The People's Pharmacy

A chance encounter with a stranger on an airplane offers lessons for all of us in how to disagree without fighting. Infectious disease expert Morgan Goheen, MD, was wary when the person in the seat next to hers struck up a conversation with questions about the origins of Lyme disease and the value of being vaccinated against COVID. His views were quite different from hers. Yet they managed, in the course of the flight, to exchange perspectives in a respectful manner. Can we all learn how to do that? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, March 28, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on March 30, 2026. Can You Disagree Without Fighting? Dr. Goheen did her best to answer the questions her seatmate had. She also listened carefully to his description of life during the pandemic, particularly his objections to mandatory vaccination and his fears of a reaction to the vaccine. As a health care provider, she had been working in a hospital that was overwhelmed with COVID-19 patients. Far too many of them died, and at the height of the pandemic, most died alone rather than with family nearby. She was able to recognize that this had colored her perception of the pandemic and had led her not to give enough attention to the real economic hardship some public health mandates triggered. The Value of Vaccines Before the polio vaccine was developed, parents lived in terror of polio epidemics that would tear through communities, leaving some children paralyzed and a few dead. We no longer have to fear polio, pertussis, diphtheria or measles because vaccines can protect children from these common diseases. In a sense, though, their very success has led to skepticism of their value. Most Americans do not know anyone who has died of pertussis (aka whooping cough) because the majority of children have been vaccinated against this pathogen. Recently, there have been few birth defects caused by rubella because pregnant women can be protected from the infection. Can Trust Be Regained? During the pandemic, opinions became polarized. People who would once have trusted the FDA or the CDC became suspicious. Public health messages about masking were initially based on conjecture, because no one had conducted actual studies until later in the pandemic. The nature of this new virus and its transmission was not yet well understood. Yet authorities occasionally made dogmatic pronouncements, possibly out of fear. Some opportunities to build trust were squandered, and it will take time and patience to get it back. Learning to disagree without fighting is a great place to start. Learning to Disagree Without Fighting After talking with Dr. Goheen, we turn to Dr. Laura Gilliom. She is a clinical psychologist active in the Braver Angels movement. This organization brings people together to bridge the partisan divide. The volunteers run workshops in which people with divergent viewpoints discuss issues of the day. They model basic approaches to good communication, including treating the other person in the conversation with respect. It is important to listen for understanding of the intellectual and emotional bases for their perspective. After all, people have reasons for their opinions. Even if you don’t understand them, those reasons make a lot of sense to them and are usually the result of significant life experiences. When you speak, the aim is not to win the argument, but to be heard and understood. That is also the goal as you listen–to understand where the other person is coming from. When Braver Angels bring people together, all agree to state their views freely and without fear. That isn’t always the case in other situations. Sometimes people fail to speak out because they are afraid of the possible reaction. Another rule for Braver Angels interactions is that people treat each other, including those who disagree, with honesty, dignity and respect. Curiosity and kindness are also critical when we talk with people whose views are very different from ours. In some situations, it may be appropriate to reflect back what you have heard and ask if that is a fair representation of what they said. Before sharing your own ideas, you might ask permission. One other point to keep in mind: humans sometimes make mistakes. That might apply to those on “our side” as well as to those on a different side. Humility can help. This Week’s Guests Morgan Goheen, MD, PhD, serves as faculty Instructor in the Section of Infectious Diseases within the Department of Internal Medicine at Yale School of Medicine. As a physician scientist, her current research focuses on the mosquito vector’s role in malaria transmission dynamics and drug resistance spread in sub-Saharan Africa with lab work based in the Epidemiology of Microbial Diseases Department in the Yale School of Public Health. Within her clinical specialty of infectious diseases, Dr. Goheen has specific interest in tropical medicine and helped start the Travel and Tropical Medicine Clinic at the Yale Center for Infectious Diseases. Dr. Goheen is a Public Voices Fellow of The OpEd Project in Partnership with Yale University. https://www.theopedproject.org/fellowships. https://www.huffpost.com/entry/infectious-disease-doctor-anti-vaccine-airplane_n_68d2e961e4b03fb4d93463e7 Laura Gilliom, PhD, is a licensed clinical psychologist in Chapel Hill, North Carolina, a State Coordinator for Braver Angels, and a member of the Central NC Alliance of Braver Angels. https://nc.braverangels.org/ Listen to the Podcast The podcast of this program will be available Monday, March 30, 2026, after broadcast on March 28. You can stream the show from this site and download the podcast for free.

Chronic diseases make up the bulk of the problems that modern health care must address. Each condition seems to have its own drivers–cholesterol for heart disease, airway hyperreactivity for asthma, neurotransmitter imbalance for depression and other psychiatric disorders, a buildup of amyloid beta in the brain for Alzheimer disease. What if all these conditions had similar origins? Today we’ll consider the evidence suggesting that hidden infections may be driving many chronic diseases. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen to this conversation through your local public radio station or get the live stream at 7 am EST on Saturday, March 21, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on March 23, 2026. How You Can Watch our Interview with Nikki Schultek: Here is the YouTube video podcast of our interview with Nikki. We think you will find it compelling. Treating the causes of chronic diseases instead of the symptoms makes sense to us. How Could Hidden Infections Be Driving Chronic Disease? Nikki’s Story We begin this episode with the personal account of Nikki Schultek. She is a patient who has transformed herself into a research leader after a horrendous experience with unexplained chronic disease. She was a healthy active young mother whose lifelong well-controlled asthma suddenly took a dramatic turn for the worse. She then developed atypical pneumonia, heart arrhythmia and interstitial cystitis, along with a slew of autoimmune conditions. All the doctors could tell her was that these were idiopathic conditions driven by inflammation. As she notes, “idiopathic” basically is doctor-speak for we don’t understand what is going on here. When she developed neurodegenerative symptoms that made her physician suspect MS, she was terrified. That low point became a turning point. Her background had equipped her to read scientific studies, so she began trying to figure out what was driving chronic disease in her own situation. A search linking atypical pneumonia and interstitial cystitis led her to the clinician who was able to help her regain her health, Dr. Charles Stratton. He had conducted a small study linking both conditions to a respiratory infection caused by Chlamydia pneumoniae. What Is Chlamydia pneumoniae? When people hear “Chlamydia,” they think immediately of the sexually transmitted infection caused by Chlamydia trachomatis. Although the organisms are related, they have completely different modes of transmission. People catch C. pneumoniae (Noo-mo-knee-eye) simply by breathing in air that contains infectious respiratory particles. These bacteria are extremely common, but it is difficult to detect an infection. That’s because C. pneumoniae hides out inside human cells. It doesn’t show up in blood tests or urine cultures. The study that caught Nikki’s eye used PCR, polymerase chain reaction, which detects DNA. That analysis revealed that 80 percent of the women in the study with interstitial cystitis had C. pneumoniae. The researchers concluded that this sneaky pathogen can lead to chronic inflammation. The Link Between C. pneumoniae and Asthma Remember that Nikki’s troubles started with a severe asthma exacerbation. Research has shown a link between that infection and hard-to-treat asthma (PLoS One, April 19, 2021). When Dr. Stratton tested Nikki, they discovered that she indeed harbored a C. pneumoniae infection. The treatment required multiple antibiotics over a prolonged period of time. Luckily, it eventually cleared the interstitial cystitis, the neurodegenerative symptoms, the other autoimmune problems and brought her asthma back under control. Other Pathogens Causing Trouble C. pneumoniae was not the only germ lurking in Nikki’s body. She discovered that she also carried Borrelia burgdorferi, the organism that causes Lyme disease. In addition, an examination of her red blood cells revealed both Babesia and Bartonella, possibly transmitted by the same tick bite that gave her the Lyme disease. These experiences inspired Nikki to start the Intracell Research Group, the Pathobiome Research Center and the Alzheimer’s Pathobiome Initiative. All are aimed at discovering if hidden infections such as C. pneumoniae or Babesia or Borrelia burgdorferi could be driving chronic disease such as dementia. More Research on Covert Pathogens Driving Chronic Disease One of Nikki’s colleagues at the Alzheimer’s Pathobiome Initiative as well as at the Philadelphia College of Osteopathic Medicine is Dr. Brian Balin. He has spent more than 25 years studying the connections between C. pneumoniae infections and brain inflammation. This, in turn, has been linked to neuroinflammation and dementia. Dr. Balin points out that respiratory pathogens like C. pneumoniae are accustomed to entering the body through the nose. The nose offers access not only to the respiratory tract, but also to the brain. However, it can be difficult to detect microbes in the brain while the patient remains alive. This has limited research on infection and cognitive impairment in the past (Alzheimer’s & Dementia, Nov. 2023). The COVID pandemic poses another huge risk. Like C. pneumoniae, the SARS-CoV-2 virus often enters the body through the nose. From there, it has ready access to the brain (Frontiers in Aging Neuroscience, June 13, 2025). Further, when the immune cells called macrophages respond to these infections, they engulf the pathogen and may carry it throughout the body. Might long COVID be the latest example of unacknowledged infection driving chronic disease? What Are the Implications for Treatment? If it can be firmly established that pathogens trigger the inflammation driving chronic disease, that offers several different approaches for treatment. First, we would need to use a high level of suspicion and appropriate technology (such as PCR) to detect infection. These bugs don’t show up through urine cultures or other typical diagnostic techniques. Secondly, we would need to figure out treatment strategies. Antibiotics can be useful, but they may not be the only tools. Vaccines could help the body fight off these pathogens. Specific antibodies might also be developed to block them. In addition, phage therapies targeted to specific bacteria may also work when antibiotics cannot. If you are unfamiliar with the idea of phage therapy, you might want to listen to our radio shows on this topic. Just think of these viruses the way you think of the enemy of my enemy. That entity becomes your friend! Here are some interviews you may find intriguing: Show 1155: Can Bacteriophages Save Your Life? Show 1407: Battling Superbugs with Nature’s Viral Warriors This Week’s Guests Nikki Schultek is Founding Director of the Pathobiome Research Center, and Research Assistant Professor at Philadelphia College of Osteopathic Medicine , Executive Director and Co-Founder of the Alzheimer’s Pathobiome Initiative (AlzPI), and Principal and Founder of Intracell Research Group, LLC. A former life sciences professional with Pfizer and Genentech, she now works to unite global researchers studying infection-associated chronic illnesses, including Alzheimer’s disease and other brain diseases. Following her own recovery from Lyme Disease, Chlamydia pneumoniae and co-infections, Nikki builds and leads patient-centered interdisciplinary research collaborations to examine microbial drivers of chronic diseases. She has catalyzed philanthropic funding to launch AlzPI research at multiple academic centers and co-lead authored a 2023 roadmap in Alzheimer’s & Dementia outlining a rigorous strategy to investigate infections in brain disease. www.PCOM.edu/research/pbrc www.AlzPI.org www.IntracellResearchGroup.com Nikki Schultek, founder and director of Intracell Research Group, LLC Brian J. Balin, PhD, is a tenured Professor of Neuroscience and Neuropathology at the Philadelphia College of Osteopathic Medicine. He directs the Center for Chronic Disorders of Aging (an Osteopathic Heritage Foundation Endowed Center), and the Adolph and Rose Levis Foundation Laboratory for Alzheimer’s Disease Research. An internationally recognized Alzheimer’s researcher, Dr. Balin has spent over 25 years investigating links between infection—particularly Chlamydia pneumoniae—and neuroinflammation, blood–brain barrier dysfunction, and neurodegeneration. His NIH- and foundation-funded work has significantly advanced the “pathogen hypothesis” of Alzheimer’s disease and Dr. Balin is regarded as a global expert and pioneer in this research field. Dr. Balin is a Co-Founder of The Alzheimer’s Pathobiome Initiative (AlzPI). Brian Balin, PhD, Philadelphia College of Osteopathic Medicine Listen to the Podcast The podcast of this program will be available Monday, March 23, 2026, after broadcast on March 21. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1466: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Chronic diseases continue to plague humans. We’re good at treating symptoms, but the root causes often remain a mystery. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:45 Are pathogens responsible for many of our most troubling and persistent conditions? We don’t think of heart disease, arthritis, or Alzheimer’s disease as having an infectious origin, but might they? Joe 00:46-00:52 Our guests today are studying the connection between infection and chronic disease. Terry 00:53-01:00 Not every pathogen is obvious. Some like to lurk inside cells where we have a hard time detecting and eradicating them. Joe 01:01-01:07 Coming up on The People’s Pharmacy, how hidden infections can lead to chronic disease. Terry 01:14-02:26 In The People’s Pharmacy Health Headlines: The American Heart Association and the American College of Cardiology have just issued new guidelines for preventing heart disease. For one thing, the experts suggest starting cholesterol testing much younger, possibly even in childhood. Younger adults, between 20 and 30, should aim for LDL cholesterol levels below 100. People at higher risk will be encouraged to get their LDL level below 70. Cholesterol is not the only risk factor addressed by the new guidelines. They also recommend testing for lipoprotein A, also known as LP little a. This is an independent risk factor for atherosclerosis. The cardiologists who compose the guidelines want their colleagues to use a new risk calculator that evaluates a much longer risk period than the previous calculator did. People with heart disease and those with diabetes need more intensive treatment than those at low risk. The guidelines also suggest measuring coronary artery calcium in cases where there’s any question about starting a statin medication to lower cholesterol. Joe 02:27-03:22 Harvard researchers and their Mongolian colleagues have just published a study of vitamin D3 supplementation during COVID infection. Patients from both the U.S. and Mongolia were recruited. Over 1,700 volunteers with newly diagnosed COVID-19 infections participated. They were randomized to receive either vitamin D3 or placebo. The dose of vitamin D was 9,600 international units for the first two days and 3,200 IUs daily for the next month. There was no difference in symptom severity or chance of hospitalization while people were taking the vitamin or placebo. There was, however, an intriguing hint that people who were taking vitamin D3 were less likely to develop long COVID after their infection. This reduction was not statistically significant, but the signal was strong enough that it deserves further study. Terry 03:23-04:28 For decades, doctors have prescribed metformin to help people with type 2 diabetes control their blood sugar. Some studies have suggested that this compound may also help reduce the risk of developing certain cancers. Now, researchers have analyzed data from five Nordic countries to compare 13,050 people newly diagnosed with esophageal squamous cell carcinoma to 130,500 healthy people of similar age and sex. Esophageal cancer is quite dangerous with low survival rates. The scientists report that people taking metformin had a 36% lower likelihood of being diagnosed with esophageal squamous cell carcinoma than those who were not. Higher doses were associated with even lower risk, about 48%. The authors note the observed association between metformin use and a significantly decreased risk of this cancer suggests a possible role of this drug in cancer prevention and treatment. Joe 04:29-05:14 Influenza cases are trending down at long last, though the CDC reports overall seasonal influenza activity remains elevated nationally. The agency notes that hospitalizations from influenza were the third highest since the 2010-2011 flu season. The CDC estimates that there were 27 million illnesses, 350,000 hospitalizations, and 22,000 deaths from flu so far this year. How well did flu shots work? Well, not so good. The H3N2 subclade K variant surfaced after the vaccines were in production, so the shots were far less effective than usual. Terry 05:14-06:17 Americans have made some important health changes over the last several decades. In particular, smoking is down dramatically. Life expectancy has improved over that time, except during the pandemic. Even before that, though, life expectancy in the U.S. had kind of flattened. Now, analysis shows that younger generations, born since 1970, have higher mortality from cancer, cardiovascular disease, and other causes than previous generations. If these trends continue, the U.S. could experience a sustained decline in life expectancy. And that’s the health news from The People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:34 And I’m Joe Graedon. Many of our most challenging conditions remain hard to cure. That’s because modern medicine has become very good at treating symptoms. We can ease the pain of arthritis, open airways for people with asthma, and overcome urinary tract infections with antibiotics. Terry 06:35-06:43 But we often don’t know what’s actually causing these chronic health problems in the first place. Is there a connection with hidden infections? Joe 06:44-07:18 To help us answer that question, we turn to Nikki Shultek. She’s founding director of the Pathobiome Research Center and research assistant professor at the Philadelphia College of Osteopathic Medicine. Nikki is also principal and founder of IntraCell Research Group and executive director and co-founder of the Alzheimer’s Pathobiome Initiative. She worked as a life science professional for Pfizer and Genentech at the start of her career. Then she had a devastating personal experience with chronic illness. Terry 07:19-07:22 Welcome to The People’s Pharmacy, Nikki Shultek. Nikki Shultek 07:22-07:27 Thank you so much, Terry and Joe, for having me. I’m incredibly grateful to be here today with both of you. Joe 07:28-07:43 Nikki, you have had quite a journey. Could you please share with our listeners your chronic illnesses associated with pathogens? Because I think this is still a field in evolution. What happened? Nikki Shultek 07:43-09:52 Absolutely. So I like to say my journey began 10 years ago, closing in on 11 years. And I went from being essentially a relatively healthy, athletic, I was a runner, mother of two children, enjoying my early 30s to being someone who was just one diagnosis after another, chronically ill. And if anyone has seen that show Mystery Diagnosis, it was sort of like that. I had about a dozen specialists helping me. And I, you know, really was unable to get a clear picture of what was actually driving the different diagnoses I had. So what I will fast forward with today is essentially I have what is known as infection-associated chronic illness. That is what was happening to me at the time. But at the time, I was just being diagnosed with one autoimmune condition after another. And I ended up having this terrible respiratory symptom. So I’d had asthma my entire life, and I developed something that was different than my typical asthma. Yes, my asthma had become incredibly severe suddenly, but also I had a symptom called air hunger, which was truly like a desire for oxygen. And this symptom came along with another odd symptom, which was one swollen joint in my finger. Terry 09:03-09:04 Huh, just one. Nikki Shultek 09:04-09:26 Mmm Hmm. At that time. And so I went to my asthma and allergy physician who had seen me for years. He said, oh, you must be having an asthma exacerbation. And I was totally, that’s a reasonable conclusion, right? Prescribed prednisone, which is not uncommon for people that have asthma. And unfortunately, 20 milligrams turned to 40, 40 turned to 80. Joe 09:26-09:27 Whoa. Nikki Shultek 09:27-09:52 And I continued to go the wrong direction with my breathing. And I got this rattle in my lung and I’m going, oh, my goodness gracious, what’s happening here? So I ended up, to make a long story short, with multiple pulmonologists just on the lung issue alone, a scan to look for pulmonary clots, pulmonary emboli. I was then subsequently having strange heart palpitations, found out I had developed an arrhythmia. Joe 09:53-09:55 And how old were you at that time? Nikki Shultek 09:55-09:57 I’m 34 at this point. Joe 09:57-09:58 So that’s pretty unusual… Nikki Shultek 09:58-10:00 Well, 33, about to be 34, yeah. Joe 10:00-10:04 …for a healthy, middle-aged woman who exercised? Nikki Shultek 10:04-10:40 Non-smoker, actually a runner. I had taken up running half marathons, so probably the best physical shape of my life. And my asthma had been previously very well controlled on GlaxoSmithKline’s purple disc, the Advair, for like years. Didn’t have an exacerbation or a serious turn in my illness. What happened next was systematically the illness spread around my body, essentially. And I went from having just respiratory symptoms to developing what is known as one of the top 10 most painful conditions someone can have, a bladder pain disorder called interstitial cystitis. Terry 10:40-10:45 Oh, yes. We have heard of this. It sounds awful. Nikki Shultek 10:45-11:37 Yeah, it’s essentially for the listeners that have had a urinary tract or bladder infection, it’s like walking around like that in perpetuity. And so when that happened to me, you know, I was quite frankly crushed. I had also started to become increasingly fatigued. I noticed cognitive symptoms. I noticed changes in my mood and my affect, which of course, now I’m walking around with difficulty breathing and bladder pain. And at this point in time, you know, it was really scary. My kids were just three and five. And I remember vividly the day my bladder pain began was on a Halloween morning. And later that day, trying to focus on just enjoying taking the little guys trick-or-treating in their cute outfits. And just being, you know, deeply concerned over why I had this pain. And the word idiopathic became my enemy. Idiopathic is a fancy way of saying we don’t know. Terry 11:37-11:38 Exactly. Nikki Shultek 11:38-12:23 Why, right? And I’m going, inflammation, inflammation. You know, I start thinking about this. And one thing that I noted was antibiotics. I ended up getting prescribed antibiotics for the terrible lung situation. People are very familiar with the Z-Pak. So that drug is azithromycin. I was placed on it first for 10 days. My air hunger went away. And then I relapsed. So they treated me again and again. And then I got a month-long prescription for that drug. And that kind of got my breathing in sort of like a serviceable but not great place. But at least I wasn’t gasping for air every night. And then the worst thing that happened to me during this horrible year was it was closer to my 34th birthday. I developed neurodegenerative symptoms that my primary care doctor thought could be MS. Joe 12:24-12:24 Wow. Terry 12:25-12:26 Oh, that’s scary. Joe 12:26-12:37 Super scary. I mean, that’s kind of a challenging diagnosis. As bad as you were, now all of a sudden somebody’s saying, well, maybe you’ve got MS as well. Nikki Shultek 12:38-14:14 Yeah, it’s one of the hardest things I’ve ever had to experience. I would truthfully go to church in sweatpants, sit out in the parking lot, and cry and pray in the parking lot because I felt like I was too much of an emotional wreck to go inside. At this point, I was, you know, when I thought that MS could be, you know, waiting for a neurology appointment, of course, you can’t get those very quickly when you’re a new patient. I had had a brain MRI and I just, I’ve, I, it never felt more of a sense of terror in terms of fear. And it was mostly fear because I was a mom, not like fearing my own existence, you know, being, you know, very limited and painful, but more so how it would impact my children and my husband. And so I started making plans someone in their early 30s shouldn’t have to make. I started, you know, writing things down that I, in case I lost more of my faculties, because I had previously worked for a pharmaceutical and biotechnology company. I knew a lot about medicine and health care, and I knew that I was an unwell person without a proper diagnosis. So at this point in time, once the desperation part kind of faded, it turned into this like sense of resolve, right? Like I accepted that I might have MS. I actually came to terms with that. I don’t, by the way. You know, I had no lesions on my MRI and didn’t feel like a really beautiful answer. It felt like, why am I still so sick, right? I didn’t really have an answer. I had knowledge. The neurologist said to me, well, it doesn’t mean you don’t have it. I see people like you all the time that may for 10 years have symptomatology, and then eventually they develop the lesions. Terry 14:15-14:17 Oh, boy, how helpful is that? Nikki Shultek 14:17-15:29 It was hurtful. It felt cold. And at that time, I remember saying, do you know anything about Lyme disease? And we’re in Connecticut. I was living in Connecticut at the time. I was at the Hartford Hospital. And he said, I don’t know much about that. And, you know, he could have just been having a terrible day. You know, I mean, health care is not an easy environment. And so I try to, my experience has taught me to approach everything with kindness and curiosity. You never know what someone is experiencing. But in a nutshell, what happened next was very important. I decided to turn into the researcher part of me. I was always an intensely curious person that loved science. And I wanted to live. So I did a Google search. And the first thing I looked up was actually atypical pneumonia and interstitial cystitis. One of my diagnoses with the respiratory issue was atypical pneumonia. Okay. And what came up was a study that saved my life. A small study. Dr. Charles W. Stratton from Vanderbilt, the late Charles W. Stratton, and a urology colleague of his, he had been studying this unusual bacteria transmitted through coughing and inhaling infected respiratory particles called Chlamydia pneumoniae. Terry 15:30-15:39 People hear Chlamydia, they think sexually transmitted infection. But that’s a different bacteria in the same family, in the same genus. Nikki Shultek 15:39-16:06 They’re relatives, and it’s the respiratory form. What people don’t realize is how common it is in the human population. It’s really ubiquitous, meaning we’re nearly all exposed to it in a lifetime. And I had never heard of it. And I read the study and it was sort of startling. It was a small cohort, a small group of women with my bladder pain diagnosis tested using PCR, which we all became very familiar with during COVID, right? Looking for… Joe 16:06-16:08 Polymerase chain reactions. Nikki Shultek 16:08-16:26 Indeed, Joe. And then they didn’t do typical urinalysis, which would never pick up on something like chlamydia because it has to live inside our building blocks, the human cells. So it wouldn’t be just floating around, free floating in the urine, and it wouldn’t be detectable this way. Terry 16:26-16:27 And you can’t culture it out of urine. Nikki Shultek 16:27-17:34 No, you can’t. So they did this PCR of the urine, and 80% of the women had evidence of Chlamydia pneumoniae. And the conclusion was this. The study’s too small to have any really meaningful results come from it, but that this organism can lead to chronic inflammation. And that got me deeply curious next. Oh, boy, I’ve had asthma my whole life. This is a chronic bacterial infection. So I did a search on PubMed for Chlamydia pneumoniae, the bacteria, and asthma. And I will say it changed the trajectory of the rest of my life. You know, I decided to start reaching out to the people publishing in the space. There were hundreds of thousands of publications on Chlamydia pneumoniae and asthma, and quite a compelling association with severe asthma, which I had been diagnosed with. And at this point in time, I ended up reaching out to some of the what would become today the founding members of a global team focused on interdisciplinary collaboration and the doctor, Dr. Charles W. Stratton, who saved my life, as well as the wonderful Dr. David Hahn, who spent his career studying infection and asthma. Terry 17:36-18:06 You’re listening to Nikki Shultek, founding director of the Pathobiome Research Center and executive director and co-founder of the Alzheimer’s Pathobiome Initiative. She’s also research assistant professor at the Philadelphia College of Osteopathic Medicine and principal and founder of IntraCell Research Group. As a former life sciences professional with Pfizer and Genentech, she’s now working to unite global researchers studying infection-associated chronic illnesses. Joe 18:06-18:09 After the break, we’ll learn more about C. pneumoniae. Terry 18:10-18:11 How did Nikki recover? Joe 18:11-18:16 Some doctors are quite wary about sustained antibiotic treatment. Why did they object? Terry 18:17-18:19 How long did she have to take the medicine? Joe 18:19-18:28 We’ll also talk about silos in medicine. How could we break them down so doctors could treat the root causes of illness? Terry 18:39-18:54 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 18:54-19:11 And I’m Joe Graedon. Terry 19:11-19:28 Many healthcare professionals have been taught that antibiotics can kill off most pathogens, such as Borrelia burgdorferi, within several days. That’s the bacterium that causes Lyme disease. For many patients, two or three weeks of doxycycline solves the problem. Joe 19:28-19:44 But there’s growing evidence that 10 to 20% of people who catch this bacterial infection experience post-treatment Lyme disease syndrome. Could this kind of infection connection also be responsible for many other health problems? Terry 19:45-19:59 The infection connection should not be a big surprise. People who catch chickenpox as children are susceptible to shingles many decades later. The virus hibernates in the body until conditions allow it to cause trouble again. Joe 19:59-20:26 Our guest is Nikki Shultek. She’s founding director of the Pathobiome Research Center and research assistant professor at Philadelphia College of Osteopathic Medicine. Nikki is also principal and founder of the IntraCell Research Group and executive director and co-founder of the Alzheimer’s Pathobiome Initiative. She has just described her personal experience with infection-related chronic illness. Terry 20:27-20:52 Nikki, that sounds like a really amazing and frightening situation that you were in. And now, as you have found out that Chlamydia pneumoniae is very common, what else did you learn about it? And how did you recover? Because it looks to us as though you’re doing much better today. Nikki Shultek 20:53-22:06 I am. So to fast forward a bit, Dr. Stratton, Charles Stratton from Vanderbilt, ended up diagnosing me officially with Chlamydia pneumoniae infection. I did have it. I also had Lyme disease and various co-infections that I acquired living in Connecticut. So I believe it was a multi-hit for me, quite honestly, Terry. It was a tipping point. I’d likely had the Chlamydia and Mycoplasma pneumoniae infections my whole life, having childhood asthma and a lot of illness, a lot of strep infections. And then, you know, multiple antibiotic therapy placed me in remission. And at the time, I was a little uncomfortable with the idea of using multiple antibiotics for a prolonged period of time. However, Dr. Stratton, being an unbelievable educator, provided me with evidence to suggest that in certain severe cases, particularly when neurodegeneration was at hand, and that was the symptomatology that I was really most worried about, that it could be warranted when the risk of the disease outweighs the risk of the treatment. And so I’m very lucky to be here and be well and have found an answer to it. Although I will say I’m not as well as I was before all of this happened to me. I have to take quite good care of myself. Joe 22:06-22:23 The idea of sustained antibiotic treatment is a little challenging for most physicians, including some of the infectious disease experts, because it’s like, well, 10 days, one and done, you know, you should be fine. And you weren’t fine. Terry 22:23-22:37 Well, and of course, they worry about antibiotic stewardship and what will we do when, not if, but when all of the antibiotics we currently have available lose their effectiveness. Joe 22:37-22:47 So how long did you have to take, for example, azithromycin, Z-Pak, and some of the other antibiotics to finally rid yourself of these pathogens? Nikki Shultek 22:49-25:12 You know, my answer will not be appealing to some. I’m not really of the belief based on the literature and our research that you can actually get rid of some of the infections once they have been on board. So people are very familiar with the use of long-term antibiotics and physicians are comfortable with it in certain settings. And it’s a bit nonsensical. If you ask me as a patient, you can have prolonged doxycycline or minocycline for acne, many years of therapy. For chronic urinary tract infections that are recurrent, patients will be placed on antibiotics in perpetuity at times. They’re used for chronic obstructive pulmonary disease, which can be very serious. They are used for asthma. We have a 3,200 patient clinical trial enrolling. One of the study sites is Chapel Hill as we speak. That’s called I Treat PC. But then for people suffering with neurodegenerative symptoms and crippling bladder pain and, you know, that it could be considered potentially controversial, and that comes to a bigger problem. And Terry, you mentioned stewardship. So I had the privilege at Pfizer to work in the antibiotic space. I launched a drug for MRSA infections, which is that drug-resistant staph. And I used to attend ID grad rounds, which is the infectious disease specialists, you know, Uber meeting where they talk about tough cases and learning. And I loved it. I was very disturbed by the idea of taking prolonged antibiotics when it was suggested to me by Dr. Stratton. And he knew my background and he was an infectious disease specialist and a medical microbiologist. But you have to actually, when you talk about stewardship, you have to stay in reality. 80% of antibiotics in the United States are used in agriculture. Okay. So the animals. Absolutely. So you should not prescribe antibiotics to people that have upper respiratory tract infections that are viral, right? That’s the low-hanging fruit for stewardship. And it’s not to say that it’s not important, but I do believe the emphasis on stewardship has led to under-treatment of certain very detrimental infections, including the bacteria that causes Lyme disease, Borrelia burgdorferi. And it’s an economic problem. Antibiotics are not profitable. And so this has been a really, you know, where understanding the business side of things is critical for me in my current work, you know, building research collaborations to unravel how infections can drive chronic diseases with emphasis on the brain is understanding the economics that are at play and the politics. Joe 25:12-25:19 And sometimes you have to take these antibiotics, not for weeks, but for months, and in some cases for years. Nikki Shultek 25:19-26:19 Yeah. So for me, just to answer your earlier question, for a number of years, I had multiple antibiotics. My case has been constantly evolving like many patients like me. Because of my enrollment in a IRB study at North Carolina State, I learned I have chronic babesiosis, which is a chronic parasitic infection that is transmitted by the same tick that I likely got Borrelia burgdorferi, Lyme disease bacteria from. This little sneaky parasite likes to hang out inside your red blood cells. And it is the likely culprit of my air hunger 11 years ago. That was a symptom that never made sense indeed, because asthma doesn’t normally, my asthma, the etiology of it, it had never had air hunger. And I remember saying to my doctor, something is different here. And that is the thing that I’ll, I like to impress upon people listening that could have illnesses. You as the patient have an intuition and a level of intimacy with what your body is experiencing. And you need to find a clinician that listens and hears you and sees you. Terry 26:19-26:28 So you have the experience of what your body has done before, and you need to pay attention when it does something different. Nikki Shultek 26:28-26:59 Absolutely, you do. And for me, unfortunately, I have previously relapsed any time antimicrobial drugs have been removed. So I have a maintenance therapy plan with my doctor, and I’m very fortunate that I actually have because Dr. Charles Stratton passed away four years ago. I’m under the care of a ILADS physician, International Lyme and Associated Diseases, which is the only infection-associated chronic illness practitioner group in the world. Joe 26:59-27:39 One of the problems that we’ve encountered over many decades of interviewing a variety of patients and physicians is the silo problem. So there are specialists, super specialists. And the cardiologists may not be talking to the infectious disease experts. And the dentists may not be talking to the cardiologists. And so you have all of these different specialties and the dentists are saying, well, yes, you do have gum disease, but they’re not talking to the cardiologist to say, well, if there’s a gum infection, that may be affecting the heart valves and that may be affecting the vessels in the heart. Terry 27:39-27:46 And of course, we know, but cardiologists don’t always remember that Lyme disease can affect the heart as well. Nikki Shultek 27:47-30:55 Absolutely. Joe and Terry, such an astute observation. And literally what you just said encapsulates my observation as a patient, a human hockey puck, as I call it, going through the medical system, being passed from one specialist to the next to address these different bodily systems that were all not working properly, you know, including my food stopped digesting properly during this horrible year. So now I’m having a colonoscopy. No one was talking to each other. And I remember thinking, who’s going to piece it all together? There’s an underlying driver. And so when I found the information about chronic infection and illness, it made so much sense. And then, you know, talking with Dr. Stratton, Dr. Hahn, and beginning to informally, in a grassroots manner, start bringing people together, I had this thought. It wasn’t a new thought for me. I had always been a collaborative person. And in my time in pharma and biotech, I was working in this manner, too, trying to connect stakeholders so that we could advance outcomes for patients. Well, what I decided I could do to help when I went into remission on the multiple antibiotics, I knew I needed to help, right? This is a huge problem. I wondered how many MS cases were indeed infections that were undiagnosed. So I knew we needed to advance research around it and raise awareness. And I thought the best thing I could start doing was introducing these folks to one another if they didn’t already meet. So the infection and asthma people with the infection, looking at bladder pain disorders, looking at neurological disorders, looking at musculoskeletal or, you know, joint disorders. Let’s start there. And I like to joke that we arrived to the space on the chlamydia train, this bacterial infection. Most of the people in the initial group, which was started in 2017, IntraCell Research Group, by me. And, you know, it was really to begin introducing folks to one another. I didn’t know what it would turn into, quite honestly. I’d been a stay-at-home mom for eight years. And, you know, I’d been extremely ill. And the idea of research collaboration was born, multidisciplinary research collaboration. Fast forwarding to today, in 2023, I had the privilege with a number of amazing colleagues from around the world, incredibly diverse in experience in all ways, the Alzheimer’s Pathobiome Initiative. And I guess I’ll start by saying, what is a pathobiome? So people know microbiome. And I think the word microbiome gives off kind of like a fuzzy, warm vibe of like everyone collaborating with one another, kind of like my team, you know, commingling happily. The pathobiome is your unhappy state. It refers to potentially, you know, different infections or organisms that might be in your body that now for one reason or the other are having a bad reaction with your immune system. They’re making your immune system angry. And so the pathobiome, I sometimes refer to these as the organized criminals. You know, they’re infections that become disproportionate and can cause inflammation and other consequences. So this idea of a pathobiome takes into account each unique response that a person’s immune system can have to an infection. And we saw this with COVID. Some people got little to no symptoms, tested positive. Other people died. Terry 30:55-30:55 Yes. Nikki Shultek 30:55-30:57 Some people remain ill today. Terry 30:57-30:58 Yes. Nikki Shultek 30:57-31:48 It’s the number one pediatric illness. It surpassed asthma as the number one chronic illness in kids is long COVID. So this research consortium of ours is comprised of, we have Dr. Ed Breitschwerdt, who’s a doctor of veterinary medicine. We have microbiologists, people focused on fungi, like Dr. David Corey, who’s also an immunologist. We have folks like Dr. Brian Balin, focused on intracellular bacteria, virologists like Kevin Zwezdaryk, neuroscientists like Dr. William Eimer, respiratory infection experts like Dr. David Hahn. And our team has more than 30 people globally collaborating actively with one another in order to essentially accelerate innovation and raise awareness, but also to bridge silos. Terry 31:49-32:05 Nikki, you have mentioned that you have this international collaboration. You’re looking at conditions that may be caused by the pathobiome. And I’m wondering if you could outline for us a few of those potential conditions. Joe 32:05-32:08 And in particular, perhaps Alzheimer’s disease. Nikki Shultek 32:09-34:24 Absolutely. So our Alzheimer’s Pathobiome Initiative team is actually working quite broadly in brain disease and infection. So over the holidays, we received a grant to study actually five brain diseases in relation to infection. ALS, Alzheimer’s, Parkinson’s, epilepsy, and conditions that affect children called PANS and PANDAS. These are pediatric neuroimmune infectious syndromes that can lead to perfectly healthy children having literally crippling anxiety, OCD, and some of these children die. So we take this incredibly seriously. Some of the infections that have been associated with Alzheimer’s disease and other diseases, and this is an important distinction. We believe it’s so important to look at the whole human lifespan, at the diseases that are occurring that are associated with infections. That’s everything from MS to schizophrenia, you know, two diseases typically associated with advanced age. And it’s literally pathogens from every category. Parasitic infections like Toxoplasma gondii have been linked with schizophrenia, have also been linked with Alzheimer’s disease. It’s organisms like herpes viruses, HSV-1 and HSV-2, the cold sore virus, that has been linked very strongly with Alzheimer’s disease and other chronic neurological and chronic illnesses. Chlamydia pneumoniae, of course, is strongly associated with Alzheimer’s disease, but also asthma, atherosclerosis, multiple sclerosis, reactive arthritis. There are also fungi that have been associated. Indeed, when we published our research roadmap for the AlzPi team, the Alzheimer’s Pathobiome Initiative in 2023, we identified 86 cases of infectious dementias of all different types in which some of these were reversible with antimicrobial therapy. One of them was a stunning case of a person with a healthy immune system. They did not have HIV that got a rare fungal infection called Cryptococcus neoformans, and this person ended up getting antifungals and getting better. Their neurodegenerative symptoms went away. Terry 34:24-34:51 Nikki, I’m so excited that you have taken your vast and deeply unpleasant and frightening experience, and turned into a researcher. So you are a patient. You are leading a research collaboration. Tell us more about patient-led research because I think it’s not widely appreciated that patients can do this. Nikki Shultek 34:51-36:25 Absolutely. I have had such a privilege to learn over the last decade and to try to turn, you know, pain into purpose, truly. And I’m not alone by any stretch of the imagination. There are quite a few people out there like me that have not only had these journeys, but then become subject matter experts in a domain, can even be rare disease. You see this quite a lot. You see parents like me, you know, looking for a better future for their children. And thus, what is the greatest motivator? I think it’s love. And so out of love, I think patients can become an unbelievable tool to researchers and become researchers themselves, which is the case for me. I was very privileged that our president, Dr. Jay Feldstein at PCOM and Dr. Brian Balin, with whom I’ve collaborated for nearly a decade, saw the value in, you know, me becoming a, you know, bona fide member of the research team. I’m publishing in the space with the researchers. I’m creating, you know, and generating hypotheses, serving as a principal investigator on NIH submissions. It is the gift and blessing of a lifetime. And I think that, you know, more purposeful integration and patients having a seat at the table, knowledgeable patients. There’s