yourself feel better.

Troy: Yeah, it makes me feel better. It's not that important because I put it low on the list, so it couldn't matter that much.

Scot: But it is important.

Troy: It is important. There's no question it's important. And again, I put it a little bit lower on the list because we're talking about priorities in terms of hierarchy and things to tackle before trying to tackle other things. But I feel like if you're addressing a lot of these other things, hopefully, this sleep improvement follows. Not always the case.

Mitch, we've talked about your struggles with sleep and addressing all of these other things and just seeing the sleep not improve. But I think the hope would be if you're exercising more, you're eating better, mental health is improving, that your sleep is going to improve as well. That's why I would just say don't try and tackle that right off the bat.

Mitch: Do I want to disagree? No. It's accurate. He's right.

Troy: Please, disagree.

Scot: You want to disagree with the doctor?

Mitch: That's where I'm at. It's like, "Let me just tell you."

Troy:I'm just the ER doctor.

Scot: That was a test, Mitch. You absolutely can disagree.

Troy: Please do. I'm open to feedback.

Mitch: No, but it is true. Sleep was something I was concerned about, but it was lower on the list. And it has improved with getting some things figured out. But it was a lot worse when I was still smoking, when I was drinking every single night, when I was not getting any activity. I had full-blown insomnia. Could not fall asleep, stayed up until like 4 or 5 in the morning, and just kept going.

And once I got those other things figured out, I could at least fall asleep. Now the quality of the sleep, that's what I'm kind of working on now with my shaky legs, etc. But I went from not being able to fall asleep, feeling tired all the time, to being able to fall asleep by increasing and improving some of those other aspects.

Troy: I guess it's a good question, though. If you had started from the start and gone to see a sleep expert and had addressed the underlying sleep issues, do you think it would have been easier to quit smoking and easier to address mental health issues just because you were more well-rested? I don't know.

Mitch: I don't know. That is a hard question.

Scot: It is. And there's no research on that, Troy?

Troy: I don't know. There's probably something out there somewhere, but it is tough. Again, in my mind, I feel like if you can address these other things, hopefully the sleep falls into place. I just think it's hard to just say, "I'm going to sleep, and I'm going to sleep better, and I'm going to improve my sleep hygiene, yet I'm smoking, and I'm anxious, and my diet is horrible, and I'm drinking a lot." It's hard to start with sleep. That's the way I thought about it.

Scot: Yeah. So you're pointing something out. This is a hierarchy, what you should focus on first, but that does not discount how important sleep is.

Troy: Exactly.

Scot: We know good sleep definitely can reduce the chance of disease and has a lot of other health benefits. Just simply saying to try to take care of some of these other things first, and hopefully sleep will take care of itself. If it doesn't, like with Mitch, then you need to kind of investigate, "Why am I still not sleeping? I tend to be doing these other things right. So what can I do to improve that sleep?"

Troy: Exactly. I look at this as a hierarchy not in terms of what is the most important thing on this list to your health, but if you are just not doing . . . You just feel like, "I've got to start somewhere," where do you start?

Mitch: I like that.

Scot:All right. We're getting close to the end here. What's after sleeping?

Troy: We're getting there. Nagging health issues is next. So once you've gotten through all these things . . . And again, you could argue, "Well, if I address that nagging health issue, I could exercise more." But I feel like you've started exercising, you're at least moving, you've got that short burst of activity, and then maybe you increase to 30 minutes three times a week.

And then as you address those nagging health issues, maybe they're orthopedic issues or just other things that have been on your mind that you've just wanted to get checked out, then I think it helps you get to the next level in terms of that activity, or whatever these things may be holding back on the list in terms of what we've already talked about.

Scot: Yeah. So the activity, you would start doing some limited activity. But then if you find, "Wow, if I try to do 15, 20 minutes, my knee starts killing me and I just can't walk," then to go to that next level of activity, you'd want to take a look at whatever nagging health issue you have.

Troy: Exactly. I think it's rare that those nagging health issues would limit us so much that we can't just take the stairs. But then I think as you get more active, then you may need to address those just to be able to get to that 30 minutes three times a week, or even beyond that.