a book that I read called Range by David Epstein that I’m absolutely obsessed with, and it talks about remaining a generalist and how patients, actually, there are chapters of the book, whole chapters, about how patients and their experiences led to transformative change in particular disease domains. Joe 36:28-36:50 Nikki, there’s a term that is used throughout medicine that ends in “-itis.” And “itis” means inflammation. And so we’ve got arthritis, bronchitis, colitis, sinusitis, dermatitis, gastritis, myocarditis, which is the heart, and cystitis. Terry 36:50-36:52 And lots of other “itises” as well. Joe 36:53-37:15 You know, the pharmaceutical industry, of which you once were a part, has become extraordinarily successful at dealing with “itis” conditions. Not the root cause, mind you, but the inflammatory reactions. So there are IL-2s and IL-4s and IL… Terry 37:15-37:17 What does IL mean, Joe? Joe 37:17-38:10 Interleukins. These are anti-inflammatory drugs and they’re impacting the immune system, which is why when you look at the commercials on TV for the rheumatoid arthritis drugs and the inflammatory bowel drugs and, you know, name it. The psoriatic arthritis drugs, they all say, well, yes, you could catch a bad infection, and that infection could be very dangerous, oh, and possibly cancer. And you’re talking about attacking the problem downstream, at its earliest phase rather than at its ultimate phase when people are already in terrible shape and in pain and inflamed. Can you help us better understand what you’re trying to accomplish by ‘the root cause’ and dealing with that, rather than the end result? Nikki Shultek 38:11-38:42 So what you said is so astute about the commercials on television, you know, with the various drugs. My children who, of course, you know, get to talk with me about various topics all the time in science. They both enjoy science and they drive me. You know, it’s my boys that really push me forward to help, you know, motivate me on a daily basis to make the world better. They’re 14 and 16. They’ll go, “Mom, didn’t you say that some of these conditions can be triggered by infections? And the commercial says if you have an ongoing infection, not to take the drug. Isn’t that….?” So it’s so funny. Terry 38:42-38:44 How smart of them. Nikki Shultek 38:46-40:23 Another favorite question of my son, “Mom, if there’s a vaccine for human papillomavirus that can prevent cancer, wouldn’t we look at other viruses and other bacteria and cancer?” This was when he was 12. I was like, yes, and please do that for the rest of your life. Ask those questions. So, you know, what’s really interesting is what we talk about isn’t just limited to infection, right? There are other potential root cause drivers. We talk a lot about the exposome, which is your exposures across the human lifespan, not just germs, but pollutants, toxins, your diet, etc. We think these things are all important root causes to look at, inclusive of infection. But infection is, just so you know, the number one driver of any “itis” in the human body. And that is not me saying that. That’s in medical text sort of 101. If you look up inflammation in the National Library of Medicine on NCBI, you will see that the number one thing should be ruled out as an infection with any “itis.” We believe, though, here’s an interesting caveat. So with diseases which have been accumulated over a lifetime, right, like Alzheimer’s disease, multiple hits potentially with different pathogens, different infections that come and go, relapses, we may indeed need some of those other drugs that were developed targeting various pathways as a multifaceted approach, because it’s not to say that the immune reaction isn’t harmful. It can be. And that’s the caveat and the reason we believe it’s so important to have the immunology perspective and the diversity of these silos bridged while understanding infections because it may need to be a multifaceted approach like the way that we approach sepsis. Terry 40:24-40:51 And as you’re talking, I’m thinking about the early part of your story in which you’re describing that you are having such difficulty breathing and they kept increasing the dose of prednisone that you were on. And I’m thinking prednisone. Prednisone interferes with the body’s ability to respond to pathogens. So counterproductive, no? Nikki Shultek 40:51-41:23 Absolutely. In my case, it absolutely was that time. And again, I don’t fault the clinicians. Actually, you have to fault the whole system, right? So in Connecticut, the state where Lyme, the town of Lyme is literally situated, you know, if you ask the majority of clinicians, what would you think if you saw someone with air hunger that had prior asthma, but they’re telling you it’s different and one swollen joint? They should be thinking tick-borne illness. They should know that babesiosis has a hallmark symptom of air hunger. Terry 41:23-41:26 And Borrelia, perhaps, or just babesiosis. Nikki Shultek 41:27-41:51 Really it’s clinically significant for Babesia. And the most common one is Babesia microti. And that is what I have confirmed by North Carolina State, direct detection, so not antibody-based testing. So, you know, this is what’s key really is the education, but it’s across the whole spectrum. It’s patient awareness, it’s clinicians being educated in medical school. So there needs to really be a sea change. Joe 41:52-42:34 So I do have a pet peeve, and that is the infectious disease experts should be embracing your research, should be really excited about the idea that infectious agents could be responsible for a great many chronic conditions. And yet, a lot of the infectious disease experts seem to be obstructionists. Like, oh, no, there’s no such thing as long Lyme. And no, this thing about chronic fatigue syndrome, it’s all in your head. Terry 42:34-42:45 And ILADS physicians, you’ve got to be very careful about them, right? That’s what some of the infectious disease experts have been telling us. They may be changing their tune now. Joe 42:45-42:53 But how do you convert the ID, the infectious disease experts, from skeptics to allies? Nikki Shultek 42:54-44:59 It’s such a great question. So if you look at medical history, it just sort of repeats itself. This is human nature 101. When doctors Warren and Marshall, you know, they eventually win the Nobel Prize for linking a bacteria in the gut called Helicobacter pylori or H. pylori to the development of ulcers; for like a decade prior, they were called madmen. And these are by the thought leaders in the GI space. So thought leaders, human nature is, you know, to attach ourselves to something. If we have a hammer, we want to see nails. And we have to become super aware of this. We try to be aware of this all the time as a research team, not to drink so much of our own Kool-Aid that we don’t see other ideas as being important. The infectious disease, you know, sort of gaslighting of the chronic Lyme issue, I believe is about to change. You know, we have the current administration, HHS, Secretary Kennedy, Dr. Jay Bhattacharya, Marty Makary, and Dr. Oz all saying, you know, they’re emphasizing Lyme. So there are some very exciting developments happening. That was beginning December 15th, 2025. And I do believe that there has to be adequate patient pressure and advocacy, very much like how HIV is now something that one can even prevent getting, right? There’s a preventative. You can have HIV. There has been such a huge federal investment due to a patient-led movement, right? Now, HIV hurts people fast and really it’s very virulent and very quick if unopposed. And so it was so blatant, right? But even if you read back on the history of that, that required quite a movement from patients. Lyme and these infection-associated chronic illnesses are more like the simmering pot not boiling over. You know, it’s a chronic inflammatory process. It makes the person miserable, may rob them of quality of life, but they may not imminently die from it. And thus, it sort of has been underemphasized. But I do believe it’s changing. Joe 45:00-45:44 I do have a particular question about cardiology, because if you were to poll 100 cardiologists, 99 out of 100, maybe 100 out of 100 will tell you heart disease is caused by cholesterol, in particular, LDL cholesterol. And if you ask them, well, what about LP little a? They’ll go, oh, yeah, yeah, that’s coming along, and we’re getting a drug for that. And so, yes, we’re paying more attention because one out of five patients, they do have elevated LP little a, lipoprotein A. And then if you ask the question, what about gum disease? What about those bacteria that cause… Terry 45:45-45:46 Periodontal disease? Joe 45:46-45:48 Yes. What about those bacteria that cause… Terry 45:48-45:50 Porphyromonas gingivalis? Joe 45:51-45:51 That cause, yes. Nikki Shultek 45:52-45:52 Gingivitis. Joe 45:52-45:53 Gingivitis. Terry 45:53-45:53 Yeah. Joe 45:54-46:00 They look at you like you’re from Mars. Like, well, yeah, well, that’s not that important. Terry 46:01-46:04 But actually, the research establishes a pretty strong connection. Joe 46:05-46:06 So this idea… Nikki Shultek 46:05-46:06 Very compelling. Joe 46:06-46:20 …that infection could be connected to cardiovascular disease, it seems alien to the cardiology community and to the infectious disease community. How do we begin to change that? Nikki Shultek 46:21-47:15 We’re, I believe, and I am an eternal optimist, so take this with a grain of salt, we’re at a tipping point right now in history. There are so many favorable things happening in this space all at once, not just our work, but others. For example, a $49 million National Institute of Aging grant just went to a company developing a therapy targeting Porphyromonas gingivalis and targeting gingipains, which is the virulence factor that is believed to assault the brain. Now, you mentioned gum disease. That bacteria, Porphyromonas, actually can affect how your blood-brain barrier that’s supposed to provide protection, it impacts it negatively. It also has been linked with, as you pointed out, other conditions. And so the federal investment for this, I think, is a big signal that this particular company, Lighthouse Therapeutics, has that support is evidence of a shift. Terry 47:16-47:38 So the blood-brain barrier is supposed to keep stuff that doesn’t belong in the brain out of the brain. And you’re saying the impact of Porphyromonas gingivalis is to essentially make it more permeable, sort of like some infections make the intestines more permeable, and you get intestinal permeability, also known as leaky gut. Nikki Shultek 47:39-48:30 Indeed, yeah. Permeability of barriers is a big issue. One of the things that we’re studying within AlzPi and we have grants to look at is why are women two-thirds of Alzheimer’s cases? And we know that estrogen actually helps the immune system and that as women age, we lose estrogen and barriers of different types become less sufficient. We have not enough information on what happens to the blood-brain barrier. But I want to add the caveat is this. I heard at the National Academies when I presented, one of the other speakers referred to it as a portal. Indeed it is. It’s not really a barrier as much as it is a passageway that should be selective. Now our immune cells can traffic in and out through the blood-brain barrier. And if you have an infection like a virus or a Chlamydia pneumoniae or a Borrelia burgdorferi or Bartonella henselae inside your immune cell, it’s like a Trojan horse. Terry 48:30-48:32 Right. It would be exactly. Joe 48:33-48:49 So Nikki, as we wrap up our conversation, what would you like our listeners to take home as the message when we start speaking about the infection connection with all of these conditions and all of these nasty pathogens? Nikki Shultek 48:50-50:03 You know, just to read and educate yourself as much as you can. I realize that having certain educational level is a great privilege. Our team tries to write op-ed pieces, not just medical literature. You know, it’s a passion of mine so that it increases the accessibility of information. Always trust your gut. If you don’t feel heard by a physician, find another physician. You are, indeed, your instincts are, they can be very correct. And that if you need help with something that you think could be an infection-associated chronic illness, there are ILADS physicians, www.ilads.org. There’s a provider search with the caveat, many of these physicians do not accept insurance. That is a challenge. That’s one thing that I really hope that Health and Human Services and RFK Jr. can help impact changes is how the payers, you know, reimburse for complex chronic illness triggered by infection so that other physicians can do what the ILADS doctors do and get training like the ILADS doctors have provided. And so really look for and consider root causes. Joe 50:03-50:15 And if we put you in charge of medical education today, what would you like to tell all of the physicians and nurse practitioners and physician associates who may be listening, what should they be learning? Nikki Shultek 50:16-51:31 I think they should have infection-associated chronic illness in the differential. When they are presented with a patient that has multiple idiopathic disorders particularly, and if they’re waxing and waning, not to immediately go to a purely psychiatric diagnosis. Although I would argue that the field of psychiatry is riddled with evidence that infections can indeed impact our behaviors, such as the development of OCD from Streptococcus infection in kids with PANDAS. Overnight, suddenly, you have a kid that’s counting. So I think looking for infections, but then that gets to another caveat, which is what tests you order. So we do need better testing for some of these infections, but serology or, you know, looking simply for antibodies, antibody-based testing for herpes viruses, for Mycoplasma pneumoniae, Chlamydia pneumoniae, a tick-borne panel, which is offered by Quest or LabCorp, it’s a place to start. There are better labs, one right here in North Carolina, Galaxy Diagnostics, offering, you know, world-leading tick-borne infection testing. However, you know, it’s outside the bounds of insurance is a challenge. IGeneX, too, out in California. But, you know, again, these are barriers for patients where they won’t be able to access it, and that’s not okay. Joe 51:33-52:00 As you begin to look to the future, because you’ve described a whole bunch of conditions where there are specialists in each area in their silos, not talking to one another very effectively. What would you like to see for the future? What is your hope for your initiative, in particular around Alzheimer’s disease, but some of these other conditions as well? What does the crystal ball tell you? Nikki Shultek 52:00-52:42 We really need a large federal investment from the National Institutes of Health. I don’t know that all Americans realize, but the most powerful engine for medical innovation in the entire world is our National Institutes of Health, our government. You know, the emphasis has to be on funding this type of work. And we call that team science, and so does the NIH. There are certain mechanisms, you know, that allow research teams like ours that are incredibly diverse. And just to let everyone know, I did found a center at the Philadelphia College of Osteopathic Medicine a year ago. It’s called the Pathobiome Research Center. We essentially need more philanthropists and the government to step up to fund work that allows teams like ours to unlock root causes of these diseases. Joe 52:43-52:47 Why is the root cause so important in the 15 seconds we have left? Nikki Shultek 52:48-53:11 It is that we stop focusing on the downstream effects. You know, a lot of drugs that you see today predominantly are targeting various pathways to intercept downstream effects that are largely inflammatory or pathology. You know, like let’s target the plaque in Alzheimer’s. Targeting the root cause allows us to understand why the human immune system developed that response in the first place and allows us to intercept. Terry 53:13-53:17 Nikki Shultek, thank you so much for talking with us on The People’s Pharmacy today. Nikki Shultek 53:18-53:22 It has been an absolute pleasure. Thank you for helping us shed light on these issues. Terry 53:23-54:02 You’ve been listening to Nikki Shultek, founding director of the Pathobiome Research Center and executive director and co-founder of the Alzheimer’s Pathobiome Initiative. She’s also a research assistant professor at the Philadelphia College of Osteopathic Medicine and principal and founder of Intracell Research Group, LLC. She was previously a life sciences professional with Pfizer and with Genentech. Now she’s working to unite global researchers studying infection-associated chronic illnesses, including Alzheimer’s disease. Joe 54:03-54:10 After the break, we’ll turn to Dr. Brian Balin, an internationally recognized researcher on Alzheimer’s disease. Terry 54:10-54:23 We’ll find out how he took a different path from most Alzheimer’s disease scientists to focus on the infection connection rather than considering amyloid accumulation as the prime mover. Joe 54:23-54:32 C. pneumoniae is bad for the brain, but it might not be the only pathogen with long-term impacts. What else has Dr. Balin studied? Terry 54:32-54:38 Might there be bacterial origins for many chronic diseases? Could this change our treatments for heart disease and stroke? Joe 54:39-54:42 Find out more about the pathobiome and the infection connection. Terry 54:48-55:04 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 55:04-55:20 And I’m Joe Graedon. Terry 55:21-55:42 Can hidden infections lead to chronic disease? A few examples are quite well known. For example, the bacterium Helicobacter pylori causes stomach ulcers that in turn can lead to gastric cancer. And gum disease caused by Porphyromonas gingivalis has been linked to heart disease and even Alzheimer disease. Joe 55:42-56:09 We just spoke with Nikki Shultek about her experience and her work on hidden infection and chronic disease. We turn now to her colleague, Dr. Brian Balin, professor of neuroscience and neuropathology at the Philadelphia College of Osteopathic Medicine. He directs the Adolf and Rose Levis Foundation Laboratory for Alzheimer’s Disease Research and the Center for Chronic Disorders of Aging. Terry 56:10-56:13 Welcome to The People’s Pharmacy, Dr. Brian Balin. Dr. Brian Balin 56:14-56:16 Thank you very much for having me talk today. Joe 56:18-56:56 We look forward to speaking with you. We have just spoken with Nikki Shultek about her experience. It was quite enlightening. But I’m wondering if you can put everything into perspective because for decades now, neuroscientists such as yourself and researchers within the pharmaceutical industry have focused on what I call the amyloid garbage disposal approach when it comes to Alzheimer’s disease. And you’re moving towards the infection connection approach. Can you put us in perspective of what has changed? Dr. Brian Balin 56:56-01:00:04 Yes. So years ago, we, through a lot of serendipity, came across an issue about [an] infectious agent. The one in particular that I’ve been studying is a respiratory Chlamydia organism called Chlamydia pneumoniae. And we found that this organism was in brain tissues that were examined postmortemly from Alzheimer’s individuals, or people that died from Alzheimer’s disease. And we felt that there was some issue here with this particular infectious agent being in the brain tissues of these individuals. And over time, what we’ve realized is that this type of infectious agent can actually enter into brain tissues through our sense of smell, but also through the blood-brain barrier. And we think that it actually acts as a trigger for the early pathology that occurs in Alzheimer’s disease. And the early pathology that shows up is in the area of the brain called the entorhinal cortex, where you have direct input from the olfactory system, which basically is coming from our… originating in our noses through our olfactory nasal epithelium, olfactory neuroepithelium. And because of that issue, we think that infectious agents actually can be the triggering type of process or lead to a triggering type of process that can actually lead to early change in the brain. And in this case, leading to the pathology, the early pathology of Alzheimer’s disease. Now, this is in contrast to others that have studied the amyloid hypothesis for years, the amyloid cascade hypothesis. And that all originated from evaluation of genetic Alzheimer’s disease or familial Alzheimer’s disease, which is about one to three percent of all the people that get Alzheimer’s disease having that form. And that originated from looking at those individuals and determining that there were genetic mutations that led to the deposition overall of the amyloid peptides that accumulate in Alzheimer’s disease very early on. Well, in our work, we also see those same amyloid peptides accumulating early on in brain tissues. And we’ve also seen that infection can actually turn on cells to process the larger amyloid precursor protein into these peptide forms. So now we have a contrast. One is a genetic process that leads to this pathology, and the other is an infectious process leading to pathology. And this is why we think this is an underrepresented arena of understanding how infectious agents, and there may be many, that actually can lead to the same type of disease entity. Terry 01:00:06-01:00:18 So you’re suggesting that this bacteria, Chlamydia pneumoniae, is not the only pathogen that might be affecting the brain? Dr. Brian Balin 01:00:18-01:01:45 That’s correct. So we think that of the work that’s been done over many, many years, there’s been evidence for the herpes simplex virus 1. There’s been evidence for Borrelia burgdorferi, the agent of Lyme disease. There’s evidence for SARS-CoV-2 to actually be involved as well. And then there are oral organisms. There could be systemic organisms. There could be gut organisms that could also be involved. But what’s interesting about what we found was that this type of organism, this Chlamydia pneumoniae, is an intracellular bacterium. So it’s going to act very similar to a virus, actually, where it infects inside of our cells. Once it’s infected inside of our cells, it’s hidden from the immune response, just like the herpes virus would be or other types of viruses. If these migrate into our brains, and also this would include also the SARS-CoV-2 virus, if these migrate in, they can then stimulate change in the cells within the brain proper. And this could be anywhere from changing the infected cell itself or getting response from the glial cells like the microglial cells that would lead then to an inflammatory response that would also then lead to more damage within the brain. Joe 01:01:46-01:02:26 Dr. Balin, you just said something that sends shivers up and down my spine, and that is SARS-CoV-2, i.e. COVID. I mean, tens of millions of people in this country and hundreds of millions of people all around the world have caught COVID. And the question that you’re sort of raising is, well, will some of them develop Alzheimer’s disease as a result of this, what we’ll call viral infection that has really affected the whole wide world? Dr. Brian Balin 01:02:27-01:04:00 Yes, this is one of our greatest fears is that this is opening the scenario that there could be millions on the globe that may be destined for this type of change. And it may be that it’s not just from the SARS-CoV-2 virus, but also from other agents like what we’ve also found that are acting in concert with one another. And then you have the inflammatory response itself. If it’s generated and it’s maintained in a chronic fashion, now we have a chronic, potentially smoldering type of process that is occurring quite readily, I think, could be occurring in our brains without us knowing it because we are not having obvious symptomatology. Now, with the SARS issue and COVID issue, brain fog, memory issues, long COVID, these are things that may be giving us a clue that something is more chronically developing, along with then these other insults that are potential in our environment. For instance, pollution, air pollution, particulate matter, the diets that we have, the genetic risks that we have. These may be acting in concert to now drive the process, unfortunately, into a neurodegenerative arena leading to a dementia. Terry 01:04:01-01:04:07 Dr. Balin, I wonder if you would tell us about your recent research collaboration with Cedars-Sinai, please. Dr. Brian Balin 01:04:09-01:06:22 Yes. So with the Cedars-Sinai’s work that was led by, or coming out of Tim Crother’s lab, we actually aren’t collaborating directly with them. However, our work really is compatible with what they’re finding with the Chlamydia pneumoniae organism in the retina. So this organism, this goes to the organism’s ability, we believe, to actually become systemic as well. Once it’s inhaled into the lungs, this organism can be picked up by white blood cells that are surveilling all the vasculature in the lung tissues. And if it’s picked up this way, now you can traffic the organism within the white blood cell because the white blood cells will phagocytize the organism inside and traffic it around the bloodstream. So we think that that’s one of the ways that it’ll get into the vessels throughout the body and can also show up in the retina. The other aspect of this is that in atherosclerosis, in cardiovascular disease, the Chlamydia pneumoniae organism has been recognized and involved and sought to be involved with aspects of that disease leading to the atherosclerotic process. So we know that this organism is one of those insidious types of organisms that can traffic around the body and use multiple mechanisms for actually getting into tissue sites. So the Crother work is very significant and really follows from a lot of the early work we did where we found that the organism in human tissues, now we didn’t identify it in retina per se, but we found it in the olfactory regions of the brain, of human brains, and deeper in the brains themselves in Alzheimer’s disease. But we also did animal modeling. And with animal modeling, we showed that the infection with this organism intra-nasally can get into the brain very quickly, but also they can get into the bloodstream fairly quickly. Joe 01:06:22-01:07:15 Well, Dr. Balin, I’d like to just ask you the implications of this research, because it sounds like, well, if this nasty pathogen, C. pneumoniae, is getting into the brain, but also circulating through the body and maybe getting into the heart, there may be a bacterial origin for a lot of our chronic diseases. I think most cardiologists blame you know, LDL cholesterol, but maybe there’s a bacterium that is also contributing to atherosclerosis and maybe to strokes. How do we begin to change our mindset to recognize that chronic infection may be contributing to a lot of our ailments? Dr. Brian Balin 01:07:15-01:08:53 Well, it’s an excellent question. And I think what we need to do is to start having a better diagnostic approach to this question. And this would be something that we need to actually start instituting into the population at a much earlier age before any symptomatology actually starts to accumulate or starts to manifest. And this goes to the sampling issue. So how do we sample for these types of agents? The typical sampling approach would be to look for a presence of antibody responses in the bloodstream to these different types of agents to see if we’ve been exposed that way, to see if antibodies have been developed to the organism. But we should be also sampling saliva and urine along with blood and maybe even doing nasal swabbing as well for some of these organisms too, as these are routes of entry into our bodies. The other could be even stool sampling, for instance, and for instance, with the COVID issue, we found that the SARS virus, SARS-CoV-2, was showing up in wastewater. And these are ways then that we could actually evaluate different types of fluids from an individual to actually evaluate what is on board in a particular individual and whether those ingredients that are on board have been identified with other chronic issues that have shown up in the population. Joe 01:08:53-01:09:05 So really quickly focusing on the outcome, it sounds like if we can identify these pathogens, we might be able to come up with treatments such as antibiotics. Dr. Brian Balin 01:09:05-01:10:25 Yes. And the antibiotic approach would be probably the original approach to be taken. I actually think, though, that we may be able to also manipulate our immune responses. Now, could that be through vaccines? It could be that as well. It could also be through phage therapy, for instance, for some of the bacteria, where phage therapy, different types of bacterial phages or viruses that infect bacteria actually can be and are being designed, by the way, to actually change how an infectious agent could actually propagate in us so that it could be a phage that’s developed to kill off a particular type of bacterial strain. There are many different ways of approaching this problem. Also, there’s novel ways of looking at the components of how bacterium and virus and fungi and parasites, how they infect our cells or our bodies, cavities or tissue sites, and blocking those capabilities through either potentially using antibody blocking to using protein-protein interaction types of blocking. So these methodologies are being developed now beyond even the antibiotic approach. Joe 01:10:26-01:10:39 Dr. Balin, I wonder if you could give us the historical perspective on Schopenhauer’s three stages of truth and why that might be relevant to Alzheimer’s research. Dr. Brian Balin 01:10:40-01:13:56 Oh, OK. Wonderful. Well, the three stages of truth: First, the work being ridiculed, and then violently opposed, and then being self-evident. Well, historically, we’ve actually seen this in the medical arena. And if we take the example of Warren and Marshall actually proposing that Helicobacter pylori, a bacterium, could live in the stomachs of individuals and cause severe disease such as ulcers, MALT lymphoma, gastric carcinoma, and actually being criticized when they came out with those types of findings, criticized to the point that they were vilified. The gastroenterology world thought these people were absolutely crazy. Well, they’re not crazy, okay? It’s been shown that you have an organism that can live in the mucosal layer of the stomach and in the lining and can lead to all these severe diseases. And yet it took about 100 years for that to be accepted. Now, if we look historically here with Alzheimer’s disease, even in the day of Alzheimer and Oscar Fisher, they were considering that infectious agents could be involved with what they were seeing in human brain tissues at autopsy. And yet we’ve gone now over 100 years later, and many of us have been studying this for decades in the more modern age. And yet we still don’t have great acceptance that this is even a possibility. So originally, there’s been ridicule. And then, you know, there’s been opposition because of ignoring what we’ve been doing over time and what others have been doing. And there are a lot of people doing this work, by the way, not just coming from my laboratory or in collaboration with Nikki with the Pathobiome Research Center or the Alzheimer’s Pathobiome Initiative, etc. There are a lot of people that are working on this issue. And now we’re forcing the issue here that we have to accept that there is involvement. Now, understanding the involvement as far as causation goes is the key. And now we’re trying to come up with consensus approaches of how you detect, of how you actually even approach the experimental designs to actually prove causation. The problem we’re faced with is you have chronic diseases and you have chronic infections and you have a combination effect here happening with genetics and the exposome or what we’re exposed to with the environment. So it’s not an easy process. But not to accept that we have infectious components is just keeping one’s head in the sand, I believe. So with Schopenhauer, I think we’re getting close to this, what’s becoming more self-evident. Joe 01:13:58-01:14:39 Dr. Balin, one would think that the infectious disease community would be so excited about your research. And in fact, the idea that infectious agents might be at the causative stage of a lot of our chronic conditions, you know, anything with an itis at the end of it suggests inflammation, whether it’s arthritis or cystitis or bronchitis, fill in the blank “itis.” And so I keep wondering, why has the infectious disease community seemingly been pushing back rather than embracing this approach? Dr. Brian Balin 01:14:40-01:17:21 I believe that one part of this is that with the infectious disease community, the traditional way of thinking about, for instance, a brain infection is that you would have a meningitis, an encephalitis, a meningoencephalitis, or an abscess that would be now forming from some type of infection in the brain. What is not well accepted, I think, but should be, is that we have chronic infectious agents that can act in a very subliminal and very insidious manner to infect anywhere in our bodies, first of all. In the brain, we already know that there are a lot of organisms that can be harbored there, and you can get disease, and at times you don’t have disease. A perfect example is progressive multifocal leukoencephalopathy, PML, which can arise after treatment, for instance, for multiple sclerosis. Well, this is a very severe disease. It is caused by a virus, ’cause the John Cunningham virus, which many of us actually harbor and probably the majority of the population harbors in their brains, but does not actually suffer from disease from that organism. There are other organisms. The poliovirus, it’s an enterovirus, can be harbored in the brain and can lead to a post-polio syndrome, but it can also be harbored in the brain and you don’t have obvious deficit. The herpes simplex virus can be the same way. So we know that there are a number of different agents that can be harbored in brain tissues without obvious disease. However, we also think that they can be activated to be involved with disease. The degree to which this is happening in our nervous system is something still in the discovery process. And that’s why the consideration of a pathobiome and even at times a microbiome, which I really still am questioning whether that could even exist in the brain. But a pathobiome for sure would be present there. But this falls outside of the typical designation an infectious disease person would actually be considering in this case. Joe 01:17:21-01:17:36 We have one minute left. What would you like to see unfold over the course of the next decade with regard to this infection connection and this pathobiome? What’s your hope for the future? Dr. Brian Balin 01:17:37-01:18:45 We have tremendous chronic disease throughout our population. We need to start considering how infections and infectious organisms and these microbes are actually interfering with us or competing with us or working with us, how that actually is happening to understand how we are staying healthy or becoming diseased. So these chronic issues are key, I think, for us as a future to really understand our health. So we need to monitor much better than what we’ve ever done before, and we need to start accepting that this is a reality and not continually questioning cause and effect. We have these on board. We still have to understand causation. How are things caused in time? But we are uncovering that to a point where we now have to start monitoring and diagnosing and start affecting change prior to disease onset. Terry 01:18:45-01:18:50 Dr. Brian Balin, thank you so much for talking with us on The People’s Pharmacy today. Dr. Brian Balin 01:18:51-01:18:55 And thank you so much for inviting me to talk as well. It’s been my pleasure. Terry 01:18:56-01:19:21 You’ve been listening to Dr. Brian Balin, professor of neuroscience and neuropathology at the Philadelphia College of Osteopathic Medicine. He directs the Adolf and Rose Levis Foundation Laboratory for Alzheimer’s Disease Research and the Center for Chronic Disorders of Aging. Earlier, we spoke with Nikki Shultek, founding director of the Pathobiome Research Center. Joe 01:19:21-01:19:29 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:19:29-01:19:37 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 01:19:37-01:19:51 Today’s show is number 1,466. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 01:19:51-01:20:37 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In this week’s podcast, Nikki Shultek will talk more about patient-led research and help us better understand the root causes of some chronic conditions. Should cardiologists be considering gum disease as a factor in heart disease, as well as the levels of cholesterol and LP little a? What should health professionals be learning about the infection connection during their years of education? Dr. Balin also uses Schopenhauer’s three stages of truth to shed light on Alzheimer’s research. You could watch the interview with Nikki Shultek on YouTube. Look for The People’s Pharmacy. Joe 01:20:37-01:20:59 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be grateful if you’d write a review of The People’s Pharmacy and post it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:20:59-01:21:34 And I’m Terry Graedon. Thanks for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:21:34-01:21:44 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:21:44-01:21:49 All you have to do is go to peoplespharmacy.com slash donate. Joe 01:21:49-01:22:02 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

Every five years, the Departments of Agriculture and of Health and Human Services jointly issue guidelines on what we should eat. The most recent Dietary Guidelines for Americans (2025-2030) have been controversial. [Here is a link: https://www.dietaryguidelines.gov] Among other things, the administration decided to flip the food pyramid upside-down in illustrating its recommendations. Why did that cause such a stir, and what will it mean for you? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, March 14, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on March 16, 2026. Why Flip the Food Pyramid? Nobody has actually explained to us why they decided to flip the food pyramid on its head. The food pyramid itself debuted in 1991 as an illustration of what we should eat, but many people found it confusing. In 2011, it was replaced by a MyPlate graphic. So why return to the food pyramid now, especially upside-down? Our guest, noted nutrition researcher Christopher Gardner, suggest that it might be a way of denoting dramatic changes from previous guidance. Spoiler alert: only a few details are dramatically different. The main changes are a commendable emphasis on eating real food and attention to red meat as a protein source and full-fat rather than low-fat dairy products. Do Americans Need More Protein? If you pay attention at the supermarket, you’ll probably notice that a lot of product tout their protein content. Even things that don’t seem like they’d stand out as sources of protein (granola, pancake mix) are being offered in containers emblazoned with the promise of protein. Surprisingly, though, this is not a response to an urgent need. Most Americans get adequate protein and don’t need to concentrate on increasing their intake. Might it be a marketing tool? Should We Worry About Dairy as We Flip the Food Pyramid? Generally, public health experts recommend that we avoid foods high in saturated fat such as butter or cheese and opt instead for lower fat items, like skim milk. Consuming excessive amounts of saturated fat can raise blood levels of dangerous LDL cholesterol. On the other hand, Dr. Gardner points out that dairy fat differs in some ways from the saturated fats in meat, for instance. We don’t have enough studies to evaluate health consequences of consuming full-fat dairy. Will that raise cholesterol? Might it increase the chance of heart disease? We still need more research to be able to tell. What About Eggs? Speaking of cholesterol, what about eggs? For decades, Americans were warned not to eat eggs. Experts thought these cholesterol-rich foods would raise the level of cholesterol in our blood. But although eggs are high in cholesterol, they are low in saturated fat. Joe describes an astonishing experiment in which a person ate two dozen eggs a day. After a month, his LDL cholesterol was lower than when he started. Dr. Gardner remarks that we need to know not only what we are eating, but also instead of what and with what. Eggs with sausage and cheese are quite different from a veggie frittata. What’s for Breakfast? Let’s consider what people might be eating for breakfast instead of eggs. Quick toaster pastries, sweetened cereal, orange juice and toast with jam are all popular options that are high in refined carbohydrates. At least for some people, such foods may make blood sugar and insulin spike. That could lead to a midmorning crash, which in turn could encourage someone to have a midmorning snack. Is that a bad idea? Maybe it is one reason to flip the food pyramid. If We Flip the Food Pyramid, Will It Help with Weight Loss? Dr. Gardner has run studies comparing the results of healthful low-carb diets to healthful low-fat diets. He and his colleagues found no significant difference in the weight loss people experienced on average. But none of us is an average person. The range of responses to these diets was huge, with some people losing a lot of weight and other losing none or even gaining. How to Lose Weight Based on this research, it seems no single diet will work for everyone. What makes a big difference is satiety. If what you eat makes you feel full and keeps you feeling full, it will help keep you from eating too much. No need to flip the food pyramid in that case. And, says Dr. Gardner, no need to rely on continuous glucose monitors unless your blood sugar is out of range. Just paying attention to how food makes you feel and to the maxim Eat Real Food will be a pretty good guide for most of us. Dietary Guidelines That Flip the Food Pyramid Shape Food for Kids One important way that the Dietary Guidelines for Americans are implemented is school lunch. Institutions receiving funds from the federal government must follow these guidelines. Substituting minimally processed foods for the inexpensive ultraprocessed foods that are currently found on many school menus will probably be more expensive. The new guidelines also recommend that kids not get any foods with added sugar until they are at least ten years old. That would be a big difference in children’s diets, at as big as when we flip the food pyramid. Is it practical? This Week’s Guest Christopher Gardner, PhD, is a nutrition researcher. He is the director of nutrition studies at the Stanford Prevention Research Center and the Rehnborg Farquhar Professor of Medicine at Stanford University. Christopher Gardner, PhD, director of nutrition studies at the Stanford Prevention Research Center and the Rehnborg Farquhar Professor of Medicine at Stanford University Listen to the Podcast The podcast of this program will be available Monday, March 16, 2026, after broadcast on March 14. You can stream the show from this site and download the podcast for free. In this episode, Dr. Gardner discusses the types of fat he uses in his kitchen and why. What oils does he choose for sautés or salad dressing? What is his perspective on olive oil? what does he eat for breakfast, lunch and dinner, and what is he buying at the market? Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1465:  transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:28 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Americans keep flip-flopping on food. For years, experts recommended low-fat diets. Now, the pendulum has swung back. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:44 The new dietary guidelines for Americans prioritize protein, especially animal protein. They also encourage us to eat real food. What does that mean? Joe 00:45-00:52 Our guest today is one of the country’s leading nutrition researchers. He will explain the changes in these new recommendations. Terry 00:53-00:56 Will the new guidelines change the way you eat and feed your family? Joe 00:58-01:06 Coming up on The People’s Pharmacy, learn about the food fight. Should we flip the food pyramid upside down? Terry 01:14-02:47 In The People’s Pharmacy Health Headlines: Many medical professionals are skeptical about the value of multivitamins. A fresh analysis of data from the COSMOS trial of multivitamins and cocoa flavanols now suggests that the multivitamin-multimineral combination used in the study slowed aging. The conclusion is based on almost 1,000 study volunteers with an average age of 70. Compared to those taking placebo tablets, those on the multi for two years aged more slowly according to two markers of biological aging. In addition to slower aging, those in the vitamin supplement arm of the study had lower inflammation and better cognitive function. Epigenetic aging clocks are not perfect, but they do offer some sense of how fast a person is aging relative to chronological age. The slowing was small, between one-tenth and two-tenths of a year. People whose aging was accelerated before the study began got the most noticeable benefit from multivitamin action. The researchers suggest that aging more slowly in this way could translate to a somewhat lower risk of cancer. The author summarized: In conclusion, we provide evidence from a large-scale and long-term randomized controlled trial that a daily multivitamin and mineral combination is a safe, readily accessible, and low-cost intervention that may slow epigenetic aging. Joe 02:48-03:56 There’s something that might make you age faster at the cellular level. If you have difficult people in your life who create problems, they could be aging you at a faster rate than normal. These hasslers seemingly create biological aging in those around them. The study involved 2,345 participants ranging in age from 18 to 103 years old. The researchers measured cumulative biological aging data. Hasslers were defined as people causing problems or making life difficult. The negative interactions could range from everyday irritations and criticism to exclusion, hostility, denunciations, or even violence. The people who participated in the study reported that on average they experienced 8.1% of their network members as hasslers. The more hasslers in your life, the more pronounced the aging effect. People who make you feel bad may add roughly nine months of biological age to your life. The authors suggest avoiding hasslers whenever possible and seeking out people who are supportive. Terry 03:57-04:43 There’s a common perception that getting older means you lose your edge and start to fall apart. But what if we viewed aging as an opportunity for improvement instead? A new study published in the journal Geriatrics suggests that some of us become healthier and more creative as we age. The key seems to be in our attitude. Participants enrolled in the Health and Retirement Study and took tests of cognitive ability and walking speed. Their average age at the start of the study was 68 years. After a follow-up of up to 12 years, researchers repeated the assessment on more than 11,000 people. These volunteers had also recorded their beliefs about the aging process. Joe 04:44-05:07 Almost half, 45% of the participants, showed improvement in either cognitive performance or walking speed, or both. If the investigators also included people who stayed the same after several years, the proportion of those who did not decline with age was over half. Significantly, more of the people who improved had expressed positive views of aging at the outset of the study. Terry 05:08-06:17 Children in North America eat a lot of junk food. A study notes that nearly half of the calories consumed by Canadian preschoolers come from ultra-processed foods. The investigators wanted to know whether such a diet affects emotional and behavioral functioning. They found that ultra-processed food consumption at age 3 is associated with greater anxiety, fearfulness, and depression at age 5. These results parallel those from a British study linking burgers, fried chicken, potato chips, and chocolate to hyperactivity at age 7. The authors suggest that feeding young children less ultra-processed foods could result in better mental health as they grow older. And that’s the health news from the People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:31 And I’m Joe Graedon. Americans have been fighting about food for decades. First, eggs were bad. Now they’re good. Olive oil was too high in saturated fat. Now it’s a cornerstone of the preferred Mediterranean diet. Terry 06:32-06:44 The latest version of Dietary Guidelines for Americans is controversial. It was presented with a graphic that turns the food pyramid upside down. What should you know about healthy eating? Joe 06:45-07:02 To help us answer that question, we turn to Dr. Christopher Gardner. Professor Gardner is a leading nutrition researcher. He’s the Director of Nutrition Studies at the Stanford Prevention Research Center and the Rehnborg Farquhar Professor of Medicine at Stanford University. Terry 07:03-07:07 Welcome back to the People’s Pharmacy, Dr. Christopher Gardner. Dr. Christopher Gardner 07:08-07:10 Joe and Terry, thanks for having me back. Joe 07:10-07:49 Christopher, it is so good to have you back on the People’s Pharmacy. It’s been far too long and so much has happened in the world of food. So let’s just start at the beginning. There’s a lot of confusion and emotion around food in general. It’s so complicated. Our grandparents, they had it so simple. They went out to the garden. They cooked what was available. There was no controversy about good foods and bad foods. So we’re going to start right off with the dietary guidelines. Who sets them up? Dr. Christopher Gardner 07:50-08:10 Oh, yeah. So the secretaries of Agriculture and Health and Human Services have shared that responsibility since the beginning, which is a little odd because it seems like it should be Health and Human Services, given that the agricultural community has an obvious conflict of interest. But that’s the short answer. Terry 08:11-08:19 That definitely makes it more complicated, I think, for them to be able to collaborate on these guidelines. What are the guidelines supposed to do? Joe 08:19-08:23 Terry, before that, why do they have a conflict of interest? Terry 08:23-08:23 Okay. Dr. Christopher Gardner 08:25-08:52 Right. So you can’t, let’s say you represent the cattleman’s industry, and the pork industry, and the egg industry, and the scientists say you should eat less of something. Wow, that would work against your interest to tell somebody that you represent that the whole American public should eat less of you. But if you’re a vegetable and fruit growing type person and the scientists say eat more veggies and fruits, well, it’s easy to suggest eating more of someone you represent, but not less. Terry 08:54-08:55 Keep going. Joe 08:55-09:02 I just wanted to know why it was [a] conflict. Back to your question. Terry 09:02-09:19 Well, it sounds as though this dietary guideline project has been complicated right from the beginning if they’ve had to collaborate from the beginning. What is the function of the guidelines? What’s the big idea? Dr. Christopher Gardner 09:19-10:36 Yeah, so great question. So there’s a whole story that Marion Nestle is the best at explaining of why they originated in 1980. But when they did originate in 1980, they made a deal, or it was part of their write-up, that every five years, just in case there was new science, they would update them. And so there have been updates every five years since 1980. And the way they’ve gone about this over the last 20 years or so, not necessarily in the beginning, was they would get together a group of scientists and refer to them as the Dietary Guidelines Advisory Committee. And for two years, that group would review any new papers that came out since the last time they were issued. And the group would submit an advisory report to the secretaries of ag and health and human services. And as an advisory, they didn’t have to take the advice. And over time, there’s many times they did not take the advice, but many times they did take the advice. And then it was really USDA and HHS that issued those guidelines sometime the next year after they got this report. And I have lots of details to share with you about what happened this time, but that’s the short answer. Joe 10:36-10:48 Well, before we get to what happened, what’s the point? I mean, why do we even have dietary guidelines and what are they supposed to do for American health? Dr. Christopher Gardner 10:48-12:47 I’m really glad that you started there. So it is kind of interesting that when you read these, every time they’ve been reissued, the very beginning says these particular guidelines are really not for the American public to read. A lot of scientific work went into this, a lot of the language is rather technical. So this is really for health professionals and policymakers. It’s a really long, boring document. But at its best, what it does is it informs federal safety net programs. So if you’re thinking school lunch, school breakfast, women, infants, and children, there’s really about 20 to 25 federal safety net programs to help people who don’t have enough to eat. And so when you’re trying to provide more food for those in need, there’s some guidelines that say, well, you should make sure you emphasize this and try to avoid that because we would like these people getting federal assistance to get healthy choices. So the biggest impact of those dietary guidelines is actually on like kids getting school lunch and school breakfast, not so much the general public. And it’s well known that if you look at what’s been stated in the dietary guidelines, because this is actually part of the advisory group’s responsibility every five years to get a hint of how America is eating. And that’s done by looking at something called the healthy eating index. And actually people go through group by group, the veggies, then the fruits, then the grains, then the meat, then the dairy. And Americans for a long time have not followed the dietary guidelines, which is a super interesting part because quite often some social influencers have said, “Oh my God, the dietary guidelines as written are killing us. We have an obesity epidemic, a diabetes epidemic. Oh my God, we better change them.” And the typical response among those who made them is, well, people aren’t following them. Terry 12:47-12:48 Aha. Dr. Christopher Gardner 12:48-12:59 It’s not following them that made them sick. We have them available, but most people don’t follow them. So that would be an interesting experiment if we check their health after they did. Terry 12:59-13:13 So you can have good advice to look both ways before you cross the street. And if you fail to look both ways, you just ignore that and look at your phone instead while you’re crossing the street and you get run over. You can’t really blame the guidelines, right? Dr. Christopher Gardner 13:14-13:23 Exactly. That’s been a very frustrating point to try to deal with with social influencers lately, and it’s actually just led to more confusion than is necessary. Terry 13:24-13:46 Well, Dr. Gardner, you mentioned that these guidelines traditionally are long, boring documents. Long, I mean, 100 pages or so. And apparently, the most recent ones are a lot shorter, like maybe 10 pages. Can you tell us how they have changed the advice from the previous set of guidelines? Joe 13:46-13:49 And why are they so controversial? Dr. Christopher Gardner 13:52-14:52 Yep. Okay, so picture the last guidelines were 164 pages from 2020. But actually, the government put together all kinds of short versions of those, depending on who the audience was. There’s a five and a 10-page version. And if you look at all the marketers and the communicators, they set up different length documents depending who they were targeting. And this particular one, I honestly thought it was 12, but maybe it’s 10 pages. I think the one I have is 12 pages long. That sounds much shorter, but there’s a 90-page document that goes with it. And there’s also a 400-page document that goes with it. If you want even more detail and to put that in perspective, I worked on the 2025 Dietary Guidelines Advisory Committee. We generated a 421-page report with a 1,000-page supplement that went into the details. And I could probably pretty quickly explain why it’s so long if you want me to go there. Joe 14:52-15:25 Well, you know, I think everybody has heard by now about the food pyramid. And so I think the food pyramid kind of boils down the dietary guidelines to something that doctors and patients and just the rest of us can kind of make sense of. But this new food pyramid has got everybody all excited. Why? What’s the big deal? Dr. Christopher Gardner 15:25-17:27 Excited in both directions, like super happy and super sad. So interestingly, the original food pyramid that came about in 1991, if you look into the history of it, nobody actually really liked the food pyramid from the beginning. And one of the reasons they didn’t like it is there were tiers to this pyramid. The base of it said six to 11 servings of grains, just as one obvious example. And people thought that was bewildering. And so when you actually read the details behind the graphic, it said, well, if you’re a small, inactive person, you might need six servings. And if you’re a large, super active person, you might need 11. And so after quite a few years, they actually got rid of the standard food pyramid and then made mypyramid.gov. And you got to go online for that one and say how big and how active you are. And then instead of getting a huge range, it said, oh, you should get six and you should get eight and you should get 10. And so that was a little bit better. But at the end of the day, a lot of people didn’t understand the pyramid and they thought, oh, the tip of the pyramid, that’s the top. That must be the most important thing. So I’m going to go straight to the top and have the most of that. And the original intent had been that’s the smallest part of the pyramid is the tip. And that’s the thing you’re supposed to have the least of. So in 2011, after 20 years, they completely abandoned the pyramid and came up with myplate.gov. And they said, oh, half your plate should be veggies and fruits. And the other half can be grains and protein sources and a little circular thing of dairy on the side. And they said, these are simpler. Interestingly, if you clicked on either the pyramid or myplate.gov, there’s a mind-numbing amount of detail, and the architecture never changed. It talked about lots of different things in very specific language. Joe 17:28-17:48 Well, I have to tell you, Dr. Gardner, we have a break. We’re going to stop for just a few seconds. But when we come back, we’re going to talk about the new food pyramid and why are people so excited. So get ready. We’re going to talk food pyramid 2026. Terry 17:50-18:06 You’re listening to Dr. Christopher Gardner, Director of Nutrition Studies at the Stanford Prevention Research Center. He’s the Rehnborg Farquhar Professor of Medicine at Stanford University. Dr. Gardner has studied the effects of popular weight loss diets comparing low-fat to low-carb eating patterns. Joe 18:07-18:12 After the break, we’ll find out more about the new food pyramid and why they got rid of my plate. Terry 18:12-18:17 What does it mean that the new guidelines tip the food pyramid upside down? Joe 18:17-18:21 The new guidelines put a stronger focus on protein, especially animal protein. Terry 18:22-18:24 Is protein in short supply in the American diet? Joe 18:24-18:27 We’ll also talk about breakfast. What’s your favorite? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:54-19:11 And I’m Terry Graedon. Joe 19:11-19:24 The new dietary guidelines for Americans from 2025 to 2030 emphasize protein, especially animal protein. Are Americans really deficient in protein? Terry 19:25-19:32 The theme of the guidelines is that we should eat real food. That’s something we’ve been advocating here at the People’s Pharmacy for decades. Joe 19:32-19:45 Our guest is one of the country’s leading nutrition experts. He’s studied vegetarian diets, garlic, ginkgo biloba, fish oil, and other omega-3 fats, as well as a range of weight loss diets. Terry 19:45-19:57 We’re talking with Dr. Christopher Gardner, Director of Nutrition Studies at the Stanford Prevention Research Center. He’s the Rehnborg Farquhar Professor of Medicine at Stanford University. Joe 19:58-20:09 Dr. Gardner, food pyramid, 2026. Why is everybody so excited? What’s the deal on meat and dairy and… Terry 20:10-20:12 And why did they give up on the plate? Dr. Christopher Gardner 20:13-21:06 Yep. So I have an opinion about that. It’s my personal opinion. So I don’t have any data to support this. Interestingly, this administration has been really gung-ho for getting at ultra-processed food. They ended up calling it highly-processed food. At the end of the day, it’s basically junk food that Americans have been eating too much for a really long time. And they said, you know, we are on a mission here and we’re going to take this more seriously than any administration before us. We are going to make the most dramatic changes that have ever been witnessed in rewriting and shortening these guidelines. And to show you how revolutionary this is, let us show you the new graphic. So this is the pyramid on its head. We have flipped the entire thing upside down. Terry 21:06-21:09 So it’s teetering on the point of the triangle, right? Dr. Christopher Gardner 21:10-22:49 And I think it was meant to show that this is a really, really dramatic shift. And you should take note, we are super proud that we are taking this on for the first time. So the challenge there is if you really look through all the details, most of it hasn’t changed. So the very first recommendation is to not eat too many calories and to balance those out to watch your weight. That’s the same. The second one, let’s come back to, it has to do with prioritizing protein every day. That is the one that has the most people curiously looking into the details. But then it says eat veggies and fruits, eat four servings of whole grains, don’t eat too much added sugar, eat healthy fats. They added a cool thing about the gut for the microbiome. And most of the recommendations are really carried over from the past. The red meat and the prioritizing protein are two of the big changes. And the other one was for dairy, it very specifically said whole fat dairy and three servings a day. And for so, so long, the dairy part recommended low fat dairy. So those are the big changes. And I think there’s about 12 different points if you go through each one, one at a time. Most of them are actually the same. It’s not very radical. So my opinion of the flipped pyramid is it’s sensationalist. It’s to show how radically different things are. If you read through it, it’s not really that different except for the protein and the whole fat dairy and kind of focusing on ultra-processed food. But that’s a separate topic. Keep going. Terry 22:50-23:11 Let’s talk about that protein focus, because my recollection is and, you know, my memory’s not perfect, but my recollection is that a long time ago when we talked to you before, you said most Americans are getting already plenty of protein and don’t really need to focus on getting more. A, was that true? And B, is it still true? Dr. Christopher Gardner 23:12-25:13 Was true, still is true, but it would be hard to know that going in any grocery store or crawling out from any rock and looking around right now because everything says high protein. There’s protein water, there’s protein Pop-Tarts, there’s protein cereal, there’s protein soup. You would think as you go through the grocery store, I mean, tell me if you have experienced the same thing. I’ve seen so many foods in font 12. This is yogurt. This is grain. This is something else. But protein is in twice the size font of whatever the food is. Like it seems to be more important that they tell you it has protein than they tell you what the food is actually itself. It’s turned out to be an incredibly effective marketing tool. And so after seeing all the protein powder, all the protein bars, the David bar, which crammed more protein in a bar than anybody’s ever managed to do before, only because of this bizarre undigestible fat that they added to it, which is super processed, they put all this protein in it. And then I think because they’re saying, oh, you know what? The new target range is no longer, okay, now sorry for these units here, 0.8 grams of protein per kilogram of body weight. I don’t know if you want to stop and explain that, but that’s just the general way they refer to it. It’s no longer 0.8. It’s 1.2 to 1.6, which kind of sounds like double. And my frustration as a public health person and a nutrition scientist is somebody’s going to look at that and say, that’s why there’s protein in everything at the grocery store. Oh my God, for all these years, it’s been wrong. They’ve only been telling us to get half the amount we need. And thank God they’re labeling all that food in the grocery store. And thank God they brought red meat back. Because as an American, for most Americans, when they think of protein, they think of meat. They don’t really think of beans, legumes, peas, lentils, and… Terry 25:13-25:14 Peanut butter. Dr. Christopher Gardner 25:15-26:51 Joe and Terry, yeah, that’s been my push for years is everything has protein in it. The dietary guidelines have always pointed out what the nutrients of concern are, and those have typically been fiber and calcium and vitamin D, and for infants and young kids, iron. Protein has never been a nutrient of concern that Americans aren’t getting enough of, and so it is bizarre that they chose to do that. By the way, the National Academies is the one who comes up with the DRIs, the Dietary Reference Intakes, where they actually list amounts of nutrients that you get. The Dietary Guidelines for Americans is separate. It’s the USDA and Health and Human Services. And their main job is supposed to show you what servings of what foods would get those numbers for you. So technically [it] isn’t their purview to be putting numbers in with their recommendations. So weird that they put numbers, weird that the numbers are double what they were when there isn’t a protein problem. Weird that they brought red meat back in their new flipped pyramid. It is at the very top in the upper left. And when Americans read top to bottom and left to right, that is the first thing that they see is this big thing of red meat followed by a huge turkey and some other meat, and whole fat dairy thing. So that’s what has people questioning WTF. What happened? Was the science all wrong for all those years? Terry 26:51-26:58 And of course, Americans have a hard time with the metric system. So trying to figure out grams per kilogram is a challenge. Dr. Christopher Gardner 26:58-27:57 And so they just look for the big font. Oh, okay. All I really know is it’s protein. So I’m going to get my protein pop tarts and my protein soup and my protein candy bar. And if somebody says, no, no, no, they said eat whole food. Oh, wait, no more junk food. Okay. And I personally, Joe and Terry, I do like the no junk food, less highly processed, less ultra-processed food. But I think if they recognize how many of those high protein foods are junk foods, then they’ll say, oh, well, thank God you clarified that. Now I know to get my meat. No, no, for the last 20 years, the Dietary Guidelines advisory committees have always said less meat, less red meat and processed meat in particular. And after handing it off to the Secretary of Ag, that was transferred to choose lean sources of meat instead of eating less red meat. So that went counter. Joe 27:57-28:39 So, Dr. Gardner, let’s move on to fat. Because for years, we were told low fat, no fat, that’s the answer to good health. And there were all these dairy products. I mean, you had low fat yogurt, no fat yogurt, no fat cottage cheese. Oh, and milk, it’s got to be low fat. Or skim. Skim milk is so much healthier than whole milk. And now they’ve turned that upside down. Did they get that right? Did they get that wrong? What does Dr. Christopher Gardner think about dairy? Dr. Christopher Gardner 28:41-31:28 Okay. Well, take one step back because the fat thing was an oversimplification. They always meant saturated fat. And that seemed to be too much for the American public to handle. So the marketer said, let’s just be more simplistic. Let’s say less fat. And then quite immediately, the health community pushed back and said, no, no, no, that was supposed to be less meat and lard and butter and things like that. It was supposed to be less saturated fat, but olive oil, avocados, nuts and seeds, the unsaturated fats are okay. So let’s just differentiate saturated from unsaturated. But Joe and Terry, dairy fat is a little different. So all the different fats have different lengths of carbon chains. And part of the reason butter smells like butter is butyric acid only has four carbons. It’s a saturated fat. But there honestly aren’t that many studies that are well done of something as super practical as whole milk versus skim milk in our school kids. So this is one of the main places where the battlegrounds lies, because one of those places where it really is having an impact is not, Terry, as you were saying, going to the street and looking both ways before you cross. This is like, what are schools allowed to buy? And it says schools can’t buy whole fat dairy. Interestingly, schools could buy low fat dairy that was chocolate and full of sugar. And that’s actually appalled many of us in the health community for many years. But let’s say you got rid of the chocolate and the sugar and just had low-fat milk versus whole-fat milk, believe it or not, there’s almost no studies on that. But think about this. One of the main issues of saturated fat is cholesterol in the blood, which leads to heart disease. How many 12-year-olds have heart attacks? None. How many 15-year-olds? Okay, maybe one or two. But the main way to look at that outcome of switching your saturated fat source for adults has been a quick blood draw to see what your LDL and HDL cholesterol are like. And nobody wants to let their kids go in for blood draws for drinking different kinds of milk. So I’m actually working with a group right now that’s doing a really interesting low fat versus whole fat milk study in kids. But it’s not cholesterol that is the main outcome. It’s lots of other possible health outcomes. And so the people who are pushing back on the whole fat dairy and saying it’s okay are kind of within their right to do that cause there is not a strong evidence base against whole fat dairy and kids. Terry 31:28-31:46 So they’re saying it’s okay, but what you’re saying is we don’t have the evidence to say it is or it isn’t okay. And there are some people who worry that a very low-fat diet, if you’re very young, you know, two, three, four, might not be good for your brain. Dr. Christopher Gardner 31:47-32:03 Yes. And that’s actually what our Dietary Guidelines Advisory Committee found out, that some of that whole-fat dairy was better, especially for really young kids. So the idea is, what about middle school and high school? At what point does it switch over, if it switches over? Joe 32:03-32:09 You’ve used that bad word, LDL cholesterol. Dr. Christopher Gardner 32:10-32:11 Yeah, Ok. Joe 32:11-33:07 With regard to whole fat dairy. Now I want to switch for a moment because we seem to demonize foods. There are good foods and there are bad foods. And for a long time, eggs were bad foods because they had cholesterol and because they would therefore cause heart attacks. Well, there is this rather interesting fellow, Dr. Nick Norwitz, MD, PhD. You may have heard of him at Harvard. I think he was at Harvard. But in any event, he started eating an enormous number of eggs, 24 eggs a day, two cartons of eggs for 30 days. That’s a lot of eggs. 720 eggs, 133,200 milligrams of cholesterol over the course of a month. Terry 33:07-33:10 And most of us would never want to see another egg after we’d done that. Joe 33:11-33:16 But he measured his LDL cholesterol. It went down. How could that be? Dr. Christopher Gardner 33:17-34:59 Oh, because they probably got less saturated fat in their diet. So the saturated fat in the diet has a more direct impact on the LDL cholesterol in your blood than the dietary cholesterol. And that’s been known for decades. The liver actually makes a lot of cholesterol on a day-to-day basis. And all the cholesterol that you eat goes to the liver in your body before it goes anywhere else. And for most people, and maybe for Nick in particular, he’s probably just a super efficient compensator. He says, “Oh, I don’t need to make any liver cholesterol today. I ate 24 eggs today. So I’m just not going to make any internal cholesterol.” And it’s kind of a wash. So to be honest, Gerald Reaven, who’s a Stanford professor and who is the godfather or the father, whatever you want to call it, of insulin resistance as it relates to things like LDL cholesterol and triglyceride. And he has passed away, bless his heart. He did one of the oldest studies where people had 900, 600, 300, or zero grams, milligrams of cholesterol a day, and it didn’t impact their blood cholesterol. And you can add that to a dozen other studies that showed it’s really not the cholesterol in your diet. It’s the saturated fat, but it’s kind of a moot point, Joe and Terry, because most things that have cholesterol also have saturated fat with two exceptions. Are you ready? Drum roll, eggs and shellfish have a ton of cholesterol, but they don’t have much saturated fat. So they kind of got a bad rap from that whole saturated fat LDL cholesterol thing. Joe 35:00-35:03 Well, I remember when we weren’t supposed to eat shrimp. Dr. Christopher Gardner 35:04-35:49 Yeah, because of that. And so they’re kind of off the hook. Now picture, so I don’t know if you know this, Joe and Terry, but maybe when I was talking to you last, which was a while ago, my two favorite terms now are “instead of what” and “with what?” And eggs are my favorite example. So picture scrambled eggs or picture egg McMuffin or picture eggs with sausage and bacon versus an omelet with veggies in it and sauce on top. Picture cheesy eggs with sausage and bacon. So is it really just the eggs or is it that you had eggs with cheese, with bacon, with sausage… Terry 35:46-36:08 Or, Dr. Christopher Gardner, our favorite, Joe’s favorite breakfast specifically, is refried beans. I sauté some onions in a little olive oil, and then I put in the refried beans. And then when the refried beans are all nice and warm, I cook an egg on top. And that’s how we have our eggs. Joe 36:08-36:11 And I like peppers as well. Terry 36:11-36:11 Oh, yeah. Joe 36:11-36:36 It’s like it gets me through at least half a day or longer. It’s wonderful. Well, we do need to take another break. When we come back, we want to talk about weight loss. We want to talk about Christopher Gardner’s favorite foods. We want to talk about the future of the food industry. So keep those thoughts. We’ll be right back. Terry 36:37-36:50 You’re listening to Dr. Christopher Gardner, Director of Nutrition Studies at the Stanford Prevention Research Center. He is the Rehnborg Farquhar Professor of Medicine at Stanford University. Joe 36:51-36:59 After the break, we’ll talk about the obesity epidemic. Are there some dietary patterns that make it easier to lose weight? Terry 36:59-37:06 Dr. Gardner’s research has shown that lots of different diets can contribute to good health throughout the lifespan. Joe 37:07-37:11 How can people find out which diet works best for them? Terry 37:12-37:22 The new dietary guidelines suggest that kids should not have any food with added sugar until they’re 10 years old. That would be a big change. Joe 37:22-37:27 Find out about the risks and the benefits of the new food pyramid. Terry 37:39-37:56 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to the People’s Pharmacy. I’m Terry Graedon. Joe 37:54-38:10 And I’m Joe Graedon. Joe 38:21-38:41 Have you ever tried to lose weight by focusing on a particular dietary approach? Did it work? Some people embrace the low-carb Atkins approach, while others sing the praises of the Dean Ornish low-fat strategy. Is there one best diet for everyone? Terry 38:41-38:51 Today, we’re talking about the food fight over dietary guidelines for Americans. The food pyramid was flipped upside down. How will that affect your food choices? Joe 38:52-39:07 We are talking with Dr. Christopher Gardner, a leading nutrition researcher. He’s the Director of Nutrition Studies at the Stanford Prevention Research Center and the Rehnborg Farquhar Professor of Medicine at Stanford University. Terry 39:08-39:37 Dr. Gardner, it is no secret that one of the biggest problems for Americans in terms of diet and health is that there’s too much obesity. People are too fat. People are eating too much or else they’re eating the wrong things. So are there dietary patterns that make it easier to lose weight? We know you have done some research in this regard. Dr. Christopher Gardner 39:38-42:45 Oh, I did a lot. Yeah, so we’ve had 1,000 people across two different studies where we did a lot of focus on low-fat and low-carb. And we compared them head to head and drum roll, pretty much a wash. They both on average lead to about the same amount of weight loss and almost everybody loses weight on them, especially if they’re healthy. So our second of the two studies was one where we had a healthy low fat and a healthy low carb and the average weight loss was the same. But Joe and Terry, what was stunning was always the range of response to that. So some of the participants gained weight and some lost a lot of weight on both diets. And so a lot of people have been looking for personalization of diets. So is there, oh, maybe insulin resistant people do better on low carb and insulin sensitive people do better on low fat. That was our main hypothesis in the study. And it failed when it was a healthy low carb and a healthy low fat. At one point, we thought genetic predisposition might be part of this. And so we got what we thought were low-carb predisposed people and low-fat predisposed people, and that also failed. So everybody’s been looking sort of for this magic bullet. Is it the carbs, fats, and protein? Let me just go to protein for a second. We never focused on the protein. But I will say that I looked at our two studies and several other studies, and I know protein is a huge craze and in theory protein is satiating and helping people out. But when we looked at a bunch of studies a year or two years out, almost every group, no matter how good they were at getting lower in carb or lower in fat, ended up almost exactly at 20% protein. Even the most famous study out there called POUNDS Lost that had a 15% protein diet and a 25% protein diet. In the beginning, when they were excited about it, they did that. But a year or two out, they were both at 20%. So you could talk about whether high or low protein has a difference. But when you actually watch people over time, it kind of nullifies. They end up at the same level of protein. So I don’t think it’s a macronutrient thing. I think you can do pretty much any of the popular diets out there and find that it works for someone. And sadly, I wish the health professionals had better advice, but you’re kind of going to have to biohack and figure out which one works the best for you. A lot of health professionals say the best diet to be on is the one that you can maintain for a really long time. So if this is culturally adapted to your preferences, you like the taste, it works in social settings, it works with your family. All those are probably, I think, more important than low-carb or low-fat or high-protein. Terry 42:45-43:33 We just saw a study published in Science Advances that looked at five different types of healthful, presumably healthful diet, and found that actually people who did well on any of these diets were likely to live longer. So it looks as though there’s quite a range of diets that can be healthful, that can contribute to good health into your later years. And that kind of makes sense if you think about human evolution, I mean, humans around the world have eaten a pretty wide range of diets and done well on them until, of course, we got to the junk food. Dr. Christopher Gardner 43:34-45:58 Absolutely. And really, that’s the key. It’s not, it really isn’t low carb or low fat or high protein. It’s how much, I mean, this is my biggest concern always, added sugar and refined grain–the carbs that have a lot of calories and very little fiber to no fiber, and not very many nutrients that come with it. So one of my favorite publications is from the Harvard group that looked at NHANES, the National Health and Nutrition Examination Survey, over a course of 20 years to see if there were any trends, not just in protein, carbs, and fats, but type of protein, type of carb, and type of fat. And over 20 years, there were some very, very modest differences in all of those. But what’s most stunning about the graphic that they show of this is when they say three types of fat, saturated mono and poly, is like 10% of calories from each one of those. It’s about 10% of calories from animal protein and maybe five to eight of plant protein. We’re still in the 10 range. About 10% of calories from good quality carbohydrates that have fiber in them. Okay, that’s 10, 10, 10, 10, 10. Oh, that adds up to 60. 40% of calories from added sugar and refined grains! That is the problem. And that’s why low carb sounds very popular. If the low carb is getting rid of the added sugars and the refined grains, everybody wins. The question is, what do you replace that 40% calories with? Hopefully you don’t replace them all. Then you’ll be in calorie deficit. That will help you lose weight. But let’s say you replaced 30 of the 40… here’s my biohack to it: I think somebody can do that in a healthy way and have 10 come from more carbs. 10 come from more protein, and 10 come from more fat. Or 30 from fat or 30 from carbs (as long as it’s healthy carbs or healthy fat). So that actually gives you a whole bunch of different ways to go lower carb, but replace it all with healthy foods that are healthy sources of carbs, healthy sources of fat, and healthy sources of protein, which for me is beans, peas, and lentils, which bring fiber along with the protein. Joe 45:58-46:50 We know that you are a peas, beans, and greens kind of guy, and we love that about you. I’m interested in how people can biohack their way to success. How do you find out what’s going to be best for you? You talked a little earlier about insulin sensitivity and insulin resistance, and that’s a really big deal in metabolism these days. But how do you know what works best for you? There’s got to be some kind of a process. Some people are wearing CGMs, continuous glucose monitors to try and figure out what works. And what I discovered, by the way, is that when I have oatmeal for breakfast, my blood glucose goes pretty high pretty fast. Terry 46:50-46:56 And that’s even though I’m cooking steel-cut oats. It’s not like instant sugary oatmeal. Joe 46:56-47:18 And we had a diabetes expert who said, don’t worry about it. That’s fine. Just eat your oats and you’ll be great. But if I have those refried beans with an egg, onions, and peppers, my blood glucose doesn’t go anywhere. It just stays rock solid. So help us figure out how to biohack our way to good health. Dr. Christopher Gardner 47:19-47:23 And you sauteed those onions, right, and peppers in oil. Joe 47:24-47:25 Yeah, olive oil. Dr. Christopher Gardner 47:25-47:33 So you had fat. And if you had a fatty oatmeal breakfast, so what if you put a whole bunch of walnuts and nuts in there? Terry 47:34-47:35 Actually, I do that sometimes. Dr. Christopher Gardner 47:36-47:46 Right? And so the idea is it isn’t really just the one thing. First of all, so actually, Joe, let me just ask, do you have an issue with glucose? Joe 47:47-47:47 Nope. Dr. Christopher Gardner 47:47-47:48 Are you? Okay. Joe 47:49-48:06 I mean, my glucose is usually pretty under control, like in the 90s to 100 range. And after breakfast, if I have my refried beans and egg, it may go up to 105 or 110. But if I have that oatmeal, it’ll go up to 130 or 140. Dr. Christopher Gardner 48:07-49:53 So I’m worried that a lot of people who actually don’t have glucose problems are playing with the CGMs and taking it too seriously. And they’re trying to completely blunt any response, any glucose spike, which is ridiculous because your body is prepared to have carbs and fats and proteins. And when you have carbs, you will get a glucose spike. You will make insulin. You’ll put it away. And then the insulin gets broken down and the glucose is out of your blood. If you try too hard to have no glucose spike at all, you’re going overboard. That’s too much. But when you’re just talking about how do you biohack, you know, in theory, you could make sure you don’t get a really high peak. I actually think the bigger thing that we should try to biohack right now, Joe and Terry, is satiety. What makes you full? I actually asked this at a couple of conferences and I said, what would make you the most full and keep you full for the next hour or two? First, I’m going to tell you oatmeal with some fresh fruit and some nuts and maybe some whole fat yogurt on there and a bunch of people raised their hand versus eggs. That’s an omelet with some salsa and some veggies in there and a whole bunch of people raised their hand. I said, “Isn’t there one breakfast that makes everybody full?” And I gave a couple options. And no, different people, different things are satiating for different people. And so there’s two aspects of the satiety. One is when do you stop eating because you’re full? And when you eat again next, because you’re hungry again. So there are some things that because of bulk fill you up, but then an hour later, you’re hungry again. Joe 49:53-49:57 I’m guessing you would not recommend Pop-Tarts for breakfast. Dr. Christopher Gardner 49:57-50:40 The American breakfast for how many years has been carb on carb on carb. We have a sugary cereal, we have a piece of white bread, we put jelly on it with a glass of orange juice. That’s just simple carbs. So yes, as soon as you switch from that to your beans and eggs, or to your cheesy eggs with bacon and sausage, you would be more full. But I would say switch from that American sugary breakfast to your beans and eggs, not the cheesy eggs with bacon and sausage. But you’ll have to biohack that out for yourself and look at your numbers with your doctor for your cholesterol and your blood pressure and the things that we measure typically. Terry 50:41-51:18 Dr. Gardner, I would like to go back to the new dietary guidelines for just a moment. It is related to what you’re talking about. We know that a lot of kids eat those Pop-Tarts and sugary cereals and so forth. And my understanding is that the new dietary guidelines suggest that kids should not be eating any foods with added sugar until they’re at least 10 years old. A, have I got it wrong? And B, is that a good idea? And is it practical? Dr. Christopher Gardner 51:19-53:37 So it’s a great idea. The challenge is going to be, and this is what I’d really like to see. So I really admire the new administration for putting greater emphasis on this. It’s just obscene and obscene how much added sugar kids are eating and adults as well. And also, you know, the deal with ultra-processed food and cosmetic additives and things like red color dye. And so I know the administration said, all right, no more of these dyes. And as far as I know, M&Ms and Skittles are still colored the same way. And if they say no sugary things in schools, I have a feeling that if they recommend that, schools are going to need more money to buy more whole foods. And so part of the reason those are there, Joe and Terry, is because they’re inexpensive. They have a long shelf life for people with limited resources or for places like schools. They buy them because that’s what they have the budget for. So I totally applaud this idea of getting rid of as many added sugars as we can. But it will really take some regulatory force that I haven’t seen yet to have more, for example, farm-to-table food. I know that the administration took away a billion dollars of farm-to-school money recently, where it was going to come fresh from the farm. I know that some of the other safety net food money has been taken away. So you’d have to say, yes, get rid of the sugars. And there’s going to be some regulations so that the food industry has its feet held to the fire and they can’t make these anymore. They can’t sell these. And the immediate response, as has always been the case, is going to be: this is capitalism. We can make what we want and sell what we want, as long as people will buy it. That’s where the tension will be, not on the recommendation, not on the recommendation to avoid them, but on the power to change the food environment we all live in. That’s a, hey, if you come up with something clever and can sell it, that’s the way capitalism works. That’s a big lift. Joe 53:39-54:22 Dr. Gardner, one of the most controversial areas in your field these days is fat. And I think a lot of people were told for a very long time, no fat, low fat is the answer. And so we saw all kinds of products that were marketed as low-fat, no-fat. And that has changed. And so you now will see all kinds of products out there that will say, okay, we make our ice cream with avocado oil. It’s like, okay, instead of dairy, it’s avocado. Interesting. Terry 54:23-54:24 It’s good. Joe 54:24-54:51 But I want to get your feedback. What kind of oils are you cooking with? What do you put on your salad dressings? And what’s the deal on olive oil? Because I think everybody goes, yeah, yeah, yeah, olive oil is the greatest, but it does have some saturated fat in it. So help us understand the Christopher Gardner perspective on oils and fat. Dr. Christopher Gardner 54:52-56:42 Sure. I have very fatty foods. I put lots of avocado, lots of nuts and seeds. I drench my salads in olive oil or some kind of vinaigrette made with olive oil. Olive oil is pretty expensive, the good quality olive oil. So is avocado oil. And so to be honest, canola, sunflower, safflower, there’s this whole bizarre seed oil debacle that’s just wrong. But it would take me more than 10 seconds to tell you why it’s wrong. All those unsaturated cooking, seasoning, salad dressing oils are fine, but please keep in mind that all of them have higher and lower quality, and the higher quality oils cost more. So when you’re like, there’s this thing about seed oils that’s been going around and it’s true as you take a seed and you crush it in different ways you get the oil out, and if it’s a first press or if it’s a cold press, that’s the best quality. At some level, somebody goes along at the end of the day and squeezes the last little bit out of those seeds and puts in hexane and charcoal and bleaching to squeeze the last bit out. And that’s a lower quality oil and it will cost less. And so all of those oils have higher and lower qualities and it’s pretty snooty to say only buy the high quality oils. So there’s a lot of things you can have that have unsaturated fat, like avocados and nuts and seeds. Those are not cheap either if you buy good quality avocados and nuts and seeds. But, you know, I do a lot with the American Heart, and the American Heart for decades has embraced a high, unsaturated fat, Mediterranean-type diet that includes fatty fish, too. Joe 56:44-57:14 If we were to sit down at your table invisibly and just watch what is Christopher Gardner eating on a regular basis, walk us through breakfast, lunch, and dinner, or perhaps just breakfast and lunch. But just tell us, what are the foods that you’re putting into your groceries bag and taking home, and what are you making most often? What are your favorites? Dr. Christopher Gardner 57:16-57:23 Okay, yeah. And did you know I actually have a book coming out soon, and I put all my favorite recipes in the book. Joe 57:21-57:35 Oh well you’ve got to put us on your list because we would love to talk and and see that book. So make sure we get a hold of that book as soon as it’s available, but tell us the good stuff. Dr. Christopher Gardner 57:35-58:44 Okay, coming out in October, you’ll see that I have a couple of very basic breakfasts. One is steel-cut oats with berries, and nuts, and soy milk, and a little shaved dried coconut, and cacao beans. And then another one is I make this scrambled tofu dish. So I put in onions and bell peppers, and I put some greens in there like kale or chard. And then I mash up some tofu. And even though I’m not trying to fool myself, I put turmeric in there and nutritional yeast. So it looks kind of like scrambled eggs with veggies in it. Another one is an avocado toast with kimchi on it, because I actually study the microbiome now. And that’s one of the ways I get fermented food into my breakfast is to have avocado toast with kimchi. So those are three of my standard breakfasts. Joe 58:27-58:29 Wait, tell me about the toast. Dr. Christopher Gardner 58:29-58:44 And the toast is a whole grain bread, whatever the most whole grain thing that I can find is, which is way more expensive than the wheat bread in the grocery store that’s not really whole wheat bread. It’s just wheat. Joe 58:44-58:49 Terry is taking to baking bread and her whole wheat bread is phenomenal. Terry 58:49-59:06 And I’ve now, speaking of not inexpensive, I like to buy stone ground flour from a local miller at the farmer’s market. So I’m paying extra for my flour, but I’m putting the labor in myself. Dr. Christopher Gardner 59:06-01:00:04 Yeah. Yeah, yeah, yeah. See, so that labor or that time or that money… it all costs. If you want to talk about lunches, I’m looking at my favorite lunch. So salad. Oh, because salad is anything. There’s a grain based salad. I make a really good wheat berry salad. Today, downstairs, I went and got the regular lettuce salad. I’m just looking right now what I have. I have shaved almonds. I have garbanzo beans. I have edamame. I have tofu. I have bell pepper, carrots, red bell pepper. I have beets in it. I have cucumber in it. Just a lot of veggies and nuts and seeds and crunch and color. My salads are really beautiful. I make a really good squash eggplant tempeh dish that has a pomegranate glaze. That’s one of my favorites that I make at home. So those are some of the favorite kind of things that I make. Is that enough for now? Terry 01:00:04-01:00:05 That’s great. Thank you. Joe 01:00:04-01:00:10 That’s perfect. And when that cookbook is available, we’d love to talk to you about it. Dr. Christopher Gardner 01:00:10-01:00:21 And it’s not a cookbook. It’s called Food Sense. And actually, it’s got a chapter on protein, a chapter on seed oil, a chapter on organic, [and] my journey as a food scientist. And at the end are my favorite recipes. Joe 01:00:21-01:00:36 Christopher, we’ve got one minute left. And so I need you to summarize the benefits and risks of the new food pyramid and what you would like to see for the future. Dr. Christopher Gardner 01:00:37-01:01:20 Yeah, I love the eat real food. So if everybody would eat real food, let’s do that. I think they really, one of our strongest recommendations from the Dietary Guidelines Advisory Committee was eat more legumes, beans, peas, and lentils, and less red meat. I think they really got that one wrong. And for the dairy, I think we should all recognize that three quarters of the world is lactose intolerant. And so I don’t think the issue is whole fat versus skim. I think it’s that most of the world can’t handle dairy. And it’s pretty insensitive to suggest that everybody get three servings of dairy a day. Fall back on more veggies and fruits, more whole grains, more beans, peas, lentils, more nuts and seeds, and we’ll be okay. Terry 01:01:20-01:01:26 Dr. Christopher Gardner, thank you so much for talking with us on The People’s Pharmacy today. Dr. Christopher Gardner 01:01:27-01:01:29 Pleasure to be back. Thanks for having me. Terry 01:01:30-01:02:07 You’ve been listening to Dr. Christopher Gardner. He’s a nutrition researcher and the Director of Nutrition Studies at the Stanford Prevention Research Center. Dr. Gardner is the Rehnborg Farquhar Professor of Medicine at Stanford University. He’s focused his research on the potential health benefits of various dietary components or food patterns using randomized controlled trials. The interventions have involved vegetarian diets, soy, garlic, omega-3 fats or fish oil, antioxidants, ginkgo biloba, and popular weight loss diets. Joe 01:02:07-01:02:16 Lyn Siegel produced today’s show, Al Wodarski engineered, Dave Graedon edits our interviews, BJ Leiderman composed our theme music. Terry 01:02:16-01:02:24 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 01:02:24-01:02:39 Today’s show is number 1,465. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 01:02:39-01:03:08 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. This week’s podcast also has information on the controversy over fats. Which oils does Dr. Gardner use for cooking or salad dressing? We’ll get hints on his favorite foods for breakfast, lunch, and dinner. You could also watch the interview on YouTube. Look for The People’s Pharmacy. Joe 01:03:08-01:03:38 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We would be grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics interesting, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 01:03:38-01:04:12 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:04:12-01:04:22 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:04:22-01:04:27 All you have to do is go to peoplespharmacy.com/donate. Joe 01:04:27-01:04:40 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