Scot: But if it is getting in the way of activity, we know that activity is that one big thing, so maybe you might want to start addressing that health issue, which would probably involve some physical therapy, which is activity anyway, right?

Troy: Exactly.

Scot: All right. We're to the last one now, aren't we?

Troy: We're to the last one. What's left?

Mitch: Genetics.

Troy: Genetics is left. I just put it at the bottom because I think genetics is more interesting, and that's how I found it. I found it more just fascinating. When I learned my family history of migraines . . . And this was after our episode on migraines that my cousin contacted me.

Mitch: Oh, really?

Troy: Yeah, we did our episode on migraines. My cousin just happened upon the podcast and heard that episode and texted me and said, "Our grandmother had migraines, and she would refer to them as her sick headaches."

Scot: I love that.

Troy: And her mother had her headaches and referred to them as her sick headaches. And they would just have to go in a dark room and seclude themselves for a while, and then they would come out. Back in the early 1900s, migraines were not . . . It was funny to hear, or interesting to hear that history.

So I find genetics more . . . it can be certainly informative. It can affect some of those health screenings we talked about if you have a strong family history of heart disease or cancer. So it plays into that as well, and it will probably come up as you're looking into those health screenings.

But if it hasn't come up at that point, I think beyond that, again, it becomes interesting and it helps you understand maybe a little bit better some of the challenges you're facing or have faced as you've addressed these other issues. But it's certainly not something I would start with . . .

Scot: Start with.

Troy: . . . on this hierarchy. Yeah.

Mitch: All right. I am going to disagree with the doctor here.

Troy: Go for it. Please do it.

Mitch: For me, this list, I literally worked top to bottom with what you were talking about. I started with getting a little more activity and realizing I couldn't breathe right, and so I got rid of smoking. So I went down the list.

But it's that last bit of genetics that has unlocked a lot of stuff in this last year, right? The chronically low testosterone in my family, the ADHD diagnosis, which apparently is very much part of my family history, etc. There were a lot of pieces for me that not only fell in, but butterfly-effected through everything else but I didn't have that information.

And it's not necessarily something that came up in everyday routine screenings. I had to go to specialists. I had to whatever. To be fair, I checked everything off and then figured those out.

But there is a part of it that if you know you have a history of something, maybe go check that out. Man, not a day goes by these days that I'm like, "I wish I knew this before. I wish I knew this first." Man, oh man, I went through a lot of struggle and spent a lot of time that if I had known that this was a possibility in my genetics, if I had known, had a better family history, etc., I could have skipped a lot of these steps.

Troy: Interesting. So do you wish you had known that from the start, and that would have helped guide your journey a little bit more?

Mitch: Yes. So we'll talk more when we do the ADHD episode. But one of the things I'm finding, and when I talked to my new psych specialist and everything who's working on it with me, one of the first things they said was, "So how many times have you tried quitting smoking?" And I'm like, "What?" I didn't even bring that up, right? I thought we were here to talk about how I'm scatterbrained, whatever.

And the response was, "Well, actually, there is evidence and research that smoking and nicotine can be used as a self-medication for undiagnosed ADHD people with dopamine deficiencies." And so it's just like, "So you're telling me because my brain is wired differently it's harder for me to quit?" "Oh, yeah. I would have told you to take Chantix from the start." And it's just like, "Oh."

I had so many emotional breakdowns and everything, and it was all because . . . And I'm reading these very nice messages online about people sharing their own strategies. But I'm like, "It's not that easy, y'all." And come to find out it was actually because there's something wired up there differently. So that's kind of the look-back.

You're right when we're talking about order of operations, biggest bang for your buck. But if you know that you have a family history of something, I would just advocate for maybe checking that out, too. I didn't know. I did not know, so it was the last thing on the list to check off and it's been the most impactful in my health in the last year.

Troy: That's interesting. So, yeah, maybe that's a good starting point then of understanding your genetics more.

Scot: I don't know. That might also speak to . . . We're making this list just as a general rule, right?

Troy: Yes.

Scot: Some of the things you've been finding . . . For many people, and we don't know the numbers, obviously. This is one of those things I'm speculating on. For many people, going through this in this order very well might get them to the point they want to be. But a small percentage of people, you included, fortunately or unfortunately, however you want to look at it, there were some other things going on that you weren't aware of.

Troy: And again, that's kind of how I looked at it. It maybe then helps you fine-tune that focus. You've already focused on some aspects of your mental health, and then you feel like you've made some progress, and then you understand your genetics more and you're like, "Oh, wow. Okay, now I understand better the challenges I faced in addressing that issue," which is kind of what you experienced. But that being said, I totally get it if you understood from the start . . .

Scot: Yeah, I do too.

Troy: . . . the challenges with addiction or whatever in your family. I think it helps you in terms of being more patient with yourself as you were then trying to tackle those challenges for sure.

Mitch: Well, I'm going to blow up this whole idea and say the number one thing you should probably start doing is talking to one another about your health.

Troy: There we go.

Mitch: There we go, right? Just talking about what's going on, talking to other guys, talking to your family. I don't know. I think that that could be a really great first step.

Troy: That is a great first step. That's not on the list. We should have put that. Just start talking about your health first and then you can start with some action after that.

Scot: Troy, thanks for The Hierarchy of Health. I think this is a good roadmap for somebody to kind of go down regardless of the place they are in their journey. If they've already implemented some activity, but they're smoking, that would be a good next step. Have you reduced those sodas? Can you introduce some perhaps healthier choices into your diet? Are you looking at that emotional health? Are you getting the health screenings, watching the alcohol use, sleep, nagging health issues, and genetics?

So I think that's a very useful tool. Again, I'm going to iterate maybe that might change for you. But it's a starting point, right? And at least outlines some things as opposed to having it be all the choices. Now you have a small list of choices, and your instance might be a little bit different and you might start somewhere else.

This was this really good. Any takeaways, Troy? I mean, you kind of walked us through it, so I don't know that you have any takeaways. But sometimes when you talk about this kind of stuff with other people, you develop some new knowledge. So did you get anything out of this, or not really?

Troy: Yeah, my takeaway is it was fun to think through it and fun to prioritize this. But I'm guessing if you had 10 different doctors do it, they'd all have different orders on this list.

Mitch: Oh, really?

Troy: I can't pretend to be an expert on this. And I think anyone is going to look at this list and, depending on their specialty and even their personal life and personal interests, would maybe . . . Maybe someone else puts emotional health number one. I'm sure we've had guests who would do that.

So that's my takeaway. You may disagree. Please disagree. But I think it's a nice summary of so many things we've talked about on the show. And again, I think the takeaway is to decide where you want to start, go for it, start small, work your way through these things, and then revisit them and then continue to revisit them to improve in each area.

Scot: Mitch, jump in with yours.

Mitch: I kind of tried to do all these at once last year, or the last couple years, and you guys have on multiple occasions been like, "Hey, maybe that's too much. Are you not feeling overwhelmed? Etc." And I was, looking back.

Prioritizing, taking small steps, improving one thing or another, I think just take it from this one person who tried to fix all their health at one time, it was a lot. It was a lot and very, very overwhelming. Find out what is the biggest impact on you and focus on that first, and then go from there.

Scot: In trying to make it simple, sometimes it can make it complicated again, right? Because we had a list of nine different things. So I think my last thing, and what's worked for me, is just try to find maybe one of those things that you can sustain and then make it part of your daily routine. And then try to move on to the next thing when you're feeling better.

And if, for whatever reason, you're having difficulty trying to get that one thing, maybe try something else or figure out, "Well, why am I having a hard time trying this one thing?" And then that will lead to another problem you can solve.

Just solve one of them at a time. You don't have to make perfect progress on that one thing. Just make some progress and then maybe try something else. And like Mitch said earlier, it's all a work in progress, isn't it?

Mitch: Yeah.

Scot: Yep. It's not just something you can take for granted. It's not just something that happens unless you're actually paying attention to it, doing things actively, or talking about it, unfortunately.

So, gentlemen, thank you very much for getting together for our weekly conversation. If you are listening, what's the one thing you're going to do? Pick one, try it, and if you want to let us know how it goes for you, you can reach out to us at Thanks for listening, and thanks for caring about men's health.

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