According to the Alzheimer’s Association, nearly seven million Americans currently suffer from that type of dementia. Experts expect that more will be burdened with it in the future, as baby boomers continue to reach advanced ages. Many people are eager to protect the brain from deterioration. In this episode, we discuss an unexpected approach to lowering your risk for Alzheimer disease (AD) and other dementias–get a shingles shot! At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, March 7, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on March 9, 2026. How to Protect the Brain with Vaccination Our guest, Dr. Pascal Geldsetzer, has led three impressive studies that took advantage of natural experiments to see if vaccination against shingles could protect the brain from dementia. The results were remarkably consistent and encouraging. What Is a Natural Experiment? In Wales, when the Zostavax shot against shingles first became available, public health authorities established eligibility criteria to get it through the national health system. Welsh citizens had to be born on or after September 2, 1933, to get the shot. This created a situation in which two groups of people differed only by birth date and by whether or not they were immunized. (Most people who were eligible for the shot got it.) This mimics a randomized clinical trial in which the only difference between two groups is the intervention. The absolute risk reduction over 7 years was 3.5%, which means that people who got the shot were 20% less likely (relative risk) to be diagnosed with dementia. That big difference is statistically significant (Nature, April 2, 2025). Wales is not the only country that set up eligibility requirements. Australia did, too. In Australia, everyone between 70 and 79 years old as of Nov. 1, 2016, could get a free shingles shot and many people did. Here, too, you have a group of senior citizens who differ from each other only by whether they got vaccinated and whether their birthdays were slightly earlier or later. In this case, the absolute reduction in risk of dementia over 7 years was 1.8% (JAMA, April 23, 2025).  This difference was also significant. One More Experiment Suggests Vaccination Can Protect the Brain Another natural experiment comes not from a nation, but from a province of our norther neighbor, Canada. The province of Ontario decided that people born on or after Jan. 1, 1946, could get a shingles vaccination. People just slightly older were not eligible. Do you recognize a pattern? When the investigators analyzed health records from 1990 to 2022, they found that people eligible for the vaccine based on their date of birth were 2% less likely to get a dementia diagnosis. In other provinces of Canada that had different rules for vaccination eligibility, people don’t show a significant difference in dementia risk based on their birthday. (Lancet Neurology, Feb. 2026). Which Vaccine Were Scientists Studying? The original shingles vaccine, Zostavax, was the one available for all these natural experiments. For the most part it has now been replaced by a newer version called Shingrix, which uses different technology. Studies show that Shingrix is better at preventing shingles outbreaks and post-herpetic neuralgia, the lingering pain after shingles (Vaccines, April 28, 2025).  It is unclear whether it would also work better to protect the brain from Alzheimer disease. At least one study suggests it works quite well in reducing the risk of dementia (Vaccine, Feb. 5, 2025). Was the Single-Minded Pursuit of Amyloid Misguided? For decades, the pharmaceutical industry has focused its anti-Alzheimer efforts on amyloid plaques that are a pathological feature of brains afflicted with Alzheimer disease. They were apparent in the very first brain described by Alois Alzheimer at the turn of the 20th century. But the assumption that getting rid of amyloid plaque would solve the problem has not borne fruit. The FDA has approved three compounds that are quite effective at reducing amyloid plaque in the brain. Two, lecanemab (Leqembi) and donanemab (Kisunla), are still on the market. Their impact on cognitive decline and functionality of AD patients is unimpressive. Other Infections That May Harm the Brain It seems odd that neurologists might be resistant to the idea of an infection such as chickenpox (the virus behind shingles) or herpes (which causes cold sores and genital lesions) changing brain function. More than a hundred years ago, before the development of effective antibiotics, doctors were quite aware that tertiary syphilis could lead to dementia. Other infections such as Chlamydia pneumoniae may also interfere with brain function. The COVID pandemic demonstrated that the SARS CoV-2 virus can cause brain fog, and we worry that people with long COVID may be at higher risk for dementia. Can the Shingles Vaccine Help with Treatment? One immunization outcome that Dr. Geldsetzer’s team uncovered may help with treatment. In Wales, people with dementia who got the shingles vaccine had a slower progression of their cognitive decline. (Cell, Dec. 11, 2025).  This suggests that whatever it is doing to protect the brain may extend into the disease process itself. This definitely deserves more research. Dr. Geldsetzer would like to conduct a true randomized clinical trial to explore this possibility and to tease the differences, if any, between Zostavax and Shingrix with respect to their effects on dementia prevention. This Week’s Guest: Pascal Geldsetzer, MD, PhD, MPH is an Assistant Professor of Medicine at Stanford University and a Biohub Investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. In 2026, he was named one of the 100 most influential people in health and medicine globally by TIME Magazine (The TIME100 Health list) for his work on the link between shingles vaccination and dementia. He is currently trying to raise funds from philanthropy for a large-scale clinical trial of shingles vaccination for dementia prevention. You can contact him by email: pgeldsetzer@gmail.com Pascal Geldsetzer, MDCourtesy Stanford Medicine Listen to the Podcast: The podcast of this program will be available Monday, March 9, 2026, after broadcast on March 7. You can stream the show from this site and download the podcast for free. You can also listen to our previous interview with Dr. Geldsetzer. It is Show 1394: Viruses, Vaccines and Alzheimer Disease. Download the mp3 of this show, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1464: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:25 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Alzheimer disease is one of the cruelest conditions. It robs people of their memories and their personalities. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:42 For decades, drug companies have focused almost exclusively on removing amyloid plaque from the brain. That hasn’t worked very well. Joe 00:43-00:55 Research has been accumulating that pathogens might be contributing to dementia. There’s growing evidence that the shingles vaccine might be able to reduce the risk of developing dementia. Terry 00:55-01:03 Today, we’ll speak with Dr. Pascal Geldsetzer, the lead investigator behind that research. He’ll explain these natural experiments. Joe 01:03-01:09 Coming up on The People’s Pharmacy, can vaccines protect the brain from dementia? Terry 01:14-02:05 In The People’s Pharmacy Health Headlines: Measles cases continue to climb. The CDC reported 160 new cases during the last week of February. The total in just two months is 1,136 confirmed cases from 27 states. That’s way more than last year at this time, and it may be an underestimate. According to the Johns Hopkins University Center for Outbreak Response, the total is actually 1,189. Many measles cases go unreported. We are likely to beat last year’s record of 2,281 cases by spring and shoot way past it. States that have been hardest hit include South Carolina, Florida, and Texas. Utah, Arizona, and Ohio are also reporting new cases. Joe 02:06-02:46 Many older adults maintain that measles is not that big a deal because they remember catching this highly infectious disease as children. But the CDC points out that one in five unvaccinated youngsters will be hospitalized. One out of every 10 children with measles will get an ear infection. One in 20 will develop pneumonia and one in a thousand will develop brain encephalitis. Because measles is considered the most contagious virus known to man, it’s likely that this disease will continue to accelerate unless people begin to follow Dr. Mehmet Oz’s advice from last month: “Take the vaccine, please.” Terry 02:48-03:45 GLP-1 drugs such as Ozempic and Wegovy have clear benefits in that they help control blood sugar and enable people to lose weight. Other possible outcomes include reduced cravings for alcohol, improved kidney and heart health, and reduced fatty liver disease. But there are a number of gastrointestinal side effects that can be quite distressing. Now, two new studies suggest that GLP-1 drugs may also increase the risk for osteoporosis or bone fracture. An Israeli study included records for more than 46,000 older adults with type 2 diabetes. Those on GLP-1 drugs were 11% more likely to experience a fragility fracture. Whether it’s caused indirectly by weight loss or directly from the medicines remains to be determined. Previous research has shown that exercise can help moderate the risk of bone loss. Joe 03:46-04:28 Just as GLP-1 drugs have some unexpected side effects, such as osteoporosis, they may also have some unanticipated benefits. Researchers from Thomas Jefferson University in Philadelphia conducted an analysis of medical records. People with chronic migraine were 10% less likely to visit the ER if they started taking a prescribed GLP-1 medication. The comparison group was people with chronic migraine taking topiramate, an anticonvulsant used to prevent migraine. In addition, those on GLP-1 medicines were 14% less likely to be hospitalized and 13% less likely to get a new triptan prescription for treating migraine. Terry 04:28-05:16 A research letter in JAMA this week reports that American teenagers are not getting enough sleep. The study looked at trends from 2007 to 2023. The percentage of students reporting insufficient sleep increased from 68.9% in 2007 to 76.8% in 2023, the investigators write. The number of adolescents who sleep five hours or less a night increased dramatically. An accompanying editorial notes that inadequate sleep is linked to academic struggles, cognitive difficulties, and depression. It recommends changes in school start times and reduced use of phones and tablets in the evening. Joe 05:17-06:03 People have been paying increasing attention to the microbiome of their digestive tracts. To find out what bacteria and other microorganisms they’re hosting, some people turn to testing laboratories. How reliable are the results? A study recently found a serious lack of quality control among direct-to-consumer testing services. The authors conclude that their rigorous assessment of seven microbiome testing companies has spotlighted the systemic issue of poor comparability that plagues the industry. They blame methodological variability. Until this problem can be rectified, health care providers and patients can’t trust stool testing data to give them reliable results. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:25 And I’m Joe Graedon. The Alzheimer’s Association states that there are more than 7 million Americans currently dealing with dementia. Terry 06:26-06:38 The problem is likely to get worse, as the baby boomers age. The impact on families and society is daunting. Is there anything we can do to reduce the likelihood of developing dementia? Joe 06:39-07:10 To help us answer that question, we turn to Dr. Pascal Geldsetzer. He’s an assistant professor of medicine at Stanford University and a Biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. In 2026, Time magazine named him one of the 100 most influential people in health and medicine globally for his work on the link between shingles vaccination and dementia. Terry 07:12-07:15 Welcome back to The People’s Pharmacy, Dr. Pascal Geldsetzer. Dr. Pascal Geldsetzer 07:16-07:17 Thanks a lot for having me. Joe 07:18-07:51 Dr. Geldsetzer, it’s great to have you back. And since we last talked with you, you are now in the realm of superstardom because of your third study. We’ll get to your studies in a moment with vaccines against dementia. But first, I’d really like to find out, how did you come up with this idea in the first place? The notion that there was a natural experiment just waiting to be tested. How did that get hatched? Dr. Pascal Geldsetzer 07:52-08:30 Yeah, well, I had this NIH New Innovator Award to look at using this method that we’re using here in our natural experiments. And we came upon the Shingles vaccination program in the UK as this beautiful textbook example of this approach that we could use. And then, of course, we knew about this growing literature around herpes viruses that preferentially target your nervous system and a potential link to dementia. And in this older age group, we thought the natural outcome to look at for us would be dementia. And that’s really how it all started. Terry 08:31-08:41 Dr. Geldsetzer, do explain to us the natural experiment. You mentioned the UK. I think it was in Wales. What constitutes a natural experiment? Dr. Pascal Geldsetzer 08:42-11:33 So it’s essentially a different approach than we usually use in epidemiology and analyses of electronic health record data sets, medical claims data. Usually what we do in these studies is that we compare those who get a certain medication or a vaccine to those who don’t. And the basic problem and why often these studies are only considered to be at best hypothesis generating or suggestive but can’t get at cause and effect is that these individuals, those who decide to get vaccinated to those who don’t get vaccinated, are often very different in terms of their health motivations, health behaviors. And we have very little information on these variables, right? Like your dietary behavior, your physical activity levels. So it’s very hard to adjust for all of these differences. And we never really know whether what we’re looking at is an actual cause and effect or just that those who happen to live a healthier lifestyle of some sort or be healthier in general are the ones who decide to get vaccinated as well and therefore have a lower risk of dementia or other health outcomes. What we do in this natural experiment is that we’re using different comparison groups where we don’t rely on having perfect information on your diet and physical activity levels. Instead, we’re trying to find comparison groups that must be similar to each other in all respects. And here we have this beautiful situation in the UK and in some other countries as well in the way in which they rolled out the shingles vaccine. So specifically, for example, in the UK, they said, you are ineligible if you had your 80th birthday just prior to the start date of the shingles vaccination program, which happened to be September 1st, 2013. And you were eligible if you had it just after. So we have these beautiful comparison groups where all that’s different about them is whether they were born just a week earlier or a week later. And we know if I take a thousand people born one week, a thousand people born a week later, there shouldn’t be anything different about them in their physical activity levels, diets, etc. So we have beautiful comparison groups. And all that’s different about them is this massive difference in their probability of ever getting the shingles vaccine. And then we can look at health outcomes very similar to a situation in a clinical trial where you throw a coin and you assign people to control or intervention. And here, essentially, by random chance, just like the coin, people are born just a little bit earlier or a little bit later. So that’s why we are so excited about this research and why we really think we’re much more plausibly able to get at cause and effect rather than just correlation. Terry 11:35-11:43 And what you found was that there was a difference in the likelihood that people would develop dementia after they were 80, right? Dr. Pascal Geldsetzer 11:44-13:05 Absolutely. So we see these strong protective signals. So that was our first paper published in Nature last year, where we show that shingles vaccination appears to avert one in five new dementia diagnoses over seven years. Then we show a similarly large protective effect in Australia using primary care data from Australia. That was published just a few weeks after in JAMA. And most recently, we show this also in Canada, where Ontario was the one Canadian province that rolled out the vaccine using these date-of-birth cut-offs. Other Canadian provinces didn’t, and we only see this effect as expected in Ontario. We have got many other analyses, publications in the works. We seem to be seeing these strong protective patterns in data set after data set from different countries that rolled out the vaccine using these specific date of birth cutoffs. And it just together provides, I think, a uniquely compelling body of evidence that we’ve never had really for an intervention from observational data because we usually never have these beautiful natural experiments that we can exploit like we’re doing here with shingles vaccination. Joe 13:05-13:32 So Dr. Geldsetzer, you are three for three. You’re batting a thousand. It’s an amazing accomplishment. And you have other studies in the works. So can you just give us some sense of how they compare to one another? Are the results similar or substantially different? Dr. Pascal Geldsetzer 13:33-13:54 No, they are similar. Of course, the data sources are always a bit different. There are advantages and disadvantages. So what exactly we can look at and how [it] differs a little bit between data sets. But generally speaking, they all show the same strong protective signals that we have shown in our published studies so far. Joe 13:54-14:07 Now, one of the things that’s sort of fascinating about your research is that it used what we’ll call an old shingles vaccine. I think it was called Zostavax? Dr. Pascal Geldsetzer 14:08-14:09 Yes, correct. Joe 14:10-14:22 And that has now disappeared. We now have a, quote unquote, new and more effective shingles vaccine called Shingrix. It requires two shots. Terry 14:23-14:30 We know it’s more effective against shingles. We don’t know if it would be more effective against dementia. Joe 14:30-14:57 Well, we don’t know if it’ll even work against dementia. So that’s the big question. But we know that the old shingles vaccine was surprisingly effective at preventing an onset of dementia after several years. What is your thinking when it comes to the new, high-powered, more effective shingles vaccine called Shingrix? Dr. Pascal Geldsetzer 14:58-16:29 Yeah, that’s a very important question. I think it really comes down to what we think the effect mechanism is. If we think what links shingles vaccination to dementia is a reduction in reactivations of the chickenpox virus. So we know the chickenpox virus remains with you for life, hibernated in your nervous system after you contract chickenpox, usually in childhood. And it’s in this constant interplay with the immune system. It presumably causes some inflammatory processes. We know inflammation is a key process, a bad thing in many chronic diseases. So reducing these reactivations through shingles vaccination may well have benefits. If that is the mechanism, then we would think the newer vaccine should have at least the same protective effects for dementia because it’s more efficacious at reducing these reactivations than the old shingles vaccine. However, if we think that the effect mechanism might be through a potentially virus-independent, broader effect on the immune system, a boost to the immune system, if you like, which we know exists for many vaccines and particularly for these live-attenuated vaccines, which is the Zostavax, the old shingles vaccine, is a live-attenuated vaccine, while the newer one is not, then it’s an open question whether the newer vaccine has similar benefits or larger or smaller benefits. Terry 16:31-16:36 Dr. Geldsetzer, how have your colleagues responded to your research? Joe 16:36-16:52 And I’d like to follow up on that question because for decades, we have put all our chips on the anti-amyloid approach. This is completely new, and you have about a minute to finish that before the break. Dr. Pascal Geldsetzer 16:53-17:35 Yeah, so it’s actually been a very positive and encouraging reaction. People really, I think, understand that what we are generating here is a body of evidence from observational data that is very different and much more compelling than what we usually have for vaccines, other interventions when we do these observational data analyses. People understand this basic intuition that our comparison groups here are virtually perfect comparison groups because all that’s different about them is this tiny difference in each. And so there’s a lot of excitement now in the dementia research community around this. Terry 17:37-17:50 You’re listening to Dr. Pascal Geldsetzer, Assistant Professor of Medicine at Stanford University and a Biohub investigator. His research focuses on evaluating interventions for improving the health of older individuals. Joe 17:51-17:54 After the break, we’ll find out about the reaction to Dr. Geldsetzer’s research. Terry 17:55-18:04 Has it spurred a new way of thinking about the development of Alzheimer’s disease? It certainly is a different path from the pharmaceutical focus on amyloid plaques. Joe 18:04-18:11 The infection connection with dementia is not as new as it might seem. A hundred years ago, doctors knew syphilis caused dementia. Terry 18:11-18:18 It seems that a range of microbes might be making trouble in the brain, from herpes and chickenpox to Chlamydia pneumoniae. Joe 18:18-18:23 Will anti-vaccination sentiment have an impact on Dr. Geldsetzer’s work? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:51-20:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:54-21:09 And I’m Terry Graedon. Terry 21:23-21:51 Today, we’re talking about novel natural experiments that unexpectedly revealed a connection between infection and dementia. Policies that set arbitrary cutoffs on eligibility for vaccination with the first shingles vaccine, Zostavax, allowed researchers to compare people who were vaccinated with those who were not. This situation resembled a gold standard randomized controlled trial. Joe 21:51-22:24 This natural experiment was conducted in at least three different countries, Wales, Australia, and Canada. In all of them, vaccinated individuals did better than unvaccinated people when it came to developing dementia. Would the newer Shingrix vaccine be even more effective? Research just published in Nature Communications suggests that people who received this recombinant shingles vaccine were 51% less likely to be diagnosed with dementia. Terry 22:24-22:42 Our guest today is Dr. Pascal Geldsetzer, an assistant professor of medicine at Stanford University and a biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. Joe 22:43-23:42 Dr. Geldsetzer, I would assume that the pharmaceutical industry would be incredibly excited about your research because up until now, they’ve spent billions, perhaps tens of billions of dollars down the anti-amyloid… I won’t say exactly what I think, but down that path that has not led to much in the way of real improvement or prevention of Alzheimer’s or dementia. So along comes Dr. Geldsetzer and his colleagues, and they show that a vaccine might be effective and it might be some sort of infectious process. I mean, we’re talking about the virus that causes chickenpox. So how has the pharmaceutical industry responded to your research? And is it spurring a whole new way of thinking about Alzheimer’s disease and dementia? Dr. Pascal Geldsetzer 23:43-25:47 I do think that it is playing into, but I think generally in the dementia research community, including in the pharmaceutical industry, there’s increasing openness, I think, to other hypotheses of dementia, of Alzheimer’s disease, than the amyloid cascade. Because so far, as you’re saying, some of the large investments really have provided relatively modest output. And there’s increasing evidence that other pathways seem to also play an important role. And this year, of course, is one of these. There’s also increasing awareness of chronic disease consequences of infectious diseases more generally, for example, due to the COVID pandemic and some of the links between the SARS-CoV-2 virus and neurological consequences. So it’s certainly, I think, further opening up the openness to these possibilities. And I think, you know, for us, the next step is really trying to generate funds to run a true clinical trial on this question to be able to more conclusively test this research question. But of course, we want to use the old live-attenuated vaccine, which is off-patent, because that is the vaccine for which we have all this evidence from our natural experiments. But I think if we can provide this proof of concept that what we’re seeing in our natural experiments are true cause and effect relationships, it would be of such important implications for population health, for dementia research, that we must run this trial. And because it’s an off-patent vaccine, we are really hoping for philanthropy, private foundations to support us in getting this done. Terry 25:50-26:38 I would like to point out that the infection connection with dementia is actually not quite as new as we are imagining. A hundred years ago, or more than a hundred years ago, doctors treating patients with dementia knew that one of the possible causes of dementia was tertiary syphilis. Now, we think of syphilis as a sexually transmitted disease, which it is. It was, and it still is. But back in those days, before antibiotics, it could get to a state where it gets into the brain and actually causes pretty severe dementia. How did we forget that? Dr. Pascal Geldsetzer 26:39-27:52 Well, I think it’s always been a hypothesis in the field. But generally, it’s always been very niche because we haven’t, well, the focus was on other hypotheses, particularly the amyloid cascade. And the evidence around infectious diseases and dementia was always just in the correlational realm. So it was always comparing individuals who [were], you know, who fell sick from a certain infection or contracted a certain pathogen versus those who didn’t. And as I was saying earlier, these are always very different, usually, comparison groups, right? People who get a certain condition may have other differences to those who don’t in the immune system, in their exposure to other things in life. So we’ve never had the evidence that we have now where we have natural experiment evidence and beautiful comparison groups to show this link potentially between here an infectious agent and dementia. Joe 27:54-30:02 Dr. Geldsetzer, I’m fascinated by the idea that infections, a variety of infections, might in some way be causing dementia. So Terry mentioned neurosyphilis going way back over 100 years. But not that long ago, 30, 40 years ago, there was some suggestion that herpes simplex virus, HSV-1 and 2, might somehow get into the brain. And, you know, we know that cold sores, for example, it’s the virus traveling down the nerve to manifest itself. And, of course, sexually transmitted disease, herpes, too, can also do that. But it can also maybe go up into the brain. And so this idea that there were herpes infections, and by the way, chickenpox, varicella zoster, that causes shingles is also a herpes virus. So there were these viral infections. And more recently, there have been some studies suggesting that bacterial infections, something called C. pneumoniae, Chlamydia pneumoniae, which is not a sexually transmitted disease. It’s a respiratory disease that affects the nasal passages in the lungs. So you have C. pneumoniae, which is also easily transmitted. And then you have some other bacterial infections. I think there may be some other germs that are bad for our brains. And Dr. Geldsetzer may have a better sense of what they are. But the idea that there are a bunch of, we’ll call them pathogens, that might trigger inflammatory reactions in the brain, the neuroscience community has been somewhat resistant to that, even though it’s been out there for decades. Your thoughts? Dr. Pascal Geldsetzer 30:05-31:52 True, but in the neuroscience community’s defense as well, um we’ve never had really strong evidence on the link between these infectious agents and dementia. But you can argue easily that we should have this evidence. We should have invested by now in clinical trials for example, that treat some of these pathogens that you’re mentioning and see whether it reduces your risk of dementia. I will say, though, as well, that for the virus that causes shingles, we have a special pathogen, I think, in the sense that we know it preferentially targets your nervous system. And we know that it is in this constant interplay with the immune system and that these reactivations of the virus become more common with age. And so the idea that it may sort of act as a chronic stressor to the immune system over life and accelerate some of these chronic inflammatory pathways, the weakening of the immune system with old age, and that this may be bad for dementia disease development, maybe potentially other conditions in the nervous system, is, I think, not far-fetched. It’s highly biologically plausible. And that is a case that we don’t have for many other pathogens. So, yeah, I do think there’s something special to be said about the biological plausibility of the virus that causes shingles. Terry 31:52-32:31 Dr. Geldsetzer, we have seen over the last five or six years or perhaps a little bit longer, the development of a great deal of polarization. We have political polarization, and it’s spilled over into public health so that we have some individuals with a fair amount of prominence who have become anti-vaccination. How do you think this will affect both your research and any potential intervention that we might develop from your research? Dr. Pascal Geldsetzer 32:33-33:23 It’s hard to say. So for me really, you know I’m focused on generating the most rigorous research evidence that I can. That is everything that that I’m focused on. And I, as I was saying I’m turning particularly to to private foundations and philanthropy to hopefully be able to get a true clinical trial on this question of shingles vaccination and dementia off the ground. Because I think this would be such an important finding that we need this trial. And that’s really what I’m focused on. And I don’t think it’s my place to comment on broader societal and political issues. Joe 33:23-34:25 One of the things that distresses me is that the pharmaceutical industry has poured, as I mentioned, billions of dollars into the development of anti-amyloid drugs. And we had the great honor to interview Dr. Moir at Harvard, who had come up with the idea that amyloid might be an immune reaction to infection. In other words, it was the body’s natural immune system trying to fight off some kind of infectious agent. And unfortunately, he has died. But there are some researchers who sort of agree with him that maybe the amyloid hypothesis that if we could just get rid of amyloid, we could solve the problem, which doesn’t seem to have been the case, may have been somewhat counterproductive. Your thoughts about that original research and where it stands today? Dr. Pascal Geldsetzer 34:26-35:28 Yeah, I think it’s a very exciting line of research. And there has been more evidence generated in that line since Dr. Moir’s pioneering work on that front. So, for example, recently, there has been a team around William Eimer and Rudy Tanzi at Harvard who have shown that P-tau, so the other hallmark of Alzheimer’s disease, are these tau protein tangles. That they also appear to be produced or generated at least partially in response to herpes virus infection. So I think there is an increasing body of evidence that this antimicrobial hypothesis, as it’s called, of dementia, of Alzheimer’s disease, may well be an important line of evidence. Joe 35:28-36:23 So as I’ve mentioned, billions of dollars have been spent to try and get rid of amyloid in the body. And you would think, I mean, I would think that the pharmaceutical industry would be knocking down your door saying, Dr. Geldsetzer, please take our money. We want you to do this extraordinarily important research on vaccinations. So we’d like you to go back and look at that old vaccine that we have seen disappear from the marketplace. And, oh, by the way, we’d like you to test the new vaccine, the Shingrix vaccine, not so new anymore. But, you know, here’s $50 billion. Do this research immediately and gather your colleagues together. Why aren’t they knocking down your door? Dr. Pascal Geldsetzer 36:24-37:22 Well, it is a large investment to run a clinical trial. And in fairness, we don’t fully understand the mechanism that links Shingles vaccination to dementia or Alzheimer’s disease. That’s, of course, important. It could lead to many new insights that could lead to other potential treatments, therapeutics, preventative tools. And of course, one obstacle as well here is that the evidence from our natural experiments is for this old live-attenuated vaccine, which is an off-patent vaccine. It’s not used very widely anymore in most countries. And yeah, that’s really the main reason, I think, why I’m turning to hoping for philanthropy and private foundations to support the clinical trial. Joe 37:22-37:48 You know, there is an old vaccine, a really old vaccine called BCG. It’s a vaccine that was developed primarily against tuberculosis. There’s a little bit of data that suggests that maybe BCG would have some, we’ll call it anti-dementia benefits. In the minute we have before the break, your thoughts about BCG and the data that’s been created? Dr. Pascal Geldsetzer 37:49-38:21 Yeah, so BCG is known. It’s also a live-attenuated vaccine, just like the old shingles vaccine. And it’s known to have strong indirect effects on the immune system that appear to be important for a variety of health outcomes. So I don’t think it’s, you know, far-fetched to think that BCG may have effects on dementia disease development as well, particularly in older age. Terry 38:22-38:40 You’re listening to Dr. Pascal Geldsetzer, an assistant professor of medicine at Stanford University and a biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. Joe 38:41-38:48 After the break, we’ll consider whether antibiotics could play a role in reducing the risk of dementia. Terry 38:49-38:57 Given Dr. Geldsetzer’s research, it seems that the shingles vaccine might be a therapeutic tool in addition to helping with prevention. Joe 38:58-39:09 Scientists once thought that the brain was sterile, no bacteria, no viruses. But now it seems that it has a distinct microbiome of its own. Terry 39:09-39:17 Well, one thing we worry about is the possibility that COVID could increase the risk for dementia. How will we find out? Joe 39:17-39:24 What can we all do to reduce our chances of developing dementia? We’ll get Dr. Geldsetzer’s recommendations. Terry 39:24-39:28 He’ll also tell us about the research he hopes to conduct going forward. Joe 39:28-39:33 How does he plan to study the infection connection with Alzheimer’s disease? Terry 39:38-39:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 39:50-39:53 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 39:53-40:07 And I’m Terry Graedon. Terry 40:22-40:56 Our topic today is the infection connection with dementia. If vaccines could help delay or prevent the onset of Alzheimer’s disease or other dementias, might other anti-infective approaches also be valuable? Could vaccines help fight off dementia even after cognitive decline has begun? Dr. Geldsetzer’s research focused on the first-generation shingles vaccine called Zostavax. A new study suggests that the Shingrix vaccination might also provide protection. What about antibiotics? Joe 40:57-41:16 If bacteria like Chlamydia pneumoniae are contributing to brain problems, is it possible that treating people for infection would be helpful? Are there other bacteria or possibly even fungi that might make brain function worse? What else can we do to reduce our risk of dementia? Terry 41:17-41:35 We’re talking today with Dr. Pascal Geldsetzer, an assistant professor of medicine at Stanford University and a Biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. Joe 41:37-43:18 Dr. Geldsetzer, your research is really compelling when it comes to the issue of vaccines, especially the older vaccine, against the possibility of developing dementia, kind of what we’ll call a preventive strategy. And of course, there are literally 6 million Americans who would like to know, well, what can I do now about treatment? And there was a fascinating study in Nature Communications just recently in which the authors quoted a study from Taiwan. And they said, and I’m going to read, notably, a recent nationwide cohort study in Taiwan demonstrated that the antibiotic treatment targeting Chlamydia pneumoniae significantly reduced the risk of Alzheimer’s disease onset. These findings suggest that Chlamydia pneumoniae infection may exacerbate Alzheimer’s disease pathology and that therapeutic strategies targeting Chlamydia pneumoniae could potentially slow or mitigate AD progression. And the antibiotic in particular that they were looking at was something called a macrolide, azithromycin, Z-Pak. And I’m curious if you’ve thought at all about antibiotics as a treatment or a preventive when it comes to dementia for people who may be infected with a bacteria such as C. pneumoniae? Dr. Pascal Geldsetzer 43:21-45:10 Yeah, so I think it’s a very interesting study. Of course, as I was saying earlier, it also has this fundamental limitation that we always have in these observational data analyses usually, that patients who get this infection or patients who get this infection and then are treated versus those who don’t get the treatment for whatever reason. You know, it’s hard to know whether these are good comparison groups and whether we can really say what we’re seeing here as correlation, or actually reflect cause and effect. So that is why I think this evidence to really show a cause and effect relationship would require a clinical trial. I’m not saying that this is not true. I’m just saying that really to provide rigorous evidence that there does appear to be a link would require, in this case, a clinical trial, because there’s no opportunity here to run a natural experiment on this particular question. That is very different for Shingles vaccination, as I was saying earlier, of course. I would also say that for shingles vaccination, as you’re talking about therapeutics for dementia, we have shown in our paper in Cell in December that there are also benefits, it appears, from shingles vaccination for those who already have dementia at the time of getting vaccinated. So we see large reductions in your probability of dying from dementia in the future, which suggests that really the shingles vaccine isn’t just a preventative tool, but potentially also a therapeutic tool for dementia. Joe 45:11-45:14 Whoa. Say that again. That’s incredible. Terry 45:15-45:16 Yes, I think that’s really important. Joe 45:17-45:21 So it’s not just preventing dementia over the next five… Terry 45:21-45:24 Which in itself is a great thing. Joe 45:24-45:33 That’s huge, but the idea that it could actually be beneficial in what we’ll call a treatment situation, that’s astonishing. Dr. Pascal Geldsetzer 45:34-46:29 Yes. So I think it was for us a very important question to look at using our natural experiment approach. So we’re using the same data and same approach as we have for our first study in Wales, where we show this reduction in dementia diagnosis. And we show that there appear to be benefits across the disease spectrum as far as we can ascertain it from electronic health record data. So we show that among those without any record of cognitive impairment in the electronic health records, there is a reduction in your diagnosis of mild cognitive impairment, sort of a pre-dementia stage, if you like. And we show that among those who already have dementia, there is this large reduction in your probability of dying from dementia, really suggesting that the Shingles vaccine appears to act across the disease spectrum and not just for this prevention of dementia. Joe 46:29-46:56 Now, there are some people who may have tuned in late and they keep hearing you say this natural experiment. Could you very quickly summarize what made this a natural experiment and why it’s so critical because it’s not just one country. It’s not just the UK, Wales, but it’s also Australia and now Canada. So you’re, like I said earlier, you’re hitting a thousand, three for three. Just give us that synopsis, please. Dr. Pascal Geldsetzer 46:58-48:22 Yes. So to show in clinical medicine that a new medication or a vaccine works for a certain indication, what we always need is a clinical trial. So we throw a coin and assign participants that way to a control group or an intervention group. And the power of this approach is that we know these comparison groups must be similar to each other on average, because all that’s different about them is whether the coin landed on heads or tails. In our natural experiment, we are using the same approach. And so we are using or looking at individuals who were born just a little bit earlier and were therefore ineligible for the shingles vaccine in a number of countries. And very few people of these groups got vaccinated versus those who were born just a little bit later were eligible and a high proportion of them were vaccinated. And so just like with a coin toss, we now have two beautiful comparison groups where essentially by random chance, people were born just a little bit earlier or a little bit later. And that’s why we’re able to generate evidence that’s not just correlational in nature like we usually have with observational data analysis, but actually likely reflect cause and effect. Terry 48:22-48:56 Dr. Geldsetzer, I’d like to perhaps state the obvious. Sometimes that’s my position. But not all that long ago, we could talk to people who know a lot about the human body, and they would tell us, well, the brain is sterile, does not have a microbiome. And I think what we’re seeing with your research and some of the other related research we’ve been talking about this hour, there appears to be a microbiome in the brain. What do you say? Dr. Pascal Geldsetzer 48:59-49:56 Yes, so there’s definitely an increasing body of evidence that appears to show what you’re saying, that the brain is not sterile. But it’s also important to realize that what may link the virus that causes shingles to dementia may not be a direct invasion of the brain by the virus, but could be through chronic inflammatory processes. There’s lots of intertalk between different parts of the body and certainly between the peripheral nervous system, where we know the virus hibernates and your central nervous system, so the brain, and that these inflammatory processes may play a role in many chronic diseases. I think there’s increasing evidence, convincing evidence that this is a key process. Joe 49:57-50:43 Dr. Geldsetzer, I’m curious what you think about COVID. Here is the SARS-CoV-2 virus that has invaded the bodies of hundreds of millions of people all around the world, billions by now. And for some people, it does produce brain fog as one of the symptoms. Is it possible that some of the people who have been infected with COVID will be at higher risk in future years? And when I say higher risk, I’m talking about cognitive issues. Dr. Pascal Geldsetzer 50:44-51:23 Right. It certainly is possible. I think we still don’t understand long COVID very well from a research perspective. But I think it’s a very important area of research, as you’re saying, because it’s such a widespread infection. And, you know, even if it’s a small proportion of individuals in absolute numbers, it’s still a very important population health issue. And, yeah, certainly further investments in that area could provide really, really important insights for population health and not just for individual patients. Joe 51:22-51:28 We here at The People’s Pharmacy like to give people news that they can use. Terry 51:28-51:29 When we can. Joe 51:29-52:28 Whenever that’s possible. And so if you were to look into your crystal ball to the future, but also what people can do here and now to reduce their risk of coming down with dementia. First of all, your thoughts about shingles vaccine, even though your research was with the prior vaccine, which is no longer available, do you think the current vaccine, which is more effective, the Shingrix vaccine, is something that people should consider if they’re of a certain age? And what about other strategies? I mean, we always hear that exercise, yes, of course, that’s very, very valuable in preventing dementia. And Terry, there are some other strategies as well. But what are your recommendations these days, Dr. Geldsetzer, to prevent this debilitating, horrific condition called dementia? Dr. Pascal Geldsetzer 52:30-53:45 Right. So the shingles vaccine is a recommended vaccine for older adults in the United States because it prevents shingles. And so, you know, the evidence that it may also have benefits for cognitive health in older age, for dementia disease development, I think only provides additional motivation to get vaccinated. And yes, as you’re saying, you know, lifestyle interventions are also an important tool to reduce your risk of dementia in the future. But I think, you know, the beauty about the shingles vaccine is that it’s a one-off, relatively inexpensive, readily available, readily scalable and safe intervention. It’s not a lifestyle regimen that we know is hard to adhere to, that you have to maintain for decades. It’s not a monoclonal antibody therapy, which is what we currently have in the Alzheimer’s disease space, that has important risks as well for patients. We know this vaccine is a safe vaccine. So I think that’s what makes this particularly exciting about shingles vaccination. Joe 53:46-54:06 If we were to put you in charge of the National Institutes of Health and give you a huge pot of money and say, okay, Dr. Geldsetzer, what else should we be doing to try and reduce this risk of dementia and Alzheimer’s disease? What kinds of research would you like to fund? Dr. Pascal Geldsetzer 54:08-54:37 I would certainly like to fund a large-scale clinical trial on shingles vaccination and dementia, as I was saying before, because it would have such important implications for population health and dementia research. And if there’s anyone out there, philanthropists who think this would be an exciting project and would help us get this off the ground, I’d be incredibly grateful. Joe 54:37-54:39 How do they get in touch with you? Dr. Pascal Geldsetzer 54:37-54:55 So you can, probably email is the easiest. If you Google me, you’ll find my profile and my email. And, you know, I’ve been very excited to talk about our research, our plans, what we have in the works, et cetera. Joe 54:56-55:18 Well, we will make sure that your email address at the university is on the show notes for today. Dr. Pascal Geldsetzer 55:04-55:06 Great. Thank you. Joe 55:06-55:18 Are there any other areas, if you were to look into your crystal ball, when it comes to the infection connection with Alzheimer’s disease, that you would like to see pursued going forward? Dr. Pascal Geldsetzer 55:21-56:17 Certainly more mechanistic research would be really important here for us to try to understand particularly how shingles vaccination appears to be reducing your risk of dementia, and this dementia disease development. I don’t think I take the position that we must fully understand the mechanism before we run a clinical trial, because that’s something that will take a lot of money and a lot of time and will never have certainty. I think to me, having this proof of concept, and we don’t need to fully understand the mechanism to use this tool for reducing the risk of dementia. So to me, you know, my priority is getting this clinical trial off the ground of the old, off-patent live-attenuated vaccine for dementia. But having said that, of course, mechanistic research is an important area of investment as well. Terry 56:18-56:23 Dr. Pascal Geldsetzer, thank you so much for talking with us on The People’s Pharmacy today. Dr. Pascal Geldsetzer 56:25-56:27 Thank you for having me. Had a lot of fun. Terry 56:29-57:22 You’ve been listening to Dr. Pascal Geldsetzer. He is an assistant professor of medicine at Stanford University and a biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. In 2026, Time Magazine named him one of the 100 most influential people in health and medicine globally for his work on the link between shingles vaccination and dementia. He is currently trying to raise funds from philanthropy for a large-scale clinical trial of shingles vaccination for dementia prevention. You’ll find links to the research that we’ve been discussing in the show notes. That’s at www.peoplespharmacy.com. Joe 57:23-57:33 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 57:33-57:42 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 57:42-58:14 Today’s show is number 1,464. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email. It’s radio at peoplespharmacy.com. We would be very grateful to hear from you. Has anyone in your family dealt with dementia? What was it like? If there were a vaccine that lowered your odds, would you get the vaccine? Terry 58:14-58:24 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Joe 58:24-58:51 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We would be grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics interesting, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 58:51-59:27 And I’m Terry Graedon. Thanks for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 59:27-59:37 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 59:37-59:42 All you have to do is go to peoplespharmacy.com/donate. Joe 59:42-59:55 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

Obesity is a big problem in the US. The National Institute of Diabetes and Digestive and Kidney Diseases says 2 out of every 5 American adults are obese. What’s more, one in three is overweight, with only about 25 percent of us at a healthy weight. It’s not just adults; children are increasingly suffering weight problems as well. In this episode, we ask why we eat too much and what we can do about it. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Feb. 28, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on March 2, 2026. Why We Eat Too Much: Excess weight puts people at risk for premature death from cardiovascular disease, kidney problems and diabetes. Unfortunately, the standard advice from physicians to eat less and exercise more hasn’t often been very helpful. That’s because it doesn’t take into account the reason we eat too much: we are hungry. There are at least three different types of hunger that we need to consider, though. Most people are familiar with homeostatic hunger. If you haven’t eaten for hours, your stomach may grumble and complain. There is also hedonic hunger–eating because something tastes delicious. That’s why you can usually find room for dessert, regardless of how much dinner you’ve eaten. Hedonic hunger is often linked to emotional eating because you feel bored or stressed or depressed. The third type of hunger is conditioned hunger. Think of Pavlov’s dogs, who learned to salivate in expectation of food when they heard a bell. Some people react much the same way when they hear a dinner bell, or when lunchtime arrives, or when they get in the car. If you are accustomed to eating then, you’ll expect food and become disappointed if it isn’t available. But conditioned hunger can be addressed by deliberately changing your patterns. Set up the environment so the food is not so readily available at the times you have become conditioned to eat. Hedonic hunger yields best to figuring out the emotional basis for why we eat too much: boredom, stress, some other feeling. What other activities can help you cope with those feelings? For some people, it might be going for a walk. Others might find a different approach more helpful. How Do Weight Loss Drugs Make Us Not Eat Too Much? The most popular drugs on social media and in ads lately are the GLP-1 receptor agonists. That’s a fancy name for weight loss drugs like semaglutide (Wegovy) and tirzepatide (Zepbound). These medicines blunt the reward center in the brain that responds to food and drives some people to eat too much. They do that by mimicking satiety hormones, essentially telling our bodies “You’ve had enough.” They work pretty well for most people, at least in the short term. However, unless people retrain themselves regarding eating cues (for conditioned hunger) or emotional needs (for hedonic hunger), they are likely to gain the weight back when they stop taking the medication. For homeostatic hunger, making sure to get adequate protein and fiber in every meal can help. That tactic might not be very useful for hedonic hunger, though. Are you addicted to ultra-processed foods? That can be a challenge. On the other hand, many people who are addicted to nicotine do find ways to overcome that addiction. It is possible to overcome junk food addiction, too. Dr. Fung describes his patient Harry who used fasting, eating carbohydrates last instead of first in the meal, along with some acid such as vinegar, and was successful in losing weight and feeling better. The most important thing Harry did was to use social support from his friends. Social and environmental factors are critical in the development of obesity, so they are also paramount in overcoming it. Practical Advice to Help Us Not Eat Too Much: How do you stock up on what you need and avoid what you don’t need at the supermarket? The usual advice is to shop the perimeter, where the fresh food like vegetables, fruit, eggs, meat and dairy products are located. The ultra-processed stuff is usually in the center aisles. You also want to read labels. If that food has ingredients you can’t pronounce, you might want to put it back on the shelf. Later, you can look it up and learn if it is something you want to put in your body. Using Intermittent Fasting: Intermittent fasting can be a helpful tool, especially if you approach it as an opportunity rather than with a deprivation mindset. There are many ways to fast. Some people use time-restricted eating, eating only during the first 8 hours of the day, for example. Some skip eating every other day. It is helpful for the body to have an opportunity to burn fat from its stores. This can help regulate insulin as well as contribute to weight loss. We spoke with Dr. Fung shortly before publication of the Cochrane Collaboration’s review of intermittent fasting. These experts found that in randomized control trials, intermittent fasting is no more effective than counting calories (Cochrane Database of Systematic Reviews, Feb. 16, 2025). We are sorry we didn’t get to ask him about this. Dr. Fung’s Three Golden Rules for Weight Loss: The first is simple, if not so easy: don’t eat ultra-processed foods. The second: give your body an adequate fasting period every day. That might be at least 12 hours, but it could be longer. Each person may need to find their own “sweet spot.” Finally, find or create a social environment that will allow you to succeed. Hang out with people doing something you enjoy that is not centered on eating. This Week’s Guests: Dr. Jason Fung is the New York Times bestselling author of multiple critically acclaimed science and health books including The Obesity Code, The Diabetes Code, The Obesity Code Cookbook, The Diabetes Code Cookbook, The Diabetes Code Journal, and The Hunger Code. Dr. Fung is a Canadian nephrologist and co-founder of The Fasting Method, a program to help people lose weight and reverse type 2 diabetes and obesity. Jason Fung, MD, author of The Hunger Code His most recent book is The Hunger Code: Resetting Your Body’s Fat Thermostat in the Age of Ultra-Processed Food. The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, March 2, 2026, after broadcast on Feb. 28. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1463: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:26 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Snack foods are everywhere. Gas stations, airports, and of course in the supermarket. How can we resist such tasty treats? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:45 Obesity and metabolic disorders are major health problems in America and increasingly around the world. Ultra-processed foods are a big contributor to this growing epidemic. Joe 00:45-00:54 The pharmaceutical industry believes it solved the problem with [the] latest weight loss medications. What are the pros and cons of these drugs? Terry 00:55-00:57 What else should we be doing to overcome our hunger? Joe 00:58-01:04 Coming up on The People’s Pharmacy, why we eat too much and what to do about it. Terry 01:14-02:49 In The People’s Pharmacy Health Headlines: Highly processed foods often contain preservatives to keep them fresh. A new study from France suggests that a few of the most common preservatives may increase our risk of cancer. Researchers analyzed data from repeated dietary questionnaires completed over 15 years or longer. In this NutriNet Santé study, the majority of the 105,000-plus French adults were women. No participant had cancer at the beginning of the study. The scientists looked at customary consumption of 17 different preservatives. 11 had no link to cancer. The remaining 6, however, modestly increased the risk for a range of cancers. Total sorbates, especially potassium sorbate, for example, increased the chance of a cancer diagnosis by 14% and that of a breast cancer diagnosis by 26%. You’ll find potassium sorbate in dried fruits such as prunes or apricots. Cheese, baked goods, and soft drinks may also contain this preservative. Sodium nitrite increased the likelihood of prostate cancer, while sodium erythorbate increased the chance of any cancer by 12% and breast cancer by 21%. The investigators point out that the epidemiology linking preservatives to cancer might call for new regulations. They conclude, in the meantime, the findings support recommendations for consumers to favor freshly made, minimally processed foods. Joe 02:50-03:48 GLP-1 agonists like semaglutide have become immensely popular for weight loss as well as for blood sugar control. Now scientists suspect that tirzepatide, a combined GLP-1 and GIP agonist prescribed by the brand name Mounjaro and Zepbound, might also be useful against addiction. Researchers in Sweden tested tirzepatide in rats who had become accustomed to drinking alcohol. While they were on the drug, they cut their alcohol consumption by at least half compared to the control group. In addition, when they were once again exposed to alcohol after not having access for a while, they did not go back to their former level of alcohol consumption. The scientists found that tirzepatide reduces spikes of the reward-related neurotransmitter dopamine in the animal’s brains. It’s not clear whether the potential benefits observed in rats will translate to humans with alcohol use disorder, but it definitely deserves further research. Terry 03:49-05:03 If you’ve been wondering what you should eat to improve your chance at a long, healthy life, you’re not alone. Curious nutrition scientists analyzed dietary data from more than 103,000 UK Biobank participants. They were all middle-aged and free of disease when the study started. Over a follow-up period of about 10 and a half years, more than 4,000 of them had died. Five different diets reduced the likelihood that a volunteer would die. The helpful diets included an alternate Mediterranean diet, an alternate healthy eating index, dietary approaches to stop hypertension, a healthful plant-based diet index, and the diabetes risk reduction diet. Those ranking in the top scores of any of these eating patterns could expect to live a year and a half to three years longer than those ranking at the bottom. The best patterns for men and women were slightly different, though. Men did best on the diabetes risk reduction diet, while women fared better on the alternate Mediterranean diet. Researchers had access to genetic information about all participants. However, taking genetics into account did not alter the results on beneficial diets. Joe 05:04-05:59 Many people struggle with sleep. While experts often recommend getting more exercise during the day and improving sleep hygiene at night, these suggestions don’t always result in the improved sleep that insomniacs would like. A randomized clinical trial in China found that a combination of high-intensity circuit training and sleep health intervention is more effective than either approach alone. The scientists recruited 112 women between 18 and 30 years of age and assigned them to one of four groups, training, sleep health intervention, both or neither. The treatments lasted two months and demonstrated superiority of the combination approach. This resulted in better sleep efficiency and less waking during the night. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:32 And I’m Joe Graedon. Americans love fast food. We eat on the go. We eat in the car. We eat while watching television, and we just basically eat all the time. Snacks have become part of our routine. Terry 06:33-06:54 It’s hardly any wonder there’s an obesity crisis. According to the National Institute of Diabetes and Digestive and Kidney Diseases, two out of every five American adults are obese, and one in three is overweight. That means only about a fourth of us are a healthy weight. Increasingly, children are also suffering from weight problems. Joe 06:54-07:05 How did we end up in this mess? All those extra pounds increase our risk for diabetes, kidney disease, and even cardiovascular problems. Terry 07:05-07:14 Semaglutide and tirzepatide have made billions for the drug companies. Will they be a long-term solution for the obesity epidemic in America? Joe 07:14-07:47 To help us better understand how our food choices are affecting our health, we turn to Dr. Jason Fung. He’s a Canadian nephrologist and advocate of intermittent fasting. He’s written or co-authored numerous books, including “The Obesity Code,” “The Diabetes Code,” and his latest, “The Hunger Code: Resetting Your Body’s Fat Thermostat in the Age of Ultra-Processed Food.” He’s co-founder of The Fasting Method, a program to help people lose weight and reverse type 2 diabetes and obesity. Terry 07:48-07:52 Welcome back to the People’s Pharmacy, Dr. Jason Fung. Dr. Jason Fung 07:53-07:54 Thanks for having me. It’s great to be here. Joe 07:55-08:35 Dr. Fung, you are dealing with one of the most important topics people have to address, and shortly we will deal with the elephant in the room, the GLP-1 agonist receptors. But first, you know, you have described weight gain and the understanding about, you know, how it happens and how to lose that weight gain and keep it off. And I guess I’d like to ask you, what new understandings do we need about weight gain so that we can make the critical changes in our life that will produce sustained weight loss? Dr. Jason Fung 08:36-12:11 Yeah, so, you know, I trained pretty conventionally as a physician. You know, through medical school all this time, people are just like, well, you know, you’re just gaining weight because you’re eating too much. So therefore, the solution is just eat less. And the problem with that is that it’s very, very superficial. It really doesn’t try to understand the underlying causes of that eating behavior. Which is that if you don’t, you know, we’re not trying to, you know, see, you know, that calories in is greater than calories out. We need to understand why. So it’s just like alcoholism. Alcoholism is alcohol in minus alcohol out. So does just telling somebody just drink less alcohol, like, is that useful advice? And it’s not because you’re not understanding the reasons why people are drinking alcohol. So if the reason that somebody is alcoholic is because of depression or addiction or PTSD, then deal with the depression or the addiction or the PTSD. So it’s the same thing with understanding why people are overeating. So the simple fact is that if you are trying to understand why people are sort of overeating, you have to understand why people are eating in the first place. And it’s very simple. You eat because you’re hungry and you stop eating because you’re full. So that’s sort of a fundamental truth. So if you’re saying you’re overeating, then the problem really is over-hunger because that’s the reason you’re overeating in the first place. So that’s the thing that you have to understand. And the GLP-1s, for example, do not restrict calories. They reduce hunger. And that’s a critical difference because if you simply tell somebody to eat less, their hunger is just going to go up and your body is going to keep fighting itself. Your body is trying to make you eat more because you’re going to be more hungry and you’re trying to eat less because you’re trying to lose weight. And something always breaks at that point. So you have to understand what is hunger and how is it driving eating behavior. And it’s actually a fascinating, complex topic. And it’s not simply because you ate, you’re less hungry. There are different foods, for example, that create hunger and satiety. So you can eat, say, a three-egg vegetable omelet, and that’s going to make you really full. If you eat the same number of calories but instead drink a Frappuccino, you’re hungry five minutes later. That’s a huge difference, even though they’re the same number of calories. So it’s not the number of calories that determines hunger and satiety, it’s the hormones that are triggered. So things like GLP-1, which is affected by the drug like Ozempic, but also, you know, all these other hormones play a role. Insulin, cortisol, GLP-1, GIP, glucagon, the sex hormones play a role. So all of these different aspects of human physiology play a role because food doesn’t just contain calories, it contains information, right? And what it means is that the food energy is measured in calories. But when you eat a food, the minute you put it in your mouth, you produce different hormones. So the vegetable omelet or with some kind of meat, for example, is going to stimulate a lot of GLP-1. The Frappuccino is not. And that makes a difference. The Frappuccino will stimulate a lot of insulin, and the egg omelet will not. And that makes a difference. Joe 12:11-12:15 Let me challenge you on one thing, if I may. Dr. Jason Fung 12:16-12:16 Sure. Joe 12:16-12:51 There are lots of times when I will snack when I’m not hungry. I mean, zero hunger. But I’m anxious. I reach a kind of a point where I’m not making progress. And I go upstairs and look in the pantry and the nuts look so appealing. Not because I’m hungry, but because I hit a roadblock in something I was writing. What about all of the other reasons that we eat besides hunger? Dr. Jason Fung 12:52-13:25 Absolutely. That’s very, very important because that is a type of hunger. It’s a different type of hunger, right? So when you’re describing hunger, there’s actually three types of hunger at least. There’s probably even more. The physical hunger that we all think about is scientifically termed homeostatic hunger. That depends on the hormones. But that’s not the only reason you eat, just like you said. There’s a hedonic hunger. And hedonic hunger, hedonic is a word that means relating to pleasure, is that you eat because it makes you feel better. Terry 13:26-13:27 So that’s the dessert hunger, right? Dr. Jason Fung 13:28-17:38 Exactly. Because nobody eats dessert because they’re hungry physically. They’re eating it because it looks good. It tastes good. It makes you feel better. Same thing with comfort foods. You’re eating it to soothe that emotional hunger. You’re trying to feel better. You’re trying to give yourself pleasure because eating gives us pleasure. And that’s the reality. So why deny it? Why pretend like this hedonic hunger does not exist? If you’re under a lot of stress, you need something to make you feel better. So you go look and, oh, hey, there’s some cookies or there’s some nuts or some whatever. That’s emotional eating, right? That’s a completely different type of hunger, but it is a type of hunger. And where that’s important is really ultra-processed foods. It speaks to ultra-processed foods because ultra-processed foods are really engineered to make you want them, right? They talk about bliss points, but there’s all this artificial flavors, artificial colors. There’s all this processing that makes it easy to eat, that minimizes satiety. So there’s many, many different reasons why the ultra-processed foods are engineered to create this hedonic hunger so that you go out and eat them. Not because of the physical, you know, oh, my stomach is growling, I need something, but because of that emotional hunger. But then there’s actually a third type of hunger called conditioned hunger. And again, conditioning is a phenomenon which is well described. So the classic example is Pavlov’s dogs, for example. So you can take dogs and if you give them food, they’ll salivate, they’ll become hungry. Now you can take a neutral stimulus like a bell, which normally does not make dogs salivate. But if you pair the bell with the food consistently, when you bring a bell, the dogs will soon start to get hungry and salivate. So you’ve turned this sort of neutral stimulus into a conditioned response of hunger. But you think about what we’re doing in the United States, right? People eat all the time. The minute you get up, you have to eat. If you get a coffee, you have to eat. If you go for lunchtime, you have to eat. If it’s a meeting, you have to eat. If it’s dinner time, food everywhere. You go to the mall, there’s billboards, there’s food, there’s smells. Everywhere you look, there’s food. And what it does is you’ve paired all these things with food. So now you sit in front of the movie theater, you sit in front of the TV, now you become hungry. You stimulated this conditioned hunger. And it’s important to understand these types of hunger because they all have different toolkits that we need to fix them, right? So if your problem is you’re eating too many refined carbohydrates and not enough proteins, for example, then you can fix that. That’s homeostatic hunger. But if your problem is that you’re looking for, you’re eating out of boredom, for example, then you need to fix that. It’s not just about saying eat less. You need to say, hey, what should I do so that I will not use food for comfort and I’ll find something else? Maybe it’s going for a walk. Maybe it’s getting a hobby. Maybe it’s playing basketball. Maybe it’s talking to your parents or talking to your friends or something else, right? But what you’ve done is you’ve identified the hedonic hunger and you’ve been able to neutralize it because you understand it to say, hey, instead of, you know, going to food to feel better, I’m going to go for a walk. I’m going to go get a manicure, a pedicure. I’m going to go for a massage. I’m going to talk to my friend to feel better. And I’m going to schedule this on a regular basis, right? But it’s a different toolkit. Or if your problem is conditioned hunger, that every time you walk past the coffee store, you have to get a muffin, then you say, oh, this is conditioned hunger. But now you understand it. So say, oh, what I’m going to do, I’m going to start using my app and I’m going to order coffee and only coffee. Now when I go pick it up, that’s all I get, right? Because I’m not lining up. Terry 17:38-17:42 Or perhaps you take a different route so you don’t walk past the coffee store. Dr. Jason Fung 17:43-17:53 Exactly. Or you say, okay, well, I’m not going to go to the mall because they have the Cinnabon there that’s wafting all that, you know, wonderful cinnamon bun smell that’s snagged so many people. Terry 17:55-18:05 You’re listening to Dr. Jason Fung, nephrologist and author of “The Hunger Code: Resetting Your Body’s Fat Thermostat in the Age of Ultra-Processed Food.” Joe 18:05-18:11 After the break, we’ll discuss the GLP-1 agonists like Ozempic and Wegovy. Terry 18:11-18:13 How long might people take them and what happens when they stop? Joe 18:14-18:16 How can you fix all three types of hunger? Terry 18:17-18:24 Hedonic hunger, eating because something tastes yummy, is the hardest to address. Getting enough protein and fiber alone may not do the job. Joe 18:24-18:30 If obesity is multifactorial, which factors are most important? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:54-19:08 And I’m Terry Graedon. Terry 19:25-19:30 Today, we’re talking about why we eat too much and what we can do about it. Joe 19:30-19:56 The pharmaceutical industry thinks it’s figured out the solution. If everyone just took a drug like Wegovy or Zepbound, the problem would be solved. Except the drugs are expensive and have some serious side effects. Some researchers estimate that 50 to 75 percent of those who start on such medications quit within a year or two. What happens then? Terry 19:57-20:26 To find out, we’re talking with Dr. Jason Fung. He’s a Canadian nephrologist and advocate of intermittent fasting. He’s written or co-authored numerous books, including “The Obesity Code,” “The Diabetes Code,” and his latest, “The Hunger Code: Resetting Your Body’s Fat Thermostat in the Age of Ultra-Processed Food.” He’s co-founder of The Fasting Method, a program to help people lose weight and reverse type 2 diabetes and obesity. Joe 20:28-21:39 Dr. Fung, you’ve described elegantly the different kinds of hunger and perhaps how we can modify our response to boredom or actual, oh, I am so hungry, I can barely stand it. And we want to segue to the elephant. It’s not just an elephant. It’s a gigantic elephant. It is the GLP-1 receptor agonists, the Ozempics, the Mounjaro. There’s no question that they have changed the world because literally millions of people all around the world are taking these medications, now coming out in oral form instead of injectable form. So I guess the first question is, why do they work? And clearly they do. How long should people be taking them, and what happens when people stop? So give us your, you know, quick overview of the GLP-1s because a lot of people say, you know, I don’t have to worry about all that stuff that Dr. Fung is talking about. I’m just going to take a pill or get an injection and my hunger’s gone. Dr. Jason Fung 21:39-25:59 Yeah, and that’s the important thing. So GLP-1, so the GLP-1 system is part of a hormone system called the incretins, which includes GIP, which Mounjaro affects both GIP and GLP. There’s a third one, glucagon, which is actually in development now. There’s a new drug that’s going to target all three of them. But what you have to understand is that’s part of the homeostatic system, right? The homeostasis is a natural biological phenomenon where you set a certain point, right? A sort of set point. And, you know, if you go over it, your body tries to bring it back. If you go under, it tries to bring it up, just like body temperature. If you live in the Sahara Desert, you’re too hot, you sweat. If you live in the North Pole and you’re cold, you shiver, right? So either way, you get back to that homeostatic set point. So homeostasis is the same. So GLP-1 is part of this homeostatic system. That is, when you eat, the foods you eat are going to stimulate certain hormones like GLP-1, which tell you you’ve eaten enough. So when you eat beef, for example, and protein is probably one of the biggest stimulants of GLP-1, but also fiber, for example. So when you eat a big bulky meal of whole grains, for example, or if you’re eating a lot of beef and stuff, you’re going to stimulate the GLP-1, which tells you that you are now full, you need to stop eating. And it’s a very powerful system, right? You think about, you know, all you can eat buffet. If you’ve eaten a lot and somebody says, here, have some more pork, you’re like, I’m going to throw up, right? That’s because it’s such a powerful system. That’s part of the homeostatic system. And that’s why when you stimulate that system, you can create satiety and overwhelm the hunger from a homeostatic standpoint. The problem is with that drug is that it sometimes goes over the line and you get side effects, right? So nausea, vomiting, and that’s one of the problems. But it works, right? People stop eating because they’re full, right? So it’s not about restricting calories. It’s about restricting hunger. And this can lead into those other types of hunger. Because if you have emotional hunger, that is hedonic hunger, or if you have conditioned hunger, so you go to the car and normally you would want to eat. But what you’ve done is you’ve overwhelmed it with satiety coming from this GLP-1 system. Then you’re not going to want to eat because you actually have, you’ve sated this hunger. But it’s not a normal satiety, right? So when you look at the GLP-1 levels, the drugs don’t give you normal levels. They give you super physiologic pharmacologic doses of this GLP-1 system. That’s why it can overwhelm those other systems. So it can certainly work. The major problems is there’s a couple of them. One is that there’s side effects, right? But if you can tolerate the side effects, then the other major problem is that when you stop taking it, you will gain all that weight back. Why? Because you never learned to fix the problem. You simply overwhelmed it with GLP-1 to fix all your problems. So if your problem is emotional eating or your problem is conditioned hunger, you can take a drug and overwhelm it by affecting the homeostatic system. But you never fix the underlying emotional hunger or the hedonic hunger or the conditioned hunger, right? And that’s the problem because then when you take away that drug, all your weight comes rushing right back. And so, you know, the most effective is really to pair the two, right? It’s not to say that you should never use GLP-1. They have a role because certain people have to lose weight. So they do have a lot of benefits, right? So when you lose weight, you do better from a diabetes standpoint, you do better from a heart standpoint, fat and liver. So there are a number of medical benefits. But understand that you’re not actually fixing the problem that led to the weight gain in the first place, right? You fixed it by using a separate thing, right? So that’s why when you stop and you haven’t fixed those other problems, then it’s going to come back. So if you can use that as a sort of bridge and say, okay, well, I’m going to use this to help me now, but I’m going to try and understand what is it? Why am I eating so much? Why am I always hungry? Is it conditioned hunger? Is it hedonic hunger? Is it homeostatic hunger? And try and fix it. Then you’re going to be more successful when you do try to come off of it. Terry 25:59-26:22 Let’s talk a little bit about fixing that hunger then. Especially, I think, the hedonic hunger, I think, is something that people find very difficult to address. And I’m not sure that, you know, making sure that you eat your protein and your fiber is going to address the hedonic hunger problem, is it? Dr. Jason Fung 26:23-28:16 Yeah, the hedonic hunger is actually a very interesting problem because it actually, the two main topics within that are actually going to be ultra-processed foods and food addictions. Both of which have had sort of the research behind those two topics has sort of exploded in the last five years. And that’s really what the hunger code I cover in the new book is a lot of this new understanding of sort of hedonic hunger and the reason why ultra-processed foods are so dangerous. So to give you some history, in the 1977 dietary guidelines, the dietary villain was fat, right? So the unwanted consequence or unintended consequence was that people felt that highly processed foods that are lower in fat are good for you. And that’s where you got margarine and all these other sort of really super artificial foods. Because people thought the processing was actually something good because you took out the fat. The problem with ultra-processed foods is that you can create them in any way you want. And as a food company, if you’re making a food, you want to engineer it for maximum pleasure, right? So, you know, you want to create huge dopamine spikes, huge glucose spikes, because when you can take a food and the way you engineer it is by not just the salt and the sugar and the fat, or you talk about bliss points and stuff, but you engineer it by creating very quick absorption. So if you eat a food and it’s really, really easy to eat, it practically melts in your mouth, it goes into your stomach and then basically goes absorbed very quickly. Then you’re going to get massive spikes in your blood of all these things, which is going to give you a big hit in terms of dopamine and pleasure and so on. Terry 28:16-28:18 And of course, it tastes like “more.” Dr. Jason Fung 28:19-29:24 Yeah. And then you want more and you want less satiety. So you want maximum pleasure and also maximum absorption. And the way you do that is you engineer it with texturizers and emulsifiers for the mouthfeel and you put artificial flavors and artificial colors to get people to want it. And then you take away everything that gets in the way and creates satiety. So first is creating the pleasure. So for the hedonic side of things, because the quicker you absorb the food, the faster it goes from sort of your mouth into your bloodstream, the more effective it is. And that’s why you smoke nicotine, for example, because when you smoke cigarettes, the nicotine goes from your lungs into your blood vessels through the lungs. You don’t eat it because eating the nicotine is much slower. And that’s why you use nicotine gum to sort of wean yourself off. Because by the time you eat it and it gets through the stomach and into the intestines and into the bloodstream, it’s so much slower. You don’t get the quick hit. Terry 29:24-29:53 All right, Dr. Fung, here’s the question. You just mentioned nicotine. And I think that all of us recognize that smoking is bad for you. And a lot of people have figured out how to cut their addiction to tobacco. So they have quit smoking. What do you do about an addiction to ultra-processed foods? How do you quit that? Dr. Jason Fung 29:53-31:42 Well, you have to understand that addiction has to be treated like an addiction. So food addiction is no different. And the thing about addictions is that people say, well, you can’t stop eating food. But no, you have to understand that it’s not all foods. It’s the ultra-processed foods, right? If you’re addicted to alcohol, you don’t have to stop drinking tea, for example. If you think about how people are addicted, it’s because it’s absorbed quickly and it’s engineered and it’s ultra-processed. So therefore, you don’t have to stop all foods entirely. Like nobody says, oh, I’m addicted to beef. I’m addicted to salmon. I’m addicted to eggs, but they do say, I’m addicted to bread. I’m addicted to pizza. I’m addicted to chocolate. I’m addicted to candy. Those are all ultra-processed foods. And the key with addiction is abstinence. You have to not take it, right? You can’t say everything in moderation. Like, do you ever say to an alcoholic, just have a drink, everything in moderation? No, because that first drink is going to lead you to want more. It creates that hedonic hunger. Same thing with ultra-processed foods. If you have an ultra-processed food addiction, you need to not take ultra-processed foods, but you have to identify that. One, the ultra-processed food is the culprit, and two, you have to identify it as a real addiction. And that’s where the research in the last few years, because there’s a scale that you can use now for research called the Yale Food Addiction Score, where clearly a lot of people who have weight problems are actually addicted to food. But people who are well-meaning will say, hey, you can have this cookie, everything in moderation. It’s only 50 calories, right? That’s like saying to an alcoholic, just have a drink, everything in moderation. You haven’t had one in a while, right? It doesn’t work because you haven’t identified the problem as a food addiction. And that’s a problem with the hedonic side of the hunger. Terry 31:42-32:10 Dr. Fung, you offer us a wonderful little story in your book, The Hunger Code, a story about Harry. And I hope that you remember Harry and can tell us what he did to lose weight because you lay out several different approaches that he used, not just one thing, but several. Can you tell us the story of Harry? Dr. Jason Fung 32:10-35:44 So, yeah, Harry was somebody we worked with at The Fasting Method. And, you know, for him, he recognized that part of his problem was sort of how he ate the foods. And so one of the things that he was able to use very successfully is fasting, because fasting helps him sort of break a lot of the conditioned hunger and broke a lot of the hedonic hunger. He was able to lose some weight. But then even when he started eating again, he did, he ate differently by combining carbohydrates with other foods rather than eating them alone, for example. So when you eat carbohydrates by themselves, which I call naked carbohydrates, you’re getting a very quick hit of carbohydrates. And this is causing a lot of this hedonic hunger. But if you eat it with other things, it’s going to slow down the absorption. So it’s just sort of like if you think about alcohol, drinking alcohol on an empty stomach, not always a great idea, because the alcohol really starts to hit you. Same thing with the carbohydrates. If you’re eating with proteins and fats and you’re mixing it, you’re going to absorb it slower and get less of that hit. And using organic acids such as vinegar, vinegar is acetic acid, you can actually reduce again the sort of glucose effect and how quickly it’s absorbed because the organic acids inhibit amylase, which breaks down the carbohydrate. So because the carbohydrate is breaking down much slower, therefore you’re getting less of this hedonic hunger. The fasting is working on the conditioned hunger. And using a combination of those things, he was able to lose a tremendous amount of weight and he actually felt so much better. And these are sort of simple hacks. And again, you have to understand the problem so that you can bring different sort of a different toolkit to the problem, because you can’t use the same toolkit. And I think that’s, you know, fasting, you know eating carbohydrates with other foods eating with vinegar those are all little strategies that we cover because the problem with this whole calorie based approach which is just eat less calories is that it’s sort of like the to the man with a hammer every problem is a nail, right? So if your problem is hedonic hunger, it’s eat less calories. If your problem is you know emotional eating, it’s eat less calories. If your problem is you didn’t get enough sleep the solution is eat less calories. It’s like, what? If you’re getting not enough sleep, isn’t the solution, get more sleep, not eat fewer calories, right? So you have to understand the problem. And that’s why I say the problem of obesity is actually a very complex medical one. It’s not a math problem. It’s not a calories in calories out counting problem that some people believe it is. It’s not a thermodynamic problem, because some people say it’s about thermodynamics. But no, it’s a human physiology problem. It’s about eating behavior, right? And if you think that it’s all about the diets, well, you’ve probably already lost because it’s about all these other things, right? Your environment, you know, we saw this during COVID, right? People were gaining weight like crazy. Why? Because they were sitting at home next to the refrigerator, right? They’re eating way more and they’re drinking way more like alcohol than they normally did. Why? Because their environment had changed, had nothing to do with willpower or anything else. So understanding the problem of environment, understanding the problem of emotional eating and that sort of thing is going to just make us more successful. The more you know, the better you do. Terry 35:46-35:55 If obesity is multifactorial, as you’ve suggested, which factors are most important? And you have about a minute. Dr. Jason Fung 35:55-37:14 I would say the most important two factors, I’d say, that we actually never talked about is the sort of social environmental factors. So the people around you have an enormous influence on what you do. Like if everybody around you is hiking, you’re hiking. If everybody around you is eating and watching TV, you’re eating and watching TV. So that’s actually a very important thing. So the environment, the micro environment that we surround ourselves in, our family, our friends, but also the society around us which dictates the social norms actually plays a huge role in weight gain. And you see that because the obesity rates in different countries around the world are fantastically different, right? So in America, you have a very high rate of obesity. In Italy, you don’t, but Italians love food. They absolutely love food. But you take those Italians, stick them in America, and they all become obese. Why? It’s not the people. The people are the same. It’s the environment that they’re in, this ultra-processed environment where all our foods are sort of artificial and so on. In Italy, it’s not like that. They have a much lower level of ultra-processed foods. So the food environment, the microenvironment, ultra-processed foods, those are the most important things that we need to talk about. Terry 37:15-37:24 You’re listening to Dr. Jason Fung. His latest book is “The Hunger Code: Resetting Your Body’s Fat Thermostat in the Age of Ultra-Processed Food.” Joe 37:24-37:54 After the break, Dr. Fung will share his three golden rules of weight control. Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:54-38:07 And I’m Terry Graedon. Terry 38:21-38:26 By now, you’ve heard the term ultra-processed food more than you’d like. What does it mean? Joe 38:27-38:30 How should you be shopping to avoid these tempting treats? Terry 38:30-38:52 We’re talking today with nephrologist Dr. Jason Fung. He is co-founder of The Fasting Method, a program to help people lose weight and reverse type 2 diabetes and obesity. His books include “The Obesity Code,” “The Diabetes Code,” and his latest, “The Hunger Code: Resetting Your Body’s Fat Thermostat in the Age of Ultra-Processed Food.” Joe 38:54-39:25 Dr. Fung, I need some practical advice about shopping. So when we go to the farmer’s market, it’s easy because there are lots of vegetable vendors. They’re every place. There are people who raise chickens. There are people who are creating certain kinds of specialized foods, and there’s no ultra-processed food in sight. Terry 39:25-39:27 So the specialized foods are like cheese. Joe 39:28-40:57 Cheese, for example. But you will not find a packaged food, you know, with 14 ingredients and chemicals that you can’t pronounce. When you go to the supermarket, on the other hand, there is an extraordinary number of stuff that is impossible to know what’s in it because they have names that you’ve never heard of and couldn’t pronounce even if you were a chemist. And they’re all designed to scream at you, “Buy me.” The packaging is very creative and very enticing and you know the flavors. I mean, I’m a sucker for pretzels. I mean, walking past the pretzel aisle is very challenging. And every once in a while I give in and I grab a package of pretzels. But whether it’s the yogurt with the fancy flavors or whether it’s the cookies or whether it’s even the nut aisle, I mean, there’s just so much food calling out to you and you know how tasty it is because you’ve eaten it before and you love the flavors. How do you avoid buying the stuff that you are describing as the ultra-processed food? It just is so tasty. Dr. Jason Fung 40:59-45:00 Yeah, that’s a great question. And really, it begins with the mindset, right? And the mindset is the way you sort of filter all your information. So to give you an example, you know, sugar, for example. It used to be very popular. People love sugar and it was felt to be not bad for you, right? So in the 80s and stuff, there were cereals called like Sugar Pops and stuff. You know, they were proud of the fact that there was sugar in it. But as people sort of learned that, hey, added sugars are not really good for you, the tide started to turn, but there’s the mindset, right? People went from looking at sugar as a good thing to looking at sugar as really a real indulgence and something you really shouldn’t eat a lot. So of course, but when you do that, when you change your mindset, that’s how you change your behavior, right? Because your mindset, you know, is how you feel about things and then how you feel about things changes. So if you think sugar is something that you want, but can’t have, then you’ll get a deprivation mindset and you won’t be able to change. If you start looking at sugar as a toxin, for example, which is okay in small doses, very bad in large doses, then you’re not going to want those things. And that’s going to be all the difference. And it’s going to be the same with ultra-processed foods. So in the past, people were like, Oh, wow, hey, this is great. This is this food and it tastes really good. But people are starting to change because now they’re like, Whoa, look at all this chemical, I don’t even want this anymore. And you see that because people are saying, Oh, you know, only natural ingredients are all natural. Like you see it on the packaging now, but it’s the mindset because if you take that mindset that this is a, this is really, really bad for me and maybe it tastes good, but it’s really horrible stuff. You’re not going to want that anymore. So, you know, you go to certain places like the, the, you know, California and, you know, the, the farmers markets and stuff. Right. And then it makes it easy because those are the, what you have to do is change your mindset. And to some extent, when you decide to change your mindset, what you have to do is just repeat yourself. Oh, that’s too ultra-processed. I can’t eat that anymore. And it’s not always so obvious, right? So I give an example in the Hunger Code of sour cream. So sour cream should just be cream, right? That’s all it really should be with some bacterial cultures. Same with yogurt, right? It should be just bacterial cultures and milk. But if you look at a lot of sour creams on the market, they have xanthan gum and carrageenan and this and that. I don’t even know what it is. And I thought I was getting sour cream. I’m getting six different chemicals in my body. So I look at that. And because my mindset has changed over the last five or 10 years, now I’m sort of revulsed a little bit because it’s like I want sour cream. I’m not buying carrageenan, right? I don’t want carrageenan. Don’t put it in my sour cream or the yogurt, right? I look at certain yogurts, I was like, okay, but there’s all this sugar, there’s all this other stuff in it, there’s all this xanthan gum in it. Like, that’s terrible stuff. So I don’t even want it, right? So yes, it might be delicious, but changing your mindset actually is the first step to changing your behavior. So understanding the sort of toxic nature of those ultra-processed foods, and then repeating to yourself that, hey, this is bad for me, I don’t even want this, right? And at first it feels a little artificial, but over time, as you start to repeat it over and over to yourself, it’s like, oh, gross. So ultra-processed, so ultra-processed. Eventually you move away from actually even wanting that. And that’s where it doesn’t even have a hold on you anymore. And sure, once in a while you’re still going to have it. But what you want to do is cut down from, say, 70% ultra-processed foods, which is where the Americans, the general American diet is, to like, you know, maybe 25, 30% like the Italians. Terry 45:01-45:28 Dr. Fung, you mentioned a deprivation mindset. And I think that’s where a lot of people approach fasting. Oh, I can’t eat today. I’m going to feel terrible. And you are a proponent of fasting. That’s what we mostly talked about years ago when we spoke to you before. Can you tell us why fasting is helpful and how we can use it most effectively? Dr. Jason Fung 45:30-47:22 Yeah, so fasting is really just letting your body use up its stores of calories. Remember, body fat is simply a store of calories. So if you don’t eat, your body will release calories from its fat stores, which is great if you want to lose weight, obviously. So that’s the whole point. It’s natural. This is what it’s for. You can do it. Is it fun? No, not particularly. So the mindset is very important because if you take fasting and say, oh, this is hard work, it’s deprivation, I’m not going to do it. You’re going to fail, right? And that’s the diet mindset as well, right? I want to eat this, but I can’t, right? You have to change that. So instead of viewing fasting as a chore that you don’t want to do, you want to see it as an opportunity. You want to say, hey, this is an opportunity for me to use my stores of body fat, because as I lose this weight, I’m going to be healthier, I’m going to feel better, and I’m going to look better, right? So you have to just keep repeating that to yourself. Again, first, it feels very unnatural. Then after a while, it’s like, oh, okay. Because I remember, you know, sometimes when I do fast, I do sort of sometimes a bit longer because I find it very helpful because it helps some of the aches and pains and stuff. And so I view it very positively. And the thing about fasting is that it used to be something very positive, right? It used to be called a cleanse, a detoxification, a purification. It was always positively associated with improved outcomes, right? It’s only been in the last 10 years that people said, oh, fasting is bad for you. But because I find it, you know, I feel good sometimes on it. Like I feel some of these aches and pains better. Sometimes I get a little annoyed when people are like, oh, let’s go out for dinner. I’m like, ah, damn, I’m in the middle of a fast. I don’t want to go. Right. I don’t want to be rude. Joe 47:23-48:07 Let’s just stop there for a second. Because when you say fasting, that means a lot of different things to a lot of different people. So for some people, it means, well, I’m not going to eat for the next three days. And for other people, it’s, well, I’m only going to eat until two o’clock in the afternoon. So I’ll have breakfast and I’ll have lunch, but then I won’t eat again until the next morning. I won’t eat dinner and I won’t eat snacks before going to bed. Other people say, no, no, I’m not going to have any breakfast. I’ll just wait until noon and that’ll be my first meal. And then I’ll have a little snack at five o’clock and then I won’t eat anything again until the next day at noon. So what do you mean when you say fasting? Dr. Jason Fung 48:07-49:44 Fasting can be any of that. So fasting is just any period of time that you decide you choose to not eat. So it could be, you know, it could be any of those. It could be, it could be, you know, 12 hours. It could be 16 hours. It could be 24 hours. It could be two days, three days, four days, and so on. So it doesn’t really matter. But whatever you feel, you know, is your appropriate period of fasting that you want to do, then that’s your fasting period, right? So if you eat dinner at, you know, five o’clock, six o’clock, and you decide to have an early dinner and then push breakfast late, for example, so you have an eight-hour eating window and a 16-hour fasting window, that’s a very popular term called the 16-8 fast. And it helps for a lot of people, right? But what you want to do is make sure that you’re viewing your fasting period as your cleansing period, something you’re doing to make you feel good. And when you put down food rules like that, it helps you stick to it because it’s a lot easier to stick to that rule because you say, well, I’m not going to eat between, say, you know, six o’clock at night to, you know, 10 o’clock in the morning. That’s my fasting period. Then you’re no longer tempted because you’ve set that for your rule because you’re feeling like that’s what you need to stay healthy. Then it’s easier to stick to it rather than something very nebulous like calories, which is like eat whenever you want, whatever you want, as long as you stay within these calorie limits, right? But you don’t know how many calories you’re eating. It’s very hard to count your calories, whereas it’s easy to count your hours that you’re not eating. Terry 49:44-50:09 Dr. Fung, I do want to ask about potential hazards of fasting because we always like to ask about side effects and downsides of whatever intervention we’re discussing. And it strikes me that there might be some people who could get themselves in trouble, people who are prone to eating disorders. Can you address that at all, please? Dr. Jason Fung 50:10-52:04 Yeah, so in fact, eating disorders is always a concern. The data on the studies on fasting show that it doesn’t increase the risk of eating disorders. Because remember, fasting doesn’t mean that you’re not eating for 40 days and 40 nights, right? It could be simply you don’t eat after dinner until breakfast time, right? That’s the very term breakfast, break fast. That’s the meal that breaks your fast, which implies that you should be fasting for a period of time every single day. Because when you’re eating, you’re eating more calories than you can use at that moment. So therefore, you need to fast in order to eat the calories that you’ve stored up. And that’s completely natural and normal. Same with body fat. It’s a natural thing to use your body fat. And the only way you can use your body fat is to not eat. Because when you eat, you’re going to be storing calories. It’s only when you don’t eat that you’re going to be burning them. Eating disorders like anorexia nervosa are very important. But they’re actually psychological disorders of body perception. That is, people feel that they’re too fat and therefore they don’t eat. So when you look at even fasting in people who have, you know, anorexia in the past, you don’t find an increased risk of anorexia when people are fasting. It’s, you know, fasting is what anorexics do, but it’s not what triggers them off. It’s just like washing your hands doesn’t make you obsessive compulsive, right? It just means you’re washing your hands, right? Whereas obsessive compulsive disorder, people wash their hands, you know, two, three hundred times a day sort of thing, right? But washing your hands, it doesn’t go the other way. Washing your hands doesn’t cause obsessive compulsive disorder. Obsessive compulsive disorders do make you wash your hands, right? Same thing with the fasting. Terry 52:04-52:15 Thank you for clarifying that. We are running low on time. And I’m wondering if you could just explain to us your three golden rules for weight control. Dr. Jason Fung 52:16-55:01 So the golden rules really are very old rules that have been around for a long time. Number one is don’t eat ultra-processed foods to the maximum extent possible, right? And it’s a golden rule because it cuts across all three different types of hunger. The homeostatic hunger because these foods are processed to minimize satiety, because if you eat foods that make you full you’re not going to eat as much. So when they engineer these processed foods they don’t want you to get full, so buy more and they make more money, but you gain weight. So that’s homeostatic hunger. They’re also engineered to maximize hedonic hunger. And because they’re so heavily advertised and so easy, right? Packaging, you don’t need to cook and all this sort of stuff. They’re very easy to build into habits. So you go in front of the TV, you’re not cooking a steak, you’re grabbing a pack of Cheetos or whatever. So because it cuts across all the different types of hunger, that’s sort of the most important thing, the golden rule number one. And that’s really been identified in the most recent dietary guidelines as well. Eat real food. Number two is make sure you have an adequate fasting period. Because again, it really helps break some of those conditioned responses. And also is very effective for food addictions because food addictions have to be treated with abstinence. So again, as a rule, just don’t eat all the time. Make sure you have a good period of time where you’re going to burn off the calories that you ate, right? And that’s just natural and normal. And both of those have been around for a long time. And the third golden rule is make sure you have the social environment that allows you to succeed. Because again, what you eat, how much you eat, how you eat, all of those things are influenced to a huge extent by the people you surround yourself with and the environment that you’re with. And, you know, people think it’s all about personal choice. But clearly, there’s a huge difference when you, you know, have a Japanese person in Japan versus a Japanese person in America. There’s a big difference. And the difference is not the person. The difference is the environment. So I have to recognize that that food environment is different and plays a huge role. The social norms are different. And also, you know, people you surround yourself with. So you really have to make sure that you’re either leading your friends to good habits and explaining to them why you have to follow these habits, but creating that social environment that allows you to succeed. Everything is much more successful when you do it in a group and do it all together. Doing it by yourself is just very difficult. People generally don’t succeed like that. Terry 55:02-55:08 Dr. Jason Jung, thank you so much for talking with us on The People’s Pharmacy today. Dr. Jason Fung 55:07-55:08 Thank you. Terry 55:09-55:42 You’ve been listening to Dr. Jason Fung. He’s a Canadian nephrologist and co-founder of The Fasting Method, a program to help people lose weight and reverse type 2 diabetes and obesity. We conducted this interview before the recent publication of the Cochrane Review, showing that fasting is not more effective than calorie counting. His books include “The Obesity Code,” “The Diabetes Code,” and his latest, “The Hunger Code: Resetting Your Body’s Fat Thermostat in the Age of Ultra-Processed Food.” Joe 55:43-55:52 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 55:52-56:00 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 56:00-56:16 Today’s show is number 1,463. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email: radio at peoplespharmacy.com. Terry 56:16-56:25 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Joe 56:26-56:55 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We would be so grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics interesting, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 56:55-57:28 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 57:28-57:38 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 57:38-57:43 All you have to do is go to peoplespharmacy.com/donate. Joe 57:43-57:50 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Dr. Jason Fung 57:51-57:56 Thank you for your continued loyalty and support. We couldn’t make our show without you.

Most medical interventions are either pharmacological–prescribe a drug–or surgical–remove or repair the offending body part. If those approaches are inappropriate, doctors long for a different technology. In this episode, we discuss the development of a relatively new noninvasive technology, focused ultrasound. Doctors use it to treat conditions such as Parkinson disease or essential tremor. It may also be used for tumors in other parts of the body.At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Feb. 21, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. Subscribe through your favorite podcast provider, download the mp3 linked at the bottom of the page, or listen to the stream on this post starting on Feb. 23, 2026. Using Focused Ultrasound: Most people are familiar with ultrasound being used as a diagnostic tool. They also know about using a magnifying glass to focus a ray of sunlight. With the proper technique, this could light a small fire. In focused ultrasound, the surgeon uses an acoustic lens to target ultrasound waves very precisely inside the body. Dr. Neal Kassell, our guest expert in this episode, is a neurosurgeon. He has used focused ultrasound primarily to treat brain tumors. Treatments require from several hundred to several thousand ultrasound waves. But doctors have used focused ultrasound to treat over 180 medical conditions. Regulatory authorities around the world have approved its use to treat 35 different conditions. The first to get such approval was uterine fibroids. This technology has been used to offer noninvasive interventions for 22 years. Now, people with Parkinson disease could choose focused ultrasound as an alternative to deep brain stimulation. There are approximately 250 sites in the US that are able to offer this technology to patients. How Focused Ultrasound Works: Dr. Kassell described how ultrasound works for problems as dissimilar as liver tumors or essential tremor. There are multiple mechanisms, but scientists have concentrated on three: First, the beams of ultrasound generate heat that can destroy tissue where they are focused. So, tumor or tissue destruction is the first mode of action. Second, ultrasound involves the use of very tiny bubbles. These can be created to hold drugs. If a doctor were treating cancer, that might be a chemotherapeutic agent. But rather than exposing the entire body to the same level of medication, with focused ultrasound the microscopic bubbles trap the drug and release it only when exposed to the targeted beams. That means a high concentration of medicine where it is needed and very low concentrations elsewhere. Third, focused ultrasound appears to have an impact on the immune system. As a result, patients being treated with immunotherapy such as Keytruda get a much better result when it is combined with focused ultrasound. This approach has been shown to improve the response rate. Adopting Focused Ultrasound May Lag: Doctors and healthcare systems have customary patterns of practice, referral and reimbursement. Introducing focused ultrasound into the mix may disrupt these. Insurance companies might save money over the long run if they covered this long-lasting intervention. Perhaps they will find before long that they get a better outcome for a lower cost. Where focused ultrasound is finding more purchase is among veterinarians treating companion animals (dogs and cats) who also suffer from hard-to-treat malignancies. With the OneHealth approach, veterinary medicine shares what it learns from such treatments with healthcare providers treating humans. One might not imagine essential tremor as responding to this type of treatment, but 25,000 patients have already been cured. This entails separate treatments on two different sides of the brain, with the sessions separated by six to nine months. The durability of the effect is very good. Bobby Krause Describes His Patient Experience: Bobby Krause was dismayed to be diagnosed with young-onset Parkinson disease at the age of 42. The drugs his doctors prescribed had intolerable side effects, and he felt depressed at not being the father he wanted to be for his young sons. He was excited to learn that focused ultrasound treatments have been delivered to about 30,000 Parkinson disease patients around the world. At least 75 percent have experienced significant improvement that lasts at least five years. Although he was not eligible for the first clinical trial he heard about, he jumped at the chance to be treated a few years later at the University of Pennsylvania. In 2022, his doctors delivered three sonication treatments in one day. The results were amazing; among other visible effects, he regained an inch of height that had been compromised by the tight spasms of his back muscles. This is a story you will want to hear! This Week’s Guests: Neal F. Kassell, MD is the founder and chairman of the Focused Ultrasound Foundation. https://www.fusfoundation.org/ This is a unique medical research, education, and advocacy organization created as the catalyst to accelerate the development and adoption of focused ultrasound and thereby reduce death, disability, and suffering for patients. He was a Professor of Neurosurgery at the University of Virginia from 1984 until 2016 and the co-chairman of the department until 2006. He has contributed more than 500 publications and book chapters to medical literature and is a member of numerous medical societies in the United States and abroad. In April 2016, Dr. Kassell was appointed by Vice President Joe Biden to the National Cancer Institute’s Cancer Moonshot Blue Ribbon Panel. In our podcast, he mentioned a webinar (2/3/26) featuring Dr. Sanjay Gupta talking about pain relief. Here is a link to the webinar. Dr. Neal Kassell, director of the Focused Ultrasound Foundation Bobby Krause is the founder of the Be Still Foundation, a nonprofit dedicated to empowering patients and families affected by Essential Tremor and Parkinson’s disease. Inspired by his own journey with tremors, Bobby champions awareness, advocacy, and financial support for life-changing treatments like Focused Ultrasound, helping restore hope and dignity to those in need. https://youtu.be/LWOEwfcmLzk?si=hsB78j1BixZXBplY Bobby Krause, director of the BeStill Foundation Listen to the Podcast: The podcast of this program will be available Monday, Feb. 23, 2026, after broadcast on Feb. 21. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Medicine has changed enormously over the last several decades. As with other parts of society, digital technology has disrupted previous practices. Clinicians can now care for patients at home, monitoring them with sophisticated sensors for oxygen saturation, heart rhythm, blood pressure and much more. Even more significant, patients now have greater access to medical knowledge as well as to the state of their own bodies, measured through wearable tools such as smart watches or continuous glucose monitors. With the internet, they can connect with patient groups that offer valuable information as well as emotional support. Find out how patients are using technology to heal healthcare. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Feb. 14, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Feb. 16, 2026. How Technology Is Transforming Healthcare: When we spoke with Dr. Marschall Runge, we reminisced about the changes in medical care that have taken place since the time of his grandfather, a general practitioner. There is quite a contrast. While his grandfather made house calls, few doctors today would do so. However, some very modern medical centers now offer patients the option to recover at home from a major procedure. Dr. Runge describes his personal experience with at-home recovery following hip replacement surgery. The clinical staff was able to keep close tabs on his progress with the help of a variety of monitors, and a nurse was available to answer questions or provide advice until he was back on his feet. There are distinct advantages to the patient to be able to recover at home; among other things, he could sleep much better in his own bed. What other digital technology will healthcare employ? One possibility is using AI conversational agents to assist with differential diagnosis. Some devices can detect depression based on a patient’s speech. Others can pick up heart rate variability, an important parameter of heart health. Dr. Runge does not expect that robots will replace doctors. They could be very helpful in certain situations, though. How Patients Are Using Technology: We turn next to Susannah Fox, author of Rebel Health. She has been studying how patients are using technology to improve their health for decades. We first met Susannah through our mutual friend, Dr. Tom Ferguson. He was a staunch advocate for self-care and excited about the prospects for the internet. (His white paper, “e-Patients: How they can help us heal health care” is a classic. Look for it at the website of the Society for Participatory Medicine.) Not only do patients everywhere now have access to PubMed (the National Library of Congress), they can also connect with each other. Peer-to-peer advice and care is a topic Susannah knows well. In some cases, patients have conducted research that is focused on the questions crucial to their lives; these are not always the same things that researchers want to study. One shining example of patient-initiated research is a paper in Nature on long COVID by the Patient-Led Research Collaborative (Nature Reviews Microbiology, April 17, 2023; initial publication Jan. 13, 2023).  This paper has been downloaded 2 million times, illustrating the value of patient-led research. In addition to this outstanding example, some journals have adopted a policy of disclosing patient input into the research. Although very few studies report patient input, setting the expectation that they might make valuable contributions could help shape the perception of who ought to be involved in developing research protocols. Patients Using Technology to Access Medical Knowledge: PubMed is an impressive collection of published medical information because it is an online index of important research publications. Some of the journal articles could be difficult for patients to understand, however, as researchers are writing for other scientists and may often use specialized or complicated language. Now people are using LLMs like ChatGPT or Claude to summarize the articles in language they can understand. Indeed, these AI agents can translate articles into a different language if necessary for comprehension. With this technology, patients are better able to determine if their diagnosis makes sense and to search for potential interventions that might be useful in their specific case. Imbalances of Power and Attention: Despite these changes, there are still many medical systems that resist potential input from patients. Power is not evenly distributed, and Susannah Fox has found that many people are furious about it. We asked her to describe the schematic from Rebel Health that epitomizes where most attention is needed. It has two axes, one running from visible to invisible and the other from needs not met to needs met. A lot of medical care is devoted to the upper right quadrant–visible needs that are being met. The lower left quadrant, where the needs seem invisible and are not being met, is where patient frustration comes to a head. Rare diseases often fall into this category. Researchers and physicians need to know about patients’ lived experiences so that invisible needs not being met can be addressed. Using Technology to Repurpose Old Drugs: One of the ways in which AI is contributing to important changes in medical care is the search for medicines that can treat inadequately treated diseases. Susannah Fox praised the efforts of Dr. David Fajgenbaum, whose EveryCure organization is using AI to uncover how old drugs can be used to treat cancers, rare diseases, immunologic disorders and other problems that don’t yet have effective standards of care. Other patients who are showing the way to using AI for improving patient experience and patient health are Dave deBronkart (epatient Dave) and Hugo Campos. They have found that using an agent like ChatGPT in a dialog can help them move forward a lot more quickly in solving patient problems. Online Prescribing and Dispensing: Around the turn of the 21st century, Joe and Dr. Tom Ferguson had a heated ongoing disagreement about the concept of online prescribing. Tom was enthusiastic and Joe was skeptical, to say the least. Susannah Fox weighs in on this argument supporting Tom’s side at this point. With wearables like smart watches or continuous glucose monitors to track important markers of health, we see some patients using technology to follow up on how well their prescriptions are working, regardless of whether they were prescribed in the office or online. We also asked Susannah to provide advice for how we can successfully advocate for our own health. Her most important nugget: ask good questions! Clinicians appreciate good questions that help them re-think the patient’s situation or explain it more clearly. This Week’s Guests: Marschall S. Runge, M.D., Ph.D., is the former executive vice president for Medical Affairs at the University of Michigan, dean of the Medical School, and CEO of Michigan Medicine. During his tenure in these leadership roles, Dr. Runge implemented transformative change and positioned Michigan Medicine and the Medical School internationally for continued success. He earned his doctorate in molecular biology at Vanderbilt University and his medical degree from Johns Hopkins School of Medicine, where he also completed a residency in internal medicine. He was a cardiology fellow at the Massachusetts General Hospital. Dr. Runge is the author of The Great Healthcare Disruption: Big Tech, Bold Policy, and the Future of American Medicine Marschall Runge, MD, PhD Susannah Fox helps people navigate health and technology. She served as Chief Technology Officer for the US Department of Health and Human Services, where she led an open data and innovation lab. Prior to that, she was the entrepreneur-in-residence at the Robert Wood Johnson Foundation and directed the health portfolio at the Pew Research Center’s Internet Project. She is the author of Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care. Her website is https://susannahfox.com/ Susannah Fox, author of Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, Feb. 16, 2026, after broadcast on Feb. 14. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1461: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:26 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Medicine has changed tremendously over the last several decades. How has technology transformed health care? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:42 Clinicians can now care for patients at home and monitor them with sophisticated technology almost as well as if they were in the hospital. Joe 00:42-00:51 Patients themselves now have access to far more information than ever before. They can look at the results of lab work on their patient portal. Terry 00:52-01:01 Patients can also communicate online through thousands of support groups that are specific to health conditions. They’re also beginning to conduct research. Joe 01:01-01:08 Coming up on The People’s Pharmacy, how patients are using technology to heal health care. Terry 01:14-02:10 In The People’s Pharmacy Health Headlines: We’re still in the middle of a serious flu season, and scientists have just published another reason to try to avoid coming down with influenza. Beyond the fever, congestion, aches, coughs, and general misery of flu, influenza A infections can harm the heart. When the virus invades the heart, it can kill specialized heart muscle cells that control rhythmic pumping. People with pre-existing heart disease appear to be especially vulnerable. In some cases, white blood cells of a type called prodendritic cell 3 pick up the infection in the lungs and transfer it to the heart. The interferon that these white cells produce damage the heart muscle cells. The scientists suggest that this new information could help doctors mitigate heart risk in people with influenza A. Joe 02:11-03:16 A study published in Nature Communications demonstrates that the bacterium Chlamydia pneumoniae can lie dormant in the eye and brain for years. This respiratory pathogen can lead to sinus infections or pneumonia. It can also trigger infection-driven inflammation. C. pneumoniae has been linked to hard-to-treat asthma and COPD. The latest research, however, suggests that this microbe might also be linked to Alzheimer disease. People with dementia had substantially greater amounts of C. pneumoniae in their retinas and brain tissues than people with normal cognitive ability. The investigators report that infection-driven aggravation of neuroinflammation appears to lead to amyloid beta buildup in the brain and cognitive decline. This research opens up new opportunities. For one thing, it raises the possibility that patients with detectable C. pneumoniae bacteria might benefit from antibiotic-based treatment. Terry 03:16-04:46 If you’re a coffee drinker, you may be helping your brain. That’s the conclusion of a new study published in JAMA. The title of the article is Coffee and Tea Intake, Dementia Risk and Cognitive Function. The investigators tracked 131,821 volunteers for up to four decades. These were participants in the Nurses’ Health Study and the Health Professionals’ Follow-Up Study. The researchers were asking this question, is long-term intake of caffeinated and decaffeinated coffee associated with risk of dementia and cognitive outcomes? The authors answered that question this way. In two large prospective cohorts, including U.S. female and male participants with repeated dietary assessments and extended follow-up, higher intake levels for caffeinated coffee, tea, and caffeine were associated with a reduced risk of dementia. The researchers also reported modestly better cognitive function in the caffeinated tea and coffee consumers. Two or three cups of coffee, or one or two cups of tea, were enough to demonstrate cognitive benefits. People who drank decaffeinated coffee or tea did not seem to experience any advantage. The authors point out that their findings are consistent with other research reporting protective associations of caffeine and coffee intake with cognitive decline. Joe 04:47-05:57 Lifelong learning is also associated with a reduced risk for Alzheimer’s disease. That’s the conclusion of research published in the journal Neurology. There were nearly 2,000 octogenarians without dementia who began the study. Follow-up lasted for about eight years. The researchers questioned people about childhood learning experiences as well as current behavior. People who participated in intellectually stimulating activities such as learning a language, reading, or writing seemed to develop Alzheimer’s disease five years later than other people in the sample who had not embraced lifelong learning. Those who developed mild cognitive impairment did so seven years later than those without lifelong learning. Those with higher lifetime enrichment showed less cognitive decline before death compared with those with less opportunity to learn. The lead author noted, quote, Our findings are encouraging, suggesting that consistently engaging in a variety of mentally stimulating activities throughout life may make a difference in cognition. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:32 And I’m Joe Graedon. Medicine has changed radically over our lifetimes. It’s hard to imagine that doctors once made house calls, but medical technology is revolutionizing how doctors diagnose and treat their patients. Terry 06:32-06:40 Patients are also adopting technological advances to improve their knowledge and access to the most appropriate treatments. Joe 06:40-07:08 To learn more about how doctors envision this revolution, we turn to Dr. Marschall Runge. He was the former executive vice president for Medical Affairs at the University of Michigan, Dean of the Medical School, and CEO of Michigan Medicine. Dr. Runge is the author of “The Great Healthcare Disruption: Big Tech, Bold Policy, and the Future of American Medicine.” Terry 07:08-07:12 Welcome to the People’s Pharmacy, Dr. Marschall Runge. Dr. Marschall Runge 07:13-07:16 It’s great to be with you today. Thank you very much, and I look forward to our conversation. Joe 07:17-07:51 Dr. Runge, you come from a long line of health professionals. It’s my understanding that your grandfather was a doctor and your father was a doctor and you’re a cardiologist and you’re the head of Michigan Medicine at the very pinnacle of modern medicine in America. So how has healthcare changed since when your dad was practicing cardiology, when your grandfather was a doctor? Would they even recognize what is going on today? Dr. Marschall Runge 07:52-08:48 I don’t think they would. They’d say, ‘What is this?’ My grandfather was in an era where really everything about being a physician was talking to patients. The physical examination was critical. There were very few tests, the electrocardiogram, he was one of the early people working on electrocardiograms. And that was about the only tool we had in x-rays. Fast forward to my father. My father was a cardiologist. I grew up in Austin, Texas. And he did cardiology and internal medicine. Cardiology was just an emerging field at that time. And one of the things that was most fascinating, I would go around with him sometimes on hospital rounds. And he had a great way with people. He also did house calls, and he had gotten his car rigged up with a mobile headlight kind of thing that he could shine to see if he was at the right address. And I thought as a kid, that was so cool. Terry 08:50-09:04 Well, the very idea of making house calls is, I think, probably completely foreign to most doctors today. The whole setup of medicine must have changed so much. Dr. Marschall Runge 09:05-09:45 It has. And while there still are a few people, generally senior people, let’s call them, like myself, who would be willing to make house calls, very few people make house calls. Now, on the other hand, I think we’ll be seeing much more care in the home now and in coming years due to technology, where a person can get a very high level of care at home with what are essentially wearable devices and contact with health care providers. In fact, I had one experience like that. And it is… so I think it’s the pendulum swings one way, it swings back the other way. But the overall practice of medicine is so different than it used to be. Joe 09:45-10:09 Well, you know, we love the idea of home care, which brings up a very personal experience for you. You had a hip replacement surgery, and things did not go as anticipated, and you ended up being at home but receiving very high-quality care. Can you tell us about that whole experience shortly, please? Dr. Marschall Runge 10:10-12:31 I’m glad to. I needed a hip replacement. It’s usually a pretty routine procedure, you go home the same day. I did. But I had an unusual complication, which made me short of breath. It wasn’t a pulmonary embolism. It was little shards of fat from where they put in the implant. And so I went to the hospital, went back to the hospital, went to the emergency room. My oxygen saturation was very low. They whipped me upstairs. And after a little while, I was in the ICU. And I’d been there about 24 hours, and I was feeling much better, but I was feeling much crazier. I just couldn’t stand it. I was getting checked on every 30 minutes; I couldn’t get any sleep. And I knew we had a great home care program. So I said, how about if I go home? And they said, no, no, no, you don’t want to do that. And I said, why not? And they said, well, what if something happens? And I said, well, what do you tell other people who are you going to send to home care? And they said, yeah, but you’re different. I think they were worried that I would have a bad experience. But they let me go, and I went home. And waiting for me, by the time I got home, were several sort of wearables. I had a pulse oximeter, I had a mobile blood pressure cuff, I had several other things. I had an incentive spirometer. And I had a nurse who went through all this with me, was available over the next several days, 24-7 if needed. And I had a physical therapist who came later that same day and had physical therapy every day. And the fantastic part is I slept for about 12 hours the first night I was at home because I was just so exhausted. So I think, and my experience is very similar to others, that one of the ways that people can get better faster, have less expense, and a better outcome is to have home care. We now know in our system, some people that would ordinarily go from either a phone call to their doctor or a visit in the clinic directly to the emergency room, there’s a group of those people who can get care at home. So we’re trying to figure out how can we best expand that kind of care. Because for those of you who have been in hospitals, it’s no walk in the roses. And I think that this is one of the many ways in which technology can actually improve the care of all of us. Joe 12:32-13:13 Well, the thing that’s so fascinating to me is that there are so many devices now. I mean, you can monitor not just blood pressure, but blood glucose. You can measure respirations. You can measure temperature. And it’s even conceivable that you could have a video hookup so that a nurse back in Ann Arbor at the hospital could be monitoring you. And if there was an emergency, you could have two-way communication with a healthcare professional almost immediately. So, you know, the idea of being able to sleep at home, wow, what an improvement over trying to sleep in the hospital. Dr. Marschall Runge 13:15-14:11 You’re right. And, in fact, there is very high-level potential for monitoring, which is used in some more rural settings. And it’s, I won’t call it an ICU, but it’s not too far from an ICU with all the components you just mentioned. And the care, it’s called a virtual CCU or a virtual emergency room. And the care can be excellent. Now, you have to have health care providers, doctors, nurses, and others who are enthusiastic about this and who understand how to use the technology. But I think we’ll see much, much more of it. And for example, a day in the hospital is about $1,500 on a regular floor, more like over $2,000 in an ICU. And a day at home is about $200. And so we worry about the cost of health care. That’s one way we can make it better. But as you said, it’s much better for the person, for the patient. Terry 14:13-14:56 Well, I know there are plenty of patients who are using, as you put it, wearables to improve their own health. And they’re going online to find other people with similar problems, similar health problems, so that they can all learn from each other. I’m wondering now, how can patients and doctors work together to use, for example, artificial intelligence for diagnosis? When you’ve got something wrong with you and you don’t know what it is, how does that diagnostic process play out differently now or in the future with the access to artificial intelligence? Dr. Marschall Runge 14:58-17:35 Well, on the one hand, I am a huge fan of artificial intelligence. And I think that one of the benefits it brings is the ability to analyze huge amounts of data, very large amounts of data that would be hard to do in any other way. And I think that in the near future, we’ll see much more use of wearables. And today, it’s hard to connect the wearables to the electronic medical record, but that’s getting better. So that when you come in for a visit, or it can be done trans-telephonically, an awful lot of information can go to your doctor about what’s been going on in your life. And it can be cataloged in a way that allows it to suggest different potential early diseases or different potential approaches that might be used. To give you a couple of examples, there are devices, both devices and telephones, which can, at a very early stage, pick up depression and allow it to be detected and dealt with far before it gets to impacting one’s life. In other examples, there are wearables that can show that how much variation you have in your heart rate is one of the markers for how heart healthy you are. And that can be measured. And that’s currently being able to be measured on wearables. But once those download into your electronic medical record, I think that’ll be even much more powerful. To give you one little example of why I think AI has such promise, if you ask for your medical records these days, they’re so extensive, you get it on a CD or maybe on a USB drive, and you try to read it, and you could spend hours and hours and hours reading it. If you take that and put it on, make a PDF out of it and put it into your favorite AI engine, in about two minutes, you can get, if you say, I’d like a three-page summary of what my major medical problems are, what medications I’m currently taking, and what medications have not worked. You get it. You get it in about two minutes or less. It’s that kind of technology and that kind of reach that AI has that I think will really change healthcare. I want to put in one negative about AI. I don’t think AI bots can replace human beings and human interaction. And I think that will come to be proven over and over again. It already has in some circumstances. So this idea that you’d have an AI bot instead of a doctor or a nurse or a therapist, I don’t see that happening. Terry 17:36-17:41 Dr. Marschall Runge, thank you so much for talking with us on The People’s Pharmacy today. Dr. Marschall Runge 17:42-17:44 Well, thank you both. It’s great to talk to you. Terry 17:45-18:06 You’ve been listening to Dr. Marschall Runge. He’s a cardiologist and the former executive vice president for medical affairs at the University of Michigan, dean of the medical school and CEO of Michigan Medicine. Dr. Runge is the author of The Great Healthcare Disruption, Big Tech, Bold Policy, and the Future of American Medicine. Joe 18:07-18:13 After the break, we’ll talk with Susannah Fox, a patient advocate who helps people navigate health and technology. Terry 18:14-18:21 Dr. Tom Ferguson was a great proponent of how e-patients would help to heal healthcare itself. How is that vision holding up? Joe 18:21-18:24 We’ll discuss patient-led research in a variety of forms. Terry 18:25-18:28 The Internet and PubMed changed people’s access to medical knowledge. Joe 18:29-18:35 Now people are using AI to help them understand medical articles and check on a differential diagnosis. Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:54-19:08 And I’m Terry Graedon. Terry 19:24-19:39 Today, we’re excited to be talking with someone we have known and admired for decades. Susannah Fox was with the Pew Research Center Internet Project when the three of us were participating in Dr. Tom Ferguson’s e-patient scholars group. Joe 19:39-20:20 Our goal was to turn medicine upside down and empower patients through access to information and tools. Our organization was a precursor to the Society for Participatory Medicine. We turn now to Susannah Fox, who helps people navigate health and technology. She served as Chief Technology Officer for the U.S. Department of Health and Human Services, where she led an open data and innovation lab. Prior to that, she was the Entrepreneur-in-Residence at the Robert Wood Johnson Foundation. She’s the author of “Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care.” Terry 20:20-20:24 Welcome back to The People’s Pharmacy, Susannah Fox. Susannah Fox 20:24-20:25 Great to be here. Joe 20:27-20:55 Susannah, our mutual friend, Dr. Tom Ferguson, died 20 years ago. He was a leading advocate in the world for medical self-care. He really spearheaded this vision. I wonder how that vision has changed, how it helped lead the patient revolution in health care that you have written about. How’s it fared over the last two decades? Susannah Fox 20:56-22:13 I think Tom would be amazed at the progress that’s been made by patient survivors and caregivers who are demanding access to information, demanding access to data and tools to take care of themselves. He was a visionary. He foresaw how the internet was going to change healthcare. And yet I think he would be surprised by how quickly it’s moved forward. For example, one of the great milestones to me in research is that a paper written for Nature, one of the preeminent scientific journals that was written primarily by patients, by people who live with the disease that they’re writing about, has now been downloaded almost 2 million times. And that is a milestone that I think would make Tom so happy because he was an early advocate for people having access to information to help them make better decisions and to help clinicians and do their work better. Terry 22:14-22:22 Absolutely. I think he would be thrilled at that. Can you tell us a little bit more about that paper? What were the patients writing about? Susannah Fox 22:22-24:02 They were writing about long COVID. And as you might recall, during the early part of the pandemic, clinicians and scientists told everyone that if you got better in two or three weeks, you were through the woods. And COVID-19 was primarily a respiratory virus that if it didn’t kill you, that you would feel better. And it was patients themselves who identified that it’s not only a respiratory virus. They started tracking the symptoms that they were experiencing. They were able to not only track those symptoms, but do a worldwide survey, publish that data, get the attention of the British government, of the government in the U.S., and eventually the scientific community adopted the name that patients themselves were using, which is long COVID. And these patients, along with Eric Topol, decided to publish a paper that looked at the mechanisms and recommendations that they had for further study of long COVID. And it was led by the citizen scientists behind the patient-led research collaborative for long COVID. And it’s a milestone to see that they were, number one, able to publish it in Nature Microbiology, but now it is in the 99th percentile of most influential papers. Terry 24:02-24:40 It really is a milestone. And the fact that it was, in fact, patient-led is still pretty unusual and pretty remarkable. Another hopeful sign that I have seen is that there are a couple of journals, I think they’re mostly British journals, that will, in their little summary of the research, will say, what input did patients have into the plan or the protocol of this study? And unfortunately, most of them still say patients didn’t have any input, but at least they’re thinking that patients might have some input. Susannah Fox 24:41-25:00 I love that. Yes, British Medical Journal [BMJ] and The Lancet Psychiatry are requiring that authors share how patients, how people with lived expertise contributed to the research. And by asking that question, they’re changing the default. I love that. Joe 25:01-25:50 Susannah, you know, Dr. Tom Ferguson loved the idea that people would have access to information. And these days, people do have an extraordinary amount of access. For example, the National Medical Library in the U.S., PubMed, is available to people all over the world. And yes, most of the journals only provide abstracts, but there are more and more full-text articles available on PubMed, which means that it’s not just doctors, it’s not just scientists and researchers who access this information, it’s everybody, and people are so much more literate, most of the time they can kind of figure out what those docs are talking about. Susannah Fox 25:52-26:55 Yes, and what I also see spinning it forward is people using large language models like ChatGPT to feed those abstracts or full-text articles into essentially a translation app to say, can you put this into words for me? Or can you do a differential diagnosis based on my child’s symptoms and what we know from these latest articles? And people are leveraging these tools. Another thing that I love is you can use ChatGPT to translate it into a different language to say, my mom only speaks Spanish. Can you please translate the science into Spanish? Or can you make this into a cartoon that makes it easy for everyone in my community to understand the basics of what’s going on? That is the promise that I think Tom would be most excited about. Terry 26:57-27:10 What sorts of precautions should patients be exercising if they’re using ChatGPT, for example, to try to see whether the diagnosis they’ve been given makes sense? Susannah Fox 27:12-28:48 Well, here I look to the people who are shining a light on the path forward in terms of how patients are using AI effectively. I’m thinking of e-patient Dave DeBronckart, and I’m thinking of Hugo Campos. What they have written about is that ChatGPT and tools like it should be used to help us reason through a problem. You can be in conversation with these tools, but it’s best not to ask for a diagnosis. It’s better to say, if you were teaching a medical school class on this topic, what are the most important things for you to teach medical students? And in that way, you’re asking the tool to teach you, maybe a lay reader, about these issues that you don’t yet understand. What I really appreciate about this era that we’re in is that we are able to skip ahead from square one, where we may not even understand the diagnosis, and we have to make sure we’re spelling it correctly. And we can skip ahead three or four spaces on the game board so that we can understand the mechanisms of disease, what the latest research is, and then we can still go in and get the expert opinion based on our medical history with a clinician. Joe 28:50-30:17 Susannah, what you’re talking about in terms of medical education is quite fascinating and using artificial intelligence like ChatGPT or Claude or whichever particular program you are comfortable with. But I’m wondering how medical education has adapted to patients all over the world communicating with one another in support groups or accessing medical information. Because it seems to me, and I could be mistaken, that medical education hasn’t changed that radically in the last 20 years. It still seems like the old medical model that Tom was ranting about, that pyramid with the super specialists at the top and then the internists and then the family practice docs at the bottom and the geriatricians even below that, that it’s still the old medical model that patients, although they’ve got a lot of autonomy and a lot of access to information, that the medical system hasn’t changed that dramatically. And we still have to wait for hours in the emergency departments, and there’s still an imbalance between doctors and patients. Help me understand better how the system has adapted to this revolution that you have talked about. Susannah Fox 30:19-32:17 Well, first, I should say there are many systems, especially in the United States. And what we are observing in the research that I do and in talking with clinicians and patients is that you’re absolutely right. In areas of healthcare where people seem, whether it’s clinicians or patients, where something’s pretty well known, then they don’t seem to feel the need to look to people with lived expertise to contribute. But if there is a problem that is particularly vexing, if there is an issue that has historically been invisible or ignored, or it’s rapidly emerging, as we saw in the case of long COVID, then specialists are more likely to listen to patients. The most extreme examples that I’ve studied are in communities of people living with rare diseases and life-changing diagnoses, where they’re really medical mysteries. It’s a genetic disease. It’s something where there’s very few people who live with the condition. And so it is the communities who are pooling data, who are pooling resources, who deeply understand the mechanisms of disease. That’s when clinicians and scientists are very interested in learning from patients. And again, this could be something that is a genetic disease with a very small number of people or something more widespread like long COVID, that if there is a mystery that needs to be solved and patients, survivors, and caregivers can help solve it, that’s when companies and scientists are building those intake valves for that lived expertise. Terry 32:18-32:33 Susannah, something you just said triggered my memory of a schematic you put in Rebel Health in terms of how well-known something is. It’s a four-part schematic. Can you describe it to us, explain it to us? Susannah Fox 32:33-34:22 Sure. I came up with this as a way to try to explain why some issues are more ripe for the patient-led revolution and some are not. So if you can imagine a line right down the middle, and at the top is the word visible, and at the bottom is the word invisible, and then a line through the middle from left to right, and at the far left are the words needs not met, and at the right are the words needs met. And what I mean by that is whether things are visible or invisible to mainstream healthcare and whether people’s needs are being met or not by mainstream healthcare. So the bottom left quadrant is where I spend a lot of my time as an anthropologist, spending time in communities of people whose needs are not being met and they are or feel invisible to mainstream healthcare. At the opposite end of the spectrum are issues where people’s needs are being met and they are visible to mainstream healthcare. And here we might think of a typical pregnancy and childbirth or a cancer diagnosis. We, as an American healthcare system, we have invested a lot of money in cancer. And so people kind of know what they’re doing. It’s still really tough, but people really know what they’re doing in some areas. Whereas down in the quadrants where people’s needs are not being met, we might see a more rare genetic disease or an emerging diagnosis. Terry 34:23-34:26 Thank you, that was helpful. Joe 34:26-34:54 One of the challenges on those rare diseases, Susannah, is the cost. Because patients and specialists and researchers have teamed up to create some unbelievable treatments and in some cases cures. But the cost, it can run half a million, a million, and in some cases over two million dollars. Terry 34:54-35:08 Well, you can get that even in that upper right quadrant where your needs are theoretically being met and they’re visible. But if it’s going to cost a million dollars, I don’t think anybody would claim that it’s accessible. Joe 35:08-35:25 So in the minute that we have left, the cost of some of these breakthroughs–and even in general, the cost of medicine and medical care–it seems like it’s breaking the bank for an awful lot of Americans. Susannah Fox 35:26-35:49 It absolutely is breaking the bank. And we need to have a public conversation about where our research dollars go and where our health care delivery dollars go. What rare disease patients would say is that the breakthrough that they find for their rare disease may actually light a path forward for many diseases. Joe 35:50-36:07 And do you see affordability as being a key factor going forward? Because the medical system as it exists now, it’s going to crack and crumble over the next couple of years. Susannah Fox 36:10-36:43 That is particularly true in the U.S. When I was on my book tour with a book where the title is Rebel Health, people would come to my events and be angry that my book is not about the overthrow of the American healthcare system. People are extremely angry about the cost and lack of access to healthcare. My book is about access to the tools of innovation and invention, but we need to talk about cost and access to care. Terry 36:45-36:53 You’re listening to Susannah Fox, author of Rebel Health, a field guide to the patient-led revolution in medical care. Joe 36:54-36:59 After the break, find out why patients’ lived experience is more important now than ever. Terry 37:00-37:10 We’ll learn more about Dr. David Fajgenbaum and his Every Cure organization with patients and doctors finding novel ways to treat diseases with old drugs. Joe 37:10-37:16 What do you think about online prescribing and dispensing? I used to think it’s a terrible idea. Terry 37:16-37:19 If there were follow-up, though, it could be really helpful. Joe 37:19-37:24 How will patients take more control of their care in the future? Terry 37:39-37:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:52-37:55 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:55-38:06 And I’m Terry Graedon. We’re talking about how new technologies have changed both the practice of medicine and the ways in which people approach being patients. Joe 38:07-38:20 There was a time when physicians controlled all of the medical knowledge. That changed with the Internet. People can now interact with other patients all over the world with the same kinds of health conditions. Terry 38:21-38:28 In some cases, patient support groups are even initiating research that addresses their most challenging concerns. Joe 38:28-38:54 Our guest today is Susannah Fox. She helps people navigate health and technology. In the past, she was the entrepreneur in residence at the Robert Wood Johnson Foundation. She also directed the health portfolio at the Pew Research Center’s Internet Project. Susannah is the author of “Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care.” Terry 38:56-39:02 Susannah, why are patients’ lived experiences more important now than ever before? Susannah Fox 39:04-40:37 We are dealing with increasingly complex problems, increasingly complex treatments and decisions to be made, and we deserve to have everybody off the bench and on the field helping to solve those problems. If we do not include people with lived expertise, then we are not going to be able to recruit clinical trials that nobody wants to participate in because nobody thought to ask patients and caregivers about what are the endpoints that they care about or how to design a study that people really want to participate in and are able to participate in. We also need to have public conversations about how in the past patients have revolutionized parts of our healthcare system. In some ways, this is not new. This is very ancient that we turn to each other for help. And in the modern system, we have access to all kinds of technology. But let’s remember, peer support was revolutionized by Alcoholics Anonymous in the 1930s. When two people who are shut out of mainstream healthcare, they were dealing with alcohol use disorder, they turned to each other. That is one example of so many radical health movements of the past that we can draw inspiration from. Joe 40:39-40:49 You know, one of the things that comes to mind when we talk about patient involvement was a medical student by the name of Fajgenbaum. Terry 40:50-40:51 David Fajgenbaum. Joe 40:51-41:42 David Fajgenbaum. He was at University of Pennsylvania, and he had some very mysterious medical crises in which he got very close to death. In fact, a priest had administered last rites, he was so close. His body was shutting down. But during a slight recovery, he was able to eventually kind of figure out what was going on with the help of one of his medical mentors. And he eventually was able to, if not cure his condition, he was able to control it by using a medication that had been developed to prevent organ rejection when people got a transplanted kidney, for example. And that drug not only saved his life, but now many other people who have a condition called…? Terry 41:42-41:43 Castleman’s. Joe 41:43-42:21 Castleman’s disease. Bottom line, these off-label drugs have been coming to the rescue for a number of conditions, and Dr. Fajgenbaum is leading the charge now that he has become a physician. He has an organization called Every Cure, and we really love his approach because it brings, again, patients into the process. I’m wondering what your thought is about the idea of patients and physicians teaming up to come up with novel approaches, especially using old drugs. Susannah Fox 42:22-44:20 I’m so glad that you bring up his work because Dr. Fajgenbaum is the perfect example of someone who embodies all four of the archetypes that I talk about in my book. When he was sick, he became a seeker. And not only was he a seeker of new information, he asked his friends and family. When he was too weak to sit up at the computer and do searches, his friends and family did so. He was a networker. He found other patients and other clinician scientists who were focused on Castleman disease. He was a solver. He realized that by repurposing drugs that are already on the shelf, he could solve problems that were in that invisible needs not met quadrant that frankly, nobody was paying attention to. One of the big wake up calls that he writes about in his book, “Chasing My Cure,” is that he really thought that people were working on every disease. And it’s not true. Sometimes you have to be the one to say, wait, people need to be focused on this disease because my kid has it or it’s affecting my community. And then he became a champion. He became someone who uses his power as a clinician. He also went to business school, so he has an MBA. He was able to create the organization Every Cure and use these amazing large language models and artificial intelligence to try to match, again, the mechanisms of a rare disease with what a certain drug that’s already on the shelf can do. And he represents the full stack of the patient-led revolution. Joe 44:22-45:40 Susannah, I’d like to change gears for a moment and talk about something that Dr. Tom Ferguson and I fought about bitterly. It was one of the few things that we just could not ever agree on. Tom imagined a day when there would be online prescribing and online dispensing of medications. And I said, “Tom, these drugs are too complicated for somebody to have an online conversation with a health professional and then get their prescription filled and nobody follow up.” And he said, “No, no, no, no, no, follow up, that’s the secret. And that’s the magic sauce. You can follow up online daily, weekly, monthly. And doctors aren’t doing that right now.” And I was like, “Oh, well, that’s kind of interesting. I wonder if that’ll happen.” Well, it has happened in the sense that now there’s online prescribing like crazy. And there are a lot of private companies that are selling drugs for sexual functioning and drugs to lose weight and drugs for anxiety, and drugs for depression, and you can talk, in quotes, to an “online prescriber.” Terry 45:40-45:42 But we don’t know how good the follow-up is. Joe 45:42-46:02 That’s the question. And so I’m wondering what you think about online prescribing and dispensing. Eli Lilly, for example, is doing it, I believe, with its online very successful weight loss drug called Zepbound. So give us a little feedback on Tom’s vision and how it’s actually been implemented. Susannah Fox 46:02-48:35 Joe, I would have been in your camp up until about two years ago. I would have said, oh no, this is not a good idea. What has changed my mind is the sophistication of wearables so that we can instrument ourselves. We can wear a ring. We could wear something on our wrist. We could even have something very lightweight, a continuous glucose monitor, or any kind of lead that you could put on your chest. And that could create a real-time feed of how your body is reacting to the treatments that are prescribed by a clinician who you might not see in person. And they would have more sophisticated data to look at than they would have if you saw them twice a year in the clinic. And so that to me is one area where I’m going to come down on the side of Tom and say, it’s the follow-up that you can do not only through a screen where you can talk to someone and they can see the context of your life, but also the wearables that they can have access to the data. And this is something that the patient-led revolution has to create because it was in diabetes care that people demanded access to the data being generated by their own bodies by way of the continuous glucose monitor. And now it’s the default that we have access to that data. I think we need to go further. I think it should not only be consumer devices, these Apple Watch or Google Pixel or the Oura Ring. I think we need to demand access to every type of medical device that’s collecting data about us so that it can be in a dashboard that we have access to as well as our clinicians. Because guess what? Who’s going to look at it more often, the patient themselves, the people who love them. The clinician can check in and make sure that, yeah, okay, the dosing is correct on that. But self-management is going to be on steroids, to coin a phrase. And I’m excited about the future in that way. Terry 48:36-48:47 Susannah, you’ve talked about wearables. And just for people who may not have encountered that idea before. You’ve given us a couple of examples. Can you give us a few more? Susannah Fox 48:47-50:19 Sure. And I should disclose that I’m actually an advisor to Google and they gave me a Pixel Watch for free to try out their new AI coach that’s integrated with Fitbit. And it’s pretty amazing to, for example, wear something on your wrist that can not only track your heart rate, it can tell so much from the data that’s collected on your wrist. It can tell you the quality of your sleep. It can tell you the quality of the workouts that you’re doing. And the real promise is in being able to engage in a conversation with the AI coach where that coach can look at your personal data, not generalized data, but your personal data and give you advice that is based on all of the academic research that is available about sleep or fitness. And that to me is pretty incredible because a lot of us have access to fitness information, but very few of us have access to someone who’s actually a sleep specialist. So the democratization of access to that information, and as you know, sleep is incredibly important for brain health. Terry 50:20-50:34 And that’s what I’m really excited about. Well, that actually feeds right into the next question that I wanted to ask you, which is what has you most excited about patients taking more control of their health care in the future? Susannah Fox 50:37-51:24 I am not only excited about all the technology that we’ve talked about, whether it’s the AI or the wearable devices or the medical devices. I am very excited that people are starting to understand that they can take control of their health. And also, no matter what they face, they are not alone. There are people who would love to help you if only they knew how to find you. And you can go online and find a community of people who are facing the same mysterious symptoms, and you can navigate it together. That is the real promise of the Internet. Joe 51:26-52:03 Susannah, the idea that medicine has changed so dramatically and patients have so much more control and now they’re able to link up with other patients, other caregivers and other health professionals truly is the vision that Tom was offering us over 20, 30, 40 years ago. Where does your crystal ball lead us in the future? What can you imagine with the technology and with the interactivity, the self-help groups from all over the world? Susannah Fox 52:05-53:19 I foresee more citizen science. I see people who are frustrated by lack of access, formulating their own treatments, by the way, for good or for ill. And people using the tools that they have, ever more sophisticated tools to contribute to science. As, unfortunately, we watch people losing trust in institutions, people losing trust in government, in our healthcare system, people are turning to each other. Now, that is a mega trend that we need to be cautious about. I think we need to include patients and survivors and caregivers in the design of any tool, of any intervention, so that we can rebuild trust, so that we can show people that they are included. And it is not a faceless institution making decisions. That is what I hope will happen as we become ever more sophisticated in our own pursuit of health and well-being. Terry 53:20-53:32 Susannah, in the last minute we’ve got, can you give us some ideas about how we all can successfully advocate for health for ourselves and our families? Susannah Fox 53:35-54:16 I think it’s important to know what questions you’re asking. And you can use, for example, the data that you get from your own self-tracking, whether it’s on paper or wearables, or whether you hone your questions using Claude or ChatGPT. Ask good questions. Every clinician that I’ve ever talked to appreciates a good question. And that’s something that Tom often talked about. Don’t come in with the answer, come in with a great question. Terry 54:17-54:23 Susannah Fox, thank you so much for talking with us on The People’s Pharmacy today. Susannah Fox 54:24-54:24 Thanks for having me. Terry 54:26-55:13 You’ve been listening to Susannah Fox, a health and technology strategist. She’s a former chief technology officer for the U.S. Department of Health and Human Services, where she led an open data and innovation lab and launched InventHealth, an initiative focused on user-driven innovation for medical and assistive devices. As an entrepreneur in residence at the Robert Wood Johnson Foundation, she built project teams to bring patient and caregiver insights into its work. For 14 years, she directed the health portfolio at the Pew Research Center’s Internet Project, where she coined the phrase peer-to-peer health care. Her book is “Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care.” Joe 55:13-55:22 Lyn Siegel produced today’s show, Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 55:22-55:30 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 55:30-55:45 Today’s show is number 1,461. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 55:45-56:28 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Here at the People’s Pharmacy, we encourage our listeners to take an active role in their own health care. There is a lot of information available on the web. Some of it’s excellent, and some is just okay, and some is misleading. To help you find the latest medical research, we suggest going to PubMed. This is the National Medical Library, available online to anyone. It may be a little hard to interpret the “medicalese,” but now AI agents can help you translate. Joe 56:28-56:49 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be grateful if you’d write a review of The People’s Pharmacy and post it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 56:49-57:28 And I’m Terry Graedon. Thanks for listening. Please join us next week. Thank you for listening to the People’s Pharmacy podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 57:29-57:38 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 57:39-57:43 All you have to do is go to peoplespharmacy.com/donate. Joe 57:43-57:57 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

In this episode, we interview the doctor who first identified seasonal affective disorder (back in 1984!) and went on to develop treatments. Even when days are short (but getting longer, little by little) and skies are gray, you don’t have to suffer with a bleak outlook. Find out what you can do to counteract this common but serious problem. At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Feb. 7, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Feb. 9, 2026. One of the most effective treatments for SAD and the similar but less severe winter blues is bright light therapy. Not all sufferers respond to light therapy alone, however. Dr. Rosenthal describes the additional approaches that improve people’s response. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on November 13, 2023. What Is Seasonal Affective Disorder? By now, many people are aware that some individuals have a hard time with short days and long nights. Their appetites and sleep patterns may change, and they may retreat from social activities because they can’t get energized. They have trouble concentrating and may become irritable. It’s as if they get depressed every year at the same time, on cue. Psychiatrists estimate that about 5 percent of the population experiences seasonal affective disorder, or SAD. That could be as many as 10 million Americans. At times, physicians may prescribe antidepressants, but usually the treatment that works best for SAD is light. Evidence suggests that the lack of sunlight, especially when someone feels stressed, is a prime trigger for seasonal affective disorder. Is SAD Linked to Latitude? The further from the equator you get, the more pronounced are seasonal differences in daylight. Think of a place above the Arctic Circle, for example, like Tromsø, Norway. In the summertime, they celebrate the midnight sun. In the winter, however, people in Tromsø see very little daylight. Unless they are uncommonly resilient, they could be susceptible to SAD. Light for Seasonal Affective Disorder: The principal treatment for SAD is light therapy, usually utilizing a light box. This must be a minimum of one foot square and supply at least 10,000 lux. That is the equivalent of being outside on a cloudy day. Generally, the prescription is for 20 to 30 minutes of exposure every morning. People who would rather not use a light box might be able to spend that time outdoors under the dome of the sky. A roof, awning or umbrella would undermine the treatment. Approximately 30 to 40 percent of people with seasonal affective disorder do not respond completely to light therapy. They need additional help beyond light exposure alone. Exercise has been shown to benefit them, especially if it is conducted outside. Cognitive behavior therapy is also extremely helpful, as is meditation. Lastly, people with SAD may want to pull back from their usual social activities. If they can maintain their social connections, this is very therapeutic in the effort to defeat seasonal affective disorder. The Autumn Checklist for Defeating Seasonal Affective Disorder: Those who know that they often experience SAD should get ready before winter. Dr. Rosenthal recommends addressing the following questions: 1. Have I purchased a light box for the winter? 2. Do I have at least one bright, inviting room in my home? 3. Have I made plans for at least one winter vacation in the sun? 4. Should I check in with my doctor since I am entering my season of risk? 5. Have I notified close family members and friends that I may need extra support? 6. Do I have a physical fitness program in place? (It’s easier to keep exercising than to start.) 7. Could I reframe my attitude and look at winter as a challenge instead of an affront? 8. How can I find beauty in the colorful season of autumn, here and now? Although Dr. Rosenthal doesn’t mention it, perhaps noticing signs of spring could instill hope. Our yard in North Carolina has both snowdrops and hellebores blooming in January, reminding us that spring blossoms will start up before too much longer. This Week’s Guest: Norman E. Rosenthal, MD is a psychiatrist and scientist who first described SAD in 1984 and pioneered light therapy as a treatment. Dr. Rosenthal is currently Clinical Professor of Psychiatry at Georgetown University School of Medicine. Dr. Rosenthal is the author of several books, his most recent being Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons His website is https://www.normanrosenthal.com/about/ Dr. Norman E. Rosenthal, author of Defeating SAD Listen to the Podcast: The podcast of this program will be available Monday, November 13, 2023, after broadcast on Nov. 11. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1363: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:26 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. When the days get short and the nights get long, some people have a hard time getting out of bed. Could they be suffering from SAD? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:43 Seasonal Affective Disorder, or SAD, may affect as many as 10 million Americans. Is there a difference between SAD and ordinary depression? Joe 00:44-00:55 People who are susceptible to SAD often feel irritable or pessimistic in the winter. They may have trouble concentrating and lose interest in usual activities. Terry 00:55-01:01 Our guest today was an early pioneer in developing treatments for SAD. What should you know about light therapy? Joe 01:02-01:08 Coming up on The People’s Pharmacy, learn about defeating seasonal affective disorder. Terry 01:14-02:37 In The People’s Pharmacy Health Headlines: Your genes exert a powerful impact on your longevity. That’s the conclusion of a study published in the journal Science. The investigators studied over 2,000 siblings in Sweden and the United States to try and tease out the effects of nurture and nature. In other words, how much did genetics influence lifespan compared to other factors such as exercise, diet, and lifestyle choices? The investigators tracked data from the Swedish Adoption Twin Study of Aging. Specifically, they analyzed data from twins raised apart for lifespan heritability. They also studied American siblings of U.S. centenarians. Before this analysis, it was believed that mortality was only about 20 to 25 percent heritable. The new research suggests that genetics plays a role that’s more than double that, to about 55 percent. The authors were quick to point out that roughly half of our lifespan remains unexplained by genetics. They attribute the other half to lifestyle, access to health care, and socioeconomic factors. They conclude their research by stating that identifying the genetic variants underlying this heritability would help us to understand the fundamental mechanisms of human aging. Joe 02:38-03:24 A natural experiment involving an old shingles vaccine, Zostavax, adds additional data to the herpes virus theory of Alzheimer’s disease. There have been two prior studies, one involving people in Wales and the other examining data from Australia. In that research, scientists took advantage of natural experiments in which health care policies established arbitrary eligibility dates for people to receive the vaccine. People only slightly older did not differ in other important respects, but they could not be vaccinated. As a result, the protective effects of the vaccine were clear. Those who had been vaccinated were 20% less likely to be diagnosed with dementia over the next several years. Terry 03:25-04:21 The most recent study comes from Canada and involves people born between 1930 and 1960 in Canada. In Ontario, eligibility for the shingles vaccine was set for people born on or after January 1, 1946. Electronic health records from private practices in Ontario were analyzed from 1990 to 2022. The absolute difference in dementia diagnoses for more than 200,000 patients was two percentage points between those eligible for the shingles shot and those who missed it by a few weeks or months. Elsewhere in Canada, where there was no shingles vaccination program, there’s no clear difference in risk of dementia by birth date. The investigators conclude, in conclusion, this study provides strong evidence of a protective effect of herpes zoster vaccination on incident dementia. Joe 04:22-05:07 Metabolic syndrome is a cluster of three or more risk factors that increase the chance for cardiovascular complications such as heart attacks, strokes, peripheral artery disease, along with diabetes, kidney disease, and liver problems. Risk factors for metabolic syndrome include high blood pressure, abdominal obesity, elevated blood sugar, and high triglycerides. A study has found that six months of lifestyle interventions to encourage new habits of healthier eating and greater physical activity led to long-term benefits. The authors point out that the evolving science of sustained behavior change suggests that unique strategies are needed to achieve sustainability, one of which is new habit formation. Terry 05:08-06:17 Exercise may be beneficial for people with knee osteoarthritis. According to the CDC, over 30 million Americans have some degree of pain, stiffness, and swelling in their joints. Nearly half have some discomfort in their knees. A systematic review in the BMJ analyzed more than 200 studies and concluded that in patients with knee osteoarthritis, aerobic exercise is likely the most beneficial exercise modality for improving pain, function, gait performance, and quality of life, with moderate certainty. The authors go on to specify that patients should engage regularly in structured aerobic activities such as walking, cycling, or swimming to optimize symptom management. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:32 And I’m Joe Graedon. In the middle of the summer, we enjoy long days with lots of sunshine. The sun comes up early and goes down late. But now the days are getting shorter. In Madison, Wisconsin, the sun sets before 5 p.m. Terry 06:33-06:45 Does the lack of sunlight impact our mental health? Today we’re talking about seasonal affective disorder, also called SAD. What is it and what can we do about it? Joe 06:46-07:14 Our guest today is Dr. Norman Rosenthal. He is a psychiatrist and scientist who first described SAD in 1984 and pioneered light therapy as a treatment. Dr. Rosenthal is currently clinical professor of psychiatry at Georgetown University School of Medicine. He’s the author of several books, including his most recent, Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons. Terry 07:16-07:19 Welcome to The People’s Pharmacy, Dr. Norman Rosenthal. Dr. Norman Rosenthal 07:20-07:21 Thank you. Thank you. Joe 07:23-07:45 Dr. Rosenthal, it’s hard to believe, but more than four decades ago, you coined the term SAD for S And I think that’s one of the best acronyms in medicine. So my first question is, what got you interested in SAD? Dr. Norman Rosenthal 07:47-10:08 Well, the first clue, when I look back, was my own seasonality. In South Africa, where I was born and raised, the seasons are very mild. When I came up to New York City, it was quite a shock. Originally, it was the summer, the days were long, and I was giddy with delight. And I thought, well, that’s just because I’m in a new country and in a new city. But in retrospect, the long days were also driving my exuberance. And then after daylight savings time came, I didn’t know what hit me. And I felt a rhythm of up and down that went on for three years through my residency. And, you know, I managed. I hung in through the winter. I played and enjoyed myself in the summer, but when I came to the National Institute of Mental Health here in Bethesda, Maryland, my colleagues and I encountered a scientist who actually had much more severe seasonal problems than I did. And we had the idea to expose him to very bright light in the wintertime, and he came out of his depression, which was a wondrous thing to observe. But then I thought, you know, we’re never going to get a story unless we can collect a group of people that we can do controlled studies with and define who are these people and how do they respond to light, etc. So with that in mind, I went to a journalist here at the Washington Post and I said, would you be willing to run an article? We just had one person, but I have a few more people who’ve given us stories like this, and she was all on board. And then we got thousands of responses from all over the country. It was before the internet, so they all came in letters from all the states, especially the northern ones. And I sent them questionnaires, which asked them questions pertaining to the things I had seen that changed during the seasons. And from that, I put together the syndrome, which we then explored. And that was the beginning of it. Terry 10:08-10:31 Well, Dr. Rosenthal, we remember those days when you could recruit patients for a study through the newspaper. That would be pretty hard nowadays because nobody reads actual newspapers. But you say you put together the elements of the syndrome. Would you explain that, please? What are the elements of seasonal affective disorder? Dr. Norman Rosenthal 10:32-12:52 Well, I read through these interviews, these filled-up questionnaires, and had a growing sense of excitement because in psychiatry, there is such heterogeneity, meaning that people are so different from one another, even if they carry the same diagnosis. But these people had a sort of monotony about their symptom patterns that was thrilling to me, because it suggested that there might be some underlying biological connection that then would be more testable than if you had just a general population of depressed people. So here was a typical story: When October comes, I feel slowed down. I can’t get my work done. It’s difficulty getting up in the morning. It’s hard to keep to my diet. I get cravings for sweets and starches. I fail at my work. My relationships seem to deteriorate and so I get depressed and it lasts through the winter, and in the spring I begin to come to life again. So that, variants of that particular story I read again and again. And as I read one after the other, I thought, well, we’ve got a syndrome here because these people don’t know each other and yet they could be copying from each other’s playbook. And so that’s when I put pieces together. And with the help of my colleagues at the NIH, we ran the first cohort from the summer into the winter, into the autumn to see: would they get depressed on cue? And one of my colleagues said to me, “Won’t you look stupid if they don’t get depressed?” And I thought, well, you know, I’ve been depressed and down in the winter, so I think they will be. And, you know, it’s okay to look a bit stupid. That’s not such a bad thing. Lots of us do it accidentally. So in any event, they went into depression as on cue. And we put them through a controlled study of light therapy, and they responded. And that was the beginning of this four-decade, very exciting adventure. Terry 12:55-12:59 Now, you say a controlled study of light therapy. How do you do a controlled study of light therapy? Dr. Norman Rosenthal 13:00-14:52 That’s such a great question, you know, because we have struggled to find a good control. The first one was bright light versus dim light. And the dim light actually was yellow so that it had a sort of placebo effect. You know, you could have the yellow light or you could have the white light and we tried to camouflage the fact that the intensity was different and that proved to be that the bright white light was more effective. But then many people said, well, they could have guessed that, they could have known that. And so went a long effort on many researchers’ parts to find the best placebo. And finally, a colleague of mine, Dr. Charmaine Eastman, came up with an ion generator. You know, these ionizers have been used as air cleansers, and they give off negative ions. And she went a step further and deactivated the ion generator and found that the bright light was better than the ion generator, even though the expectations of the two treatments was equivalent. And that became a sort of standard control treatment. And basically, every control treatment has more or less worked. So the cumulative effect of all these positive studies, including ones which contained placebos that were generally agreed upon to be plausible and that they were truly blind to what our hypothesis was, have all shown collectively this very powerful effect of bright light versus whatever else we used. Joe 14:53-15:07 Now, Dr. Rosenthal, we’ll talk a little bit more about light therapy in a moment, but first, I’m curious, how does SAD, seasonal affective disorder, differ from other kinds of depression? Dr. Norman Rosenthal 15:08-16:21 Well, the first very typical way it differs is by its temporal association with the seasons. The other thing is that the picture of depression can vary between what’s called typical and what’s called atypical. In the typical classical depression, people eat less, sleep less, lose weight. That’s one kind of depression, but that’s not usually what people with SAD do. They eat more, especially sweets and starches. They gain weight. They sleep more. It’s more of a kind of hibernation-type depression than a sort of over-activated, agitated kind of depression. So from the point of view of symptom pattern, it often differs. But also the key difference is the timing. And I was going to say the response to light. However, more recently, light has been shown to be much more generally effective, not exclusively on seasonal affective disorder, but on other kinds of depressions as well. Terry 16:21-16:26 Do we have any idea how many people suffer from seasonal affective disorder? Dr. Norman Rosenthal 16:27-17:40 We’ve done population studies, and our best estimate is that about 5% of the general population adults suffer from SAD and another 10% from a less severe variant, which we call the winter blues. And these are not hard and fast distinctions because somebody could have the winter blues one winter and then the next winter maybe they have got deadline pressures and they are stuck in the office and they have to do their work for the deadlines and they could have a real case of SAD the next winter. And then the following winter, it’s easier. They may go back and just have the winter blues. But if you look at it at any given time, about 5% will respond that they have really significant troubles with the winter of the kind that occur in SAD. And a 10% more would say, yes, they have trouble, but it’s not disabling. It just interferes with their best functioning. And of course, this varies with latitude, you know, and with weather patterns. So it’s going to be much worse, for example, in New Hampshire than it is in Florida. Terry 17:41-18:01 You’re listening to Dr. Norman Rosenthal, clinical professor of psychiatry at Georgetown University School of Medicine. He was one of the first scientists to identify SAD. His most recent book is Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons. Joe 18:01-18:05 After the break, we’ll learn more about the links between latitude and SAD. Terry 18:06-18:10 Is this condition especially prevalent in northern places like Scandinavia? Joe 18:11-18:25 What are the criteria for selecting light therapy? Can you get light therapy outside as well as from a light box? How long should the exposure be for effectively alleviating SAD? Terry 18:39-19:00 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:42-20:46 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:46-21:11 And I’m Terry Graedon. Do you ever get the winter blues? Joe 21:12-21:24 When the days get short, you find yourself more irritable or on the edge of tears. Are you likely to feel stressed or anxious? Have you noticed changes in appetite or sleep patterns? Terry 21:25-21:53 The farther north you go, the shorter the days get. When we visited Tromsø, Norway, in the summertime, it was light nearly 24 hours around the clock. That city is north of the Arctic Circle, so they experience midnight sun. But during the winter, they have hardly any daylight. How does that affect people’s mood? Turning to the United States, how does living in North Dakota or Minnesota compare to living in Texas or Florida? Joe 21:54-22:03 Our guest first described S-A-D, SAD, or Seasonal Affective Disorder, in 1984 after experiencing it himself. Terry 22:04-22:31 Dr. Norman Rosenthal is a psychiatrist and scientist who pioneered light therapy as a treatment for seasonal affective disorder. He’s clinical professor of psychiatry at Georgetown University School of Medicine. Dr. Rosenthal is the author of several books, his most recent being Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons. Joe 22:33-23:09 Dr. Rosenthal, you just mentioned, I’ll call it latitude and climate. And so I’m wondering, do people in tropical climates develop seasonal affective disorder? I mean, what about in South Africa or in the Caribbean? Are people just always happy and having a great time, never experienced seasonal affective disorder? And do people in, oh, let’s say Finland and Norway and Wisconsin, do they always suffer from it? Dr. Norman Rosenthal 23:11-23:15 Well, let’s take your questions one at a time. There is… Terry 23:17-23:19 He did pile up a few. Dr. Norman Rosenthal 23:19-26:19 There is SAD all over the world. In South Africa, you’ll have more of it in Cape Town, which is further from the equator than, say, in Johannesburg, but it’s definitely been described there, and it’s also been described in Australia. However, if you look at the distribution of the continents on a map or on the globe, you will see that it’s skewed north, that there’s a greater land mass in the north than in the south, so that the northern countries, by and large, are more north than the southern countries are south. Of course, there are exceptions like Patagonia and other things that are very far south. But for the most part, the north is the more affected. That said, remember, the real cause of SAD is the lack of light. So anything that causes light to be lacking is going to be a vulnerability factor for SAD. So, for example, there are tropical areas that don’t have the dark and light seasons connected with the sun. They may have it connected with the monsoon winds. So if there are monsoon winds that block out the sky, here, for example, in the mid-Atlantic and I know in the Northeast, we’ve had this tropical storm that clouded the sky for like three or four days. And people who are vulnerable to SAD really, really felt it. I felt it was quite gloomy and overwhelming. So in places where there’s heavy cloud cover, you will get SAD. Now, for example, Hawaii, which we all think of as sunny, we think of it as sunny because when we go there, we are in holiday resorts for the most part, and they are on the sunny side of hillsides. But on the other side, where the shadows fall from these mountains, live people who are not in these upscale hotels. They are down in the valley, in the shadow, and they are often experiencing SAD. That’s not a very well-known fact. And the reason I really raise it is to really emphasize that it’s not just a seasonal problem. It’s a light deprivation problem. So that means that if you are in a basement apartment or in any situation where the light is not easily accessed, in like Manhattan, where you can be right up against another building. All of these settings are such that there’s not much light, and you’re going to be vulnerable if you have that biological tendency. Joe 26:19-26:52 Has anyone done a study of a place like Tromsø in Norway, which is north of the Arctic Circle? And in the summer, it’s like it’s sunlight all day long and most of the night. So you have to have dark shades on your windows if you want to go to sleep. But in the winter, it’s dark, really dark for like 23 hours of the day. You maybe get an hour or two of sunlight. Has anybody studied to see if people in places like Tromsø are more depressed? Dr. Norman Rosenthal 26:52-28:55 You know, it’s a wonderful question. And Tromsø is a wonderful town, and I did go and visit there personally in the midst of the winter. Some pharmaceutical company was running their symposium at that time as a PR stunt. It was the middle of the winter, and people were hunkered down into their homes. The northern lights were on display, and it was a quiet, peaceful time. But then when I went back in the summertime, people were fishing from the bridges like at one and two o’clock in the morning, and the behavior was completely different. The question of whether there is much SAD in Tromsø is a debatable one. There is a New Yorker article that was written maybe 40 or so years ago by a man named Westbrook. And he documented going up to Tromsø and how much people were complaining about the winter. But apparently it just wasn’t the thing to complain about the winter. So they would say some things like, oh, I’m feeling terrible right now in these dark days. But really, it’s not so bad. Everybody, you know what I’m saying? It was obviously a cultural bias not to complain. But a lot of complaining occurred nonetheless. The other thing is, realistically, you don’t end up in such a northern town north of the Arctic Circle unless you have a certain amount of resilience with regard to your seasonality. Lots of people, incidentally, when they fly south for a vacation in the middle of the winter, they fly south to Oslo for a vacation. And if you have to fly south to Oslo to get the sun, you know you’re in trouble. Terry 28:56-28:57 Pretty desperate. Joe 28:58-29:02 Yes, and we too have had the opportunity to visit Tromsø. Terry 29:02-29:03 In the summertime. Joe 29:03-29:09 In the summer, when it was sunny all day long and into the night, and it was a delightful experience. Terry 29:10-29:58 Dr. Rosenthal, we have had some comments on our website that are related to SAD, and I would like to read you one of them for your comment. Lindsay wrote, “I live way up north and have suffered badly with SAD for years and years. Light boxes don’t help. I refuse to take antidepressants. SAMe helps a little, but I’m just miserable for eight months of the year. I’d move south if I could. Sometimes more thyroid medication through the dark months helps.” And I could actually add my data point to Lindsay’s, which is I too find that I need a higher dose of levothyroxine in the wintertime. Your response to Lindsay’s comment? Dr. Norman Rosenthal 29:59-33:20 Well, my response, first and foremost, is absolute fascination, because I would really want to sort of drill down and find out what is going on here with the light. You know, why isn’t the light doing any good? And I would look at the kind of lights being used, make sure there was enough light. You know, some people are going to use more light. I would want to be sure that her eyes were functioning well, that she wasn’t developing cataracts, for example, that could block the light. And I would like to see what kind of light box is she using? Is she using a teeny weeny one, which is supposed to give out the so-called 10,000 lux, which is a measurement, but isn’t big enough? Should she be using more than one light box? So I would go into it like Sherlock Holmes and try and figure out what is going on with the light. But then I would shift gears and say, there are many other things you can do, even besides antidepressants. And this is, and I know it’s kind of not cool to say in my book, so I’m sort of absolutely minimizing that comment. But that is the point that I have made in my new pitch here. Even when you look at light therapy studies done in research settings, you see that the number of people or the percentage of people who don’t just respond but actually remit, which means that they virtually have no measurable symptoms because they’re doing so well with their treatments. The number or the percentage of people that really respond to that degree is rather small. It’s like 30 or 40%. So this is like a secret that 30 or 40% don’t feel 100% better with the light therapy. So you need to add things. And that’s why I say you’ve got to add exercise. You’ve got to add socialization. You’ve got to add cognitive behavior therapy, which is a wonderful tested kind of treatment for SAD. And, you know, exercise outside with natural lights. You can’t compete with a dome of the sky in terms of a light box. One of the patients I mentioned did not like the light therapy. She instead did meditation. She did a sort of meditation, which was very helpful. And in fact, I’ve written about meditation for SAD. So you’ve got to be very skillful. As I point out, you know, the Greek poet Archelaika said, the fox has many tricks, but the porcupine has one big trick. And I say, that’s how we should be when we deal with our SAD. We need to be like a porcupine with our big trick, which is our light therapy, but we also need to be like the fox with many little tricks, which collectively will help us get back to feeling almost as good as we do in the summer. Joe 33:22-34:01 Dr. Rosenthal, let’s drill down on light therapy. You’ve already described that it’s not perfect, but it’s pretty darn good. What are the different devices? What should people be looking for when they start shopping around for a light box? I suspect if they go online, they’ll find many options. How do they pick the right one for them? And then how does the light box compare to natural sunlight, even in the winter? Because even if you’re in Wisconsin, you can still get some light if you go outside. Dr. Norman Rosenthal 34:02-34:33 Wonderful questions. Yeah, I think firstly, when you choose a light box, it needs to be big enough. And all the research studies that have shown effects of light have used light boxes with a surface area of at least one foot square. They should be produced by a reputable company that’s been in business for a while. So you know that it has sort of stood the test of time, that it has met various standards, and that it stands by its products. Joe 34:34-34:35 Such as? Dr. Norman Rosenthal 34:36-35:10 You mean the names of the lightboxes? I’m happy to give them to you. I’ve got them. For the first time in defeating SAD, I’ve actually given the names of lightboxes. I would say the Day-Light by Carex is an excellent one. The Sun Square or the Sunray by Sunbox is an excellent one. These are two very good brands. There’s North Star. I’ve listed various ones. They’re big enough. They’ve been around long enough. And they put out a decent amount of light. Joe 35:11-35:15 And I’m assuming that you have listed them in your book? Dr. Norman Rosenthal 35:16-35:35 Yes, absolutely. I really, you know, I have no financial agreements with any of these companies. I’ve never wanted to do that because I knew it would detract from my credibility. And, but I’ve just I thought, finally, I really need to come out and be very specific. Joe 35:36-35:44 That’s very helpful. That is very helpful. And how much light, that is to say, lux or whatever measurement we should use, should we be looking for? Dr. Norman Rosenthal 35:45-36:04 The classic amount now is 10,000 lux of light, about three feet away from the light source. And 10,000 lux, how much is that? It’s how much light you’d get if you were outdoors on a cloudy day and you look to the sky. That’s about 10,000 lux. Joe 36:05-36:08 And for how long, either inside or outside? Dr. Norman Rosenthal 36:09-37:30 Well, how long is variable from person to person? It’s like saying how much Tylenol should you take for your headache? Well, one person may need only one and another person may need three. It’s variable in dosage. But I think the thing that I want to emphasize, because if you ask me what do I do myself for my own seasonal affective disorder, I have got a number of light boxes around the house because I don’t want to have to cart my light box around with me wherever I go. I have them in the bedroom. I have them in my study. I have them by the kitchen table. I have them in my gym room. Now, you know, that’s a lot of light boxes and it’s a lot of money. And not everybody may be able to afford that. But if you compare it to what a seven-day vacation in Hawaii costs, it’s probably much cheaper than that. And it lasts you all winter long, every single winter. So, yes, one week in Hawaii is maybe much more fun than having light boxes all over the house. But it’s a matter of how do you choose to spend your money, and it doesn’t have to be so much. Joe 37:31-37:43 Do you just leave the light boxes on and just walk from room to room? Or what if somebody said, well, I just want to buy one light box, I’ll put it in my study. How long should I sit in front of that darn box? Dr. Norman Rosenthal 37:43-38:13 I would say, you know, at least 20 to 30 minutes in the morning. And I want to also mention that there are smaller lights like they’re the size maybe of a tablet, an iPad or, you know, and they’re quite good. And you could take a couple of them, and they’re much easier to walk around the house with. And you can position them like in stereo, coming from both directions to be sure that a greater amount of your retina gets bathed in light. Terry 38:14-38:53 You are listening to Dr. Norman Rosenthal. He’s a psychiatrist and scientist who first described seasonal affective disorder in 1984 and pioneered light therapy as a treatment. Dr. Rosenthal is clinical professor of psychiatry at Georgetown University School of Medicine. He has written a number of books, including The Gift of Adversity, The Unexpected Benefits of Life’s Difficulties, Setbacks, and Imperfections, and his most recent, Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons. Joe 38:53-39:06 After the break, we’ll find out how people can use outdoor light to overcome SAD. Does cognitive behavioral therapy help? How would someone recognize that they have seasonal affective disorder? Terry 39:06-39:11 We’ll hear about the research that distinguishes SAD from other forms of depression. Joe 39:12-39:17 Can people do anything in the autumn to prevent the onset of SAD? Terry 39:31-39:46 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 39:46-40:05 And I’m Joe Graedon. Terry 40:06-40:21 Are you less productive during the winter? Is it harder to get energized or organized? We’re talking about how seasonal affective disorder affects people’s emotions and behavior and what they can do to defeat SAD. Joe 40:22-40:51 Our guest is Dr. Norman Rosenthal. He is a psychiatrist and scientist who first described SAD in 1984 and pioneered light therapy as a treatment. Dr. Rosenthal is currently clinical professor of psychiatry at Georgetown University School of Medicine. Dr. Rosenthal is the author of several books, his most recent being Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons. Terry 40:52-41:14 Dr. Rosenthal, we have just discussed light therapy for indoor situations. How can people use the outdoors, assuming there is some light outdoors and they’re not above the Arctic Circle? How do they use outdoor light to help their seasonal affective disorder? Dr. Norman Rosenthal 41:15-43:14 Well, I’m absolutely thrilled that you’re asking this question because people often get so fixated around light boxes and indoor life that they forget that they’ve got God’s light box overhead as they walk outside. And the huge dome of the sky is going to give off more light, even on a cloudy day, than you’re going to get from a light box. Now, of course, one of the problems is when it’s a cloudy day with maybe a little bit of drizzle, what have you got? You’ve got a cap on, you’ve got a hat on, you’ve got a scarf, you’ve got a muffler. You’re not seeing any of that wonderful light. So be sure to look up at that sky, even if it’s cloudy. Of course, you’re never going to stare straight at the sun. But look up at a cloudy sky and a magic combination is light plus exercise. You’re going up and down hills. You’re getting your high intermittent high intensity exercise going up and down hills. You’re looking up at the sky. And all of a sudden, don’t be surprised if your SAD just falls away and you feel so happy because it’s a powerful combination. And I love the word combination because in SAD, the fox with its many tricks combines all these different tricks. So we’ve got exercise, we’ve got bright light, we’ve got light boxes inside, we’ve got social plans that we don’t allow to drop off our agenda. We’ve got help with the training with both aerobic and resistance training. We do a little bit of yoga, we meditate. We really embrace the winter in all its different aspects and collectively that’s what’s going to hold us through the winter with light therapy as the jewel in the crown. Terry 43:14-43:25 Let’s talk a little bit about some of those individual aspects that add to the benefits of light therapy. I’m wondering if you would start with cognitive behavioral therapy. Dr. Norman Rosenthal 43:27-45:57 Well, cognitive behavior therapy has been thoroughly explored by my colleague, Dr. Kelly Rohan up in Vermont. She’s done wonderful work, and what she’s found is that cognitive therapy was as good as light therapy in the first winter where they studied it. And then in the subsequent winter, cognitive behavior therapy actually prevented the recurrence of SAD better than the previous light therapy group. And it wasn’t actually a surprise to me because when we asked our patients in our seasonal affective disorder studies at the NIH, what was the most useful thing you learned from your participation in the program? I thought they would say light therapy, but instead they said, understanding the nature of our illness. Because, you know, people are smart. And once they understand what causes what, they can think of all these inventive ways to overcome that cause and effect relationship. So Dr. Rohan shared a lot of her information on her studies with me, which I was able then to incorporate into my book. And she emphasizes the importance of behavior because SAD is an illness where your behavior contributes to the symptoms and you can modify it. So the worst thing you can do with SAD is to, when you wake up in the morning, pull the covers over your head. Because that’s preventing you from seeing the light. Instead, if you got out of bed, looked out of the window, opened the curtains, put on your light box, you’re doing behaviorally all kinds of little things that are going to make a huge difference. So the magical word about treating seasonal affective disorder, SAD, is combination. So if you combine with your light therapy, exercise, cognitive behavior therapy, a few winter vacations, maintain your social connections, and know and understand what are the factors that make you feel down and how can you reverse them, you will do a great job in managing your winter depression. Joe 45:57-46:23 Thank you for that, Dr. Rosenthal. I guess it’s important for us to go back and review what is SAD, seasonal affective disorder. What are the symptoms? How would somebody know that they are vulnerable to maybe bad winter blues or, in fact, Seasonal Affective Disorder. Dr. Norman Rosenthal 46:23-47:15 If you wonder, have I got Seasonal Affective Disorder? Look back. How do I feel normally at Christmas time, at Thanksgiving? Am I the life and soul of the party, or am I the one sitting in the corner because I’m feeling down? In fact, I don’t even want to go to the parties. I don’t want to celebrate. I don’t want to make all these things that a lot of people say is necessary for the holidays because I’m just not feeling myself. If you have that pattern, then you can say, do I need more sleep? Do I eat more? Do I gain weight? Do I withdraw from friends and family? Is it hard for me to get my work done? And this happens each year in the wintertime and it gets better in the spring and summer. Chances are you have seasonal affective disorder. Joe 47:16-48:41 I’d like to share a message that we got from Teresa, and it’s a little different, and I wonder if she’s doing the right thing. So help us come up with an answer for Teresa. She says, “I really enjoy your program on KERA here in Texas. I profoundly suffer every winter from SAD, and it seems like everyone around me is unaffected. Things always seem more hopeful by February because I reside in the South. I’m always hopeful around March for the return of the light.” “My whole life revolves around the natural, the only thing that makes me happy. I prefer to work in the winter and be off in the summer, which is rarely possible, though. When it’s a sunny day, I can’t stand to have to leave the house. I just want to sit and look out at the sun like I’m starved for those UV rays. On gloomy days, I prefer to go out for mundane activities.” “I reside in the South, but sunny days still seem like rare gold to me. If it’s a sunny day, I love to stay home just staring out the window. The light means more than food, water, anything. If I had money, I’d book flights to the hemispheres according to the season. By that, I mean I would fly down to New Zealand in December while it’s summer there.” So what advice do you have for Teresa? Dr. Norman Rosenthal 48:42-50:16 The first thing I would say is that description is so beautiful because in one point in my writing, I quote the line, drink to me only with thine eyes and I will pledge with mine. The idea of drinking with the eyes is so profound to me because if you are one of those people who long for the light, you are like a thirsty man in the desert. And when you come up with a little bit of water on your tongue, it feels so wonderful. The receptors of your tongue are responding to the water and feeling so joyful. And that’s how it is when you long for the light. So I really think Teresa’s done a fantastic job of explaining it. Now, what’s happening with Teresa is that she is very, very sensitive to the light. And even far into the South, she misses it terribly in the winter and craves it in the summer. So I’ve had some of those people who have actually moved down to the South. And even in the South, when there’s a lot of light for most people, they have still needed to use light therapy to supplement their natural light, even though it’s a sunny climate. So she just has the problem to a greater extent, and she needs to exercise these options that we’ve been describing to a greater degree than most people. Terry 50:18-50:45 Dr. Rosenthal, I’m going to raise an issue that is somewhat controversial now. You introduced the concept of seasonal affective disorder decades ago, and most people accept it. But apparently, some of your colleagues are now questioning whether it is a real thing. Can you tell us about the research and your reaction to it? Dr. Norman Rosenthal 50:47-54:17 Yeah, I know the research. What the researchers did was they looked at depression ratings in a large data set that was collected for various reasons, whether it was an insurance company or someone had these large data sets where they looked at parameters of various behaviors over the year and they looked at depression as one of them. And when they looked at that, they did not find a winter peak. It was all kind of flat. But the problem was nobody really knew who these people were. I mean, were they people with summer depression? You know, they’re people who get depressed every summer. They’re people who get depressed every spring. They’re people who get depressed at all kinds of different times of the year. So you’ve got a very mixed database. And those people who get depressed in the autumn, you see, remember, winter depression, it’s not just winter. People are getting depressed already in September, some even as early as August, because the light is already waning in some parts of the country at that time. So August, September, October, November, December, January, February, March, people with SAD could be affected in all of those months. So that’s half of their data. And the other half of the data, there may be summer depression, there may be all kinds of things. It’s a mixed data set where the signal has been camouflaged. And in fact, until we looked at people longitudinally, the signal didn’t emerge. People found that they looked at hospitalizations for depression and most occurred in spring and fall. Well, most people with SAD don’t get hospitalized. It’s not that kind of depression. So when you’ve got a heterogeneous data set and you’re sampling people in this particular way, you are bound to miss a signal, whatever that signal happens to be. I’ve got colleagues who are working in similar areas where signals get camouflaged because of, like, let’s say you looked for PMS and you looked all over and you looked at it not by when people’s menstrual periods were, but when the seasons were. You wouldn’t necessarily find any link at all. So it’s the methodology that led to a negative finding. And then the negative finding was very boldly interpreted as a complete revolution in scientific discovery, debunking 40 years of work, which I think was extremely… a very kind self-interpretation of the data by the researchers. So I think that, yes, it’s a kind of man-bites-dog story as far as I’m concerned, and I don’t think it’s really been replicated. I don’t think much has happened with it, but it does stand out there as an interesting, controversial item that I think really doesn’t have any bearing on debunking what really is hundreds of papers. Terry 54:18-54:35 Well, Dr. Rosenthal, before we conclude our conversation today, I wonder if you can tell us, are there things that people who suspect they might have SAD can do in the autumn to prevent the onset of symptoms? Dr. Norman Rosenthal 54:36-54:50 That is an absolutely wonderful question. And I think we really need to have an autumn checklist. And so, may I read an autumn checklist over here? Terry 54:50-54:51 Yes, please do. Dr. Norman Rosenthal 54:51-56:11 Because I have one right here in my book, and it’s so important. Here is the checklist. One: Ask yourself, One: Have I purchased a light box or boxes for the winter? Two: Do I have at least one room in my home that is bright and inviting? Three: Have I made plans for a winter vacation or two, in the sun? Four: Is this a good time to check in with my doctor and put her or him on notice that I’m entering my season of risk? Five: Have I notified those close to me that I may need a bit more support from them in the coming months? Six: Have I put a physical fitness program in place? If you start an exercise program before winter hits in full force, it will be easier to continue when your energy and motivation flag. Number seven: Have I evaluated my outlook to see whether it could be improved? For example, can I view winter at least in part as a challenge and an adventure rather than an unmitigated pain in the neck, as it so often feels? And finally: How can I find beauty in this colorful season of autumn, resplendent with the fruits of summer? Terry 56:12-56:18 Dr. Norman Rosenthal, thank you so very much for talking with us on The People’s Pharmacy today. Dr. Norman Rosenthal 56:20-56:22 Thank you so much for having me as a guest. Terry 56:23-57:07 You’ve been listening to Dr. Norman Rosenthal. He’s a psychiatrist and scientist who first described seasonal affective disorder in 1984 and pioneered light therapy as a treatment. Dr. Rosenthal is clinical professor of psychiatry at Georgetown University School of Medicine. He’s the author of several books, including Winter Blues, Everything You Need to Know to Beat Seasonal Affective Disorder, and Transcendence, Healing and Transformation Through Transcendental Meditation. His most recent book is Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons. Joe 57:07-57:15 Lyn Siegel produced today’s show, Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 57:15-57:23 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Terry 57:45-58:10 Today’s show is number 1,363. You can find it online at peoplespharmacy.com. That’s where you can share your comments about today’s interview. Tell us about your experience with SAD. Have you ever tried a light box? How well did it work for you? We’d like to hear about it. You can also reach us through email, radio at peoplespharmacy.com. Joe 58:10-58:19 Our interviews are available through your favorite podcast provider. You’ll find the show on our website on Monday morning. At peoplespharmacy.com, Terry 58:19-58:36 you can sign up for our free online newsletter. Get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast, so you can find out ahead of time what topics we’ll be covering. Joe 58:37-58:39 In Durham, North Carolina, I’m Joe Graedon. Terry 58:39-59:20 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 59:20-59:30 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 59:30-59:35 All you have to do is go to peoplespharmacy.com/donate. Joe 59:35-59:48 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

Inflammation is a double-edged sword. When you have a sudden injury or infection, your body responds by calling immune cells to the site of the problem. It may become red, swollen and painful, but all that is supposed to be part of the healing process. What happens with chronic inflammation is more insidious. Many serious diseases, such as diabetes, depression or heart disease, feed off chronic inflammation. Anti-inflammatory drugs can control the problem temporarily, but they have drawbacks if they must be used continuously. How can we go about calming chronic inflammation without medication? At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Jan. 31, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Feb. 2, 2026. How Inflammation Works: One of the hallmarks of modern life is the impact of stress on the digestive tract. Excess weight, unrelenting stress and environmental toxins can all contribute to an immune system that goes into overdrive. Sometimes the consequence will be an imbalance in the microbiota, with the result that the tight junctions of the gut are disrupted. That can lead to “leaky gut,” more respectably termed “intestinal permeability.” When pathogens or toxins that should be confined to the gastrointestinal tract start circulating elsewhere, the immune system reacts. If the process continues, the consequence is chronic inflammation. Are there natural approaches to calming chronic inflammation? Calming Chronic Inflammation: When we want to help our immune system so that it doesn’t have to be hypervigilant all the time, we should start with our diet. If dysbiosis contributes to leaky gut and inflammation, the best approach might be to feed our gut microbes what they need. In most cases, that means increasing our fiber. Gut microbes thrive on fiber, and most Americans don’t get close to eating enough. Another important aspect, of course, is to avoid foods that might cause trouble. According to Dr. Low Dog, fructose degrades tight junctions in the intestines and could contribute to intestinal permeability and inflammation. To reduce fructose, we just need to cut back on sweets Finding Fiber in our Food: Where can we find fiber in our diet? Starting with breakfast, a lot of folks enjoy cold cereal, pancakes or pastries. There’s not much fiber in any of those, unless you’ve chosen bran cereal. But even a choice as simple as eating an apple with the skin on can provide a good amount of fiber. Do you like salmon for breakfast? That’s a very anti-inflammatory choice. One worrisome development is the spread of microplastics throughout our diet. As a result, most of us have microplastics in our bodies. Some of the compounds in these little particles of plastic are endocrine disruptors that contribute to inflammation. Maintaining Healthy Barriers: The colon is not the only part of the digestive tract that provides an important barrier. The mouth is also susceptible. Brushing, flossing, dental care and a low-sugar diet are important steps to protecting our bodies against chronic inflammation. Periodontal disease contributes in a major way. To maintain good tight junctions, we need to eat about 20 grams of insoluble fiber and 8 grams of soluble fiber daily. Beans and vegetables are great sources of both. Nuts and seeds like sunflower seeds or walnuts are also good sources. So are whole grains. And if we have any trouble reaching our fiber goals with diet, there is nothing wrong with adding a daily dose of psyllium, which is mostly soluble fiber. It lowers cholesterol and can reduce the risk of diabetes as well as promote regularity. Herbs to Ease Inflammation: In addition to paying attention to a high-fiber anti-inflammatory diet, we can benefit by using certain herbs or spices to calm chronic inflammation. Green tea, garlic, onions, hot peppers and other flavorings all have anti-inflammatory power. Turmeric, the yellow spice in curry, is a potent anti-inflammatory. To get the best benefit from adding turmeric to food, it should be used to spice a meal with some fat in it. Black pepper as part of the spice profile also helps with the absorption of compounds from turmeric. Dr. Low Dog cautions us all to vet our turmeric carefully, though. Some brands are high in lead. She suggests that Simply Organic and McCormick are both brands that were relatively free of lead when tested by ConsumerLab.com or Consumer Reports. One supplement that may be unfamiliar to most listeners is nattokinase. It is derived from natto, a fermented soybean dish that is very popular in Japan. People who are taking anticoagulants should probably avoid nattokinase, even though it has anti-inflammatory activity. It could interact with anticoagulants and increase the danger of bleeding. We would add that precaution should also hold for curcumin supplements derived from turmeric. They should not be taken by anyone on an anticoagulant. Other Natural Approaches to Calming Chronic Inflammation: When we asked Dr. Low Dog about her favorite way to calm chronic inflammation, she mentioned walking in nature. High cortisol levels drive chronic inflammation, but green spaces reduce stress and help bring cortisol down. Other marvelous approaches include seeking out ways to embrace contentment and joy and humor. For some people, that will mean meditation. For others, it will mean hanging out with good friends or going for a run. Nourishing our mental and spiritual health with art and poetry help connect us with meaning and purpose in our lives. This Week’s Guest: Tieraona Low Dog, MD, is a founding member of the American Board of Physician Specialties, American Board of Integrative Medicine and the Academy of Women’s Health. She was elected Chair of the US Pharmacopeia Dietary Supplements/Botanicals Expert Committee and was appointed to the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Tieraona Low Dog, MD, author of Fortify Your Life Her books include: Women’s Health in Complementary and Integrative Medicine; Life Is Your Best Medicine and Fortify Your Life: Your Guide to Vitamins, Minerals and More. Dr. Low Dog’s latest is eBook is Healing Heartburn Naturally. Physical copies are available for purchase via Amazon: Click here.
Her websites are drlowdog.com and https://www.medicinelodgeranch.com/ The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, Feb. 2, 2026, after broadcast on Jan. 31 You can stream the show from this site and download the podcast for free. The podcast is supported in part by Superpower.com. For a limited time, our listeners get an additional $20 off with code PPOD. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1460: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:26 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Immune reactions are both helpful and harmful. Immune cells fight infection, but they can also trigger inflammation. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:47 Dr. Tieraona Low Dog is a medical doctor and an expert in botanical medicine. She explains the complexity of the immune system, how it can heal in the short term, and what happens when inflammation persists. Joe 00:48-00:57 Tens of millions of people take non-steroidal, anti-inflammatory drugs every day. Is there a downside to quelling inflammation? Terry 00:58-01:05 Ongoing inflammation is behind many serious diseases, including cancer, diabetes, and heart trouble. Can we address it naturally? Joe 01:05-01:10 Coming up on The People’s Pharmacy, calming inflammation without drugs. Terry 01:14-02:44 In The People’s Pharmacy Health Headlines: Appendicitis, an acute inflammation of the appendix, is a surprisingly common problem, affecting an estimated 7 to 8 percent of people over their lifetimes. Until about 10 years ago, appendicitis was nearly always treated as a surgical emergency. In 2015, scientists published a randomized clinical trial comparing surgery to antibiotic treatment. A large majority of patients who got antibiotics did not require surgery for a recurrence of appendicitis within one to two years after treatment. That study included 273 people undergoing surgery and 257 taking antibiotics. Over the years, some of those who were initially treated with antibiotics did require surgery. Five-year follow-up showed that 39% who got antibiotics later required surgery. Now the same scientists are reporting the results of 10 years of follow-up. They were able to check in with 253 of the original 257 patients. More than half of them did not require surgery. The researchers conclude, among patients initially treated with antibiotics for uncomplicated acute appendicitis, the rate of recurrence in appendectomy at 10-year follow-up supports the use of antibiotics as an option for uncomplicated acute appendicitis in adult patients. Joe 02:44-03:37 High blood pressure contributes to heart attacks, strokes, congestive heart failure, and kidney damage. Accurate measurement is important for diagnosis and treatment. Researchers at Harvard and Brigham and Women’s Hospital in Boston recruited over 3,000 patients with uncontrolled hypertension. All participants were given a free home blood pressure monitor that could send data electronically to the research database. They also received personalized coaching and reminders to monitor blood pressure. One-third failed to take their blood pressure even once, and only about a third managed the 24 to 28 weekly measurements the researchers were hoping for. The authors conclude that the, quote, low engagement rates observed highlight the need for alternative approaches that are more convenient for patients. Terry 03:37-05:02 There are several medications used to treat type 2 diabetes. A new study compares the effects of two different classes with respect to their effects on kidney function. People with diabetes are vulnerable to developing acute kidney disease. Now, Danish researchers have analyzed health records to compare how two classes of diabetes drugs affect the kidneys. The SGLT inhibitors include drugs like empagliflozin, better known by its brand name Jardiance. GLP-1 receptor agonists are medicines like semaglutide, known as Ozempic. The population included people with type 2 diabetes who were taking metformin. When an additional drug was needed, 36,000 plus took one of the gliflozin drugs, while more than 18,000 took a GLP-1. Over five years, 6.7% of those on SGLT-2 drugs developed chronic kidney disease. In comparison, 8.2% of those on GLP-1 drugs had that outcome. The investigators conclude collectively these findings support a lower risk of acute and chronic kidney outcomes with SGLT2I versus GLP-1RA, especially among individuals with a low a priori risk of kidney disease. Joe 05:02-05:58 There was a time, not so long ago, that if you wanted to know if you had the flu, you had to make an appointment with your physician to be tested. That could cost precious time. But now, pharmacies sell over-the-counter flu and COVID tests for rapid detection at home. The FDA has approved another test. The new four-in-one home test called FlowFlex Plus can detect RSV as well as influenza A and B and COVID-19. RSV, an abbreviation for respiratory syncytial virus, is dangerous in babies and young children and accounts for many hospitalizations. This test may be used in infants as young as six months old and could help parents manage this serious infection at the earliest possible stage. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:33 And I’m Joe Graedon. When you hear the word inflammation, what comes to mind? We have frequently been told that inflammation is our enemy. Tens of millions of people take anti-inflammatory drugs every day to overcome pain. Terry 06:33-06:45 But inflammation is an essential process for healing injuries, infections, and other acute problems. It’s part of the immune system’s initial response to a wide range of threats. Joe 06:46-07:29 To find out how inflammation can be both our friend and our enemy, we are talking today to Dr. Tieraona Low Dog. She is a founding member of the American Board of Physicians Specialties, American Board of Integrative Medicine, and the Academy of Women’s Health. She was elected chair of the U.S. Pharmacopeia Dietary Supplements Botanicals Expert Committee and was appointed to the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include: “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Terry 07:30-07:34 Welcome back to The People’s Pharmacy, Dr. Tieraona Low Dog. Dr. Tieraona Low Dog 07:34-07:37 Oh, thank you for having me back. It’s so good to be with you. Joe 07:38-07:48 Well, Dr. Low Dog, you are perhaps the most frequent guest on The People’s Pharmacy and one of the longest. We have been talking to you for so many years. Terry 07:49-07:49 And our favorite. Joe 07:50-07:50 And our favorite. Terry 07:51-07:52 Don’t tell anybody else. Joe 07:52-07:54 But don’t share that information. Dr. Tieraona Low Dog 07:55-07:56 Thank you. Joe 07:56-08:29 So, Dr. Low Dog, we’re going to talk about a couple of things today on The People’s Pharmacy. But we’d like to take advantage of your expertise as both a medical doctor and a natural healer. And we’re going to start with inflammation because it seems to be at the center of so many health problems. First of all, can you tell us when we say inflammation, what are we talking about? And why does it play such an important role both in healing and harming our bodies? Dr. Tieraona Low Dog 08:31-10:39 Oh, you know, the inflammatory response is absolutely crucial for our survival, right? So we’ve recognized sort of the five hallmarks of inflammation for a long time, right? You know, 2000 years ago, they were writing about heat, redness, swelling, pain, and loss of function, right? So those are kind of the five cardinal pieces. And that really was speaking a lot to like an acute inflammatory reaction. So you are out running and you fall down and you skin your knee and you break the skin and it’s kind of bloody and messy and you go home and clean it. Well, if you feel it, it will be warm because you’re bringing more blood flow to the area. It will be red because of the heat and the increased blood flow. Swelling as you’re trying to bring in all your good white blood cells and all of your, you know, warriors to come and clean out any debris, pain and loss of function because we’d like you, you know, to kind of favor that knee for a little bit so that we give the body opportunity to heal it. This inflammatory response is absolutely necessary for cleaning out debris, dead cells, making sure there’s no infection taking place, and also then stimulating, in that case, collagen and wound repair. So a lot of times it’s easiest for people to think about inflammation because everybody’s had a wound and they’ve all experienced that pain and swelling, redness and recovery. I think what a lot of people don’t realize is that you can have similar inflammatory responses that are acute, like when you get a fever, that’s your body’s opportunity, right, to generate heat and activate your white blood cells and fight off infection, and then you get better. But you can also have inflammation that becomes more chronic, and I think that’s something that’s much newer on the scene, this understanding that there can be a low-grade chronic burn going on in the body that is driving a lot of chronic disease. Terry 10:40-11:09 Let’s talk a little bit about some of those chronic diseases, because when we talk to various experts over the years about diabetes or Alzheimer’s disease or arthritis, all kinds of problems that people have, various types of digestive problems, we say, well, what’s behind it? And they say inflammation. So tell us a little bit about chronic inflammation and how it affects the body. Dr. Tieraona Low Dog 11:10-13:15 So, you know, the whole thing with chronic inflammation and the fact that it is the uniting, underpinning root cause of all the conditions you just talked about, the progression of cancers, metabolic diseases, type 2 diabetes, depression, you know, mental health challenges, heart disease. You know, when I went to medical school, heart disease was just cholesterol, right? It’s all cholesterol. And now we know that cardiovascular disease is really a disease of inflammation. So, you know, when we look at these diverse things like depression, pain, periodontal disease, how do those all connect? They connect through this thing we call systemic inflammation. And, you know, today we do so many things that drive that inflammation. We put on weight around the midsection, right? So visceral fat or tummy fat, and I don’t mean the kind you can pinch. I’m talking about the deep fat that develops around our organs, high fructose, high saturated fat diets, that combination pattern, Western diets, not exercising, not moving, prolonged stress, you know, just chronic physiologic or psychosocial stress. And then, of course, environmental exposures, endocrine disrupting chemicals and toxins in the environment. And an area that I have been mostly focused on lately is alterations in the oral and gut microbiota, the bugs that live there, and then leaky gums and leaky gut and how that drives this systemic inflammation. Hippocrates said more than 2,000 years ago that all disease begins in the gut. And if we’re going to think about chronic inflammation, we really have to focus on what’s happening in the mouth and what’s happening in the gut. Joe 13:16-13:26 Well, Dr. Low Dog, I want to talk just a moment about that leaky gut. The gastroenterologists have a very nice terminology for it. Terry 13:26-13:42 Oh, yes. They call it intestinal permeability, which sounds a lot more respectable than leaky gut. Actually, some gastroenterologists laugh at leaky gut, but they don’t laugh at intestinal permeability, which is actually the same thing. Joe 13:42-14:24 And, you know, tens of millions of Americans swallow a non-steroidal anti-inflammatory drug every single day. Maybe it’s for their arthritis or their headache, whatever. And that’s whether it’s Advil or Aleve, that’s to say ibuprofen or naproxen. And these drugs that we just take as if they were, you know, a vitamin can have a profound impact on our digestive tract and can contribute a bit to leaky gut. But I suspect our diet and other things can as well. Can you just describe quickly what this intestinal permeability is all about and why it might lead to chronic inflammation? Dr. Tieraona Low Dog 14:24-17:21 Sure… and I think intestinal permeability is the medical term that we do use. But when I speak to many audiences, what they’ve heard of is leaky gut. And I think that, you know, in many ways, it allows people to visualize what’s happening. The intestine, I mean, think about all the food that we’re digesting and everything that goes along with that coming into the stomach, into the small bowel and the large intestine. And we all know what comes out the other end, right? So there is a critical need for the intestinal, the cells inside of the intestine, to be able to have the selective ability, you know, to decide when water or nutrients or electrolytes are being, you know, absorbed from food out into the systemic circulation, right? And keeping harmful substances inside the intestine, right? So it has to be able to act like a gatekeeper. Well, inside of those cells, the things between the cells are something called tight junctions. And think of these as just like tightly fitting bricks, right? And when we need to absorb things, these proteins open up and they allow the body from the inside of the intestine, things to move out into the lymphatics and the bloodstream, keeping things that need to stay in the intestine inside. The problem is there are a lot of things, including what you just mentioned, like the continuous use of nonsteroidal anti-inflammatories that disrupt those tight junctions. And they allow larger molecules, endotoxins, and even some viable bacteria to pass through that lining out into the bloodstream. And that is a problem. These endotoxins, mostly they’re coming from gram-negative bacterial membranes and walls. When those get out into the bloodstream, they’re highly immunogenic. They trigger an immune response. And that then just drives this systemic inflammation. Now, if it happens once in a while, that’s not really a big problem. When this is occurring on a regular basis, it’s driving this ongoing inflammation that affects insulin regulation. It affects the blood brain barrier, you know, causing neuroinflammation. It affects metabolism. I mean, it is the great unifier, if we think about it, of what is driving this slow burn inside of us. This dysbiosis, anything that disrupts those bacteria and other microbes inside of the intestine also will disrupt those tight junctions and they lead to inflammation. So there’s a lot on this. This is not a mystery. It’s pretty well defined. It’s just biology. Terry 17:23-17:49 You’re listening to Dr. Tieraona Low Dog, a founding member of the American Board of Integrative Medicine and the Academy of Women’s Health. She has served on the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include: “Life is Your Best Medicine” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest book is “Healing Heartburn Naturally.” Joe 17:49-17:57 After the break, we’ll learn what to do to help the immune system so it doesn’t feel like it has to be vigilant every second. Terry 17:57-18:03 If fiber is a great way to support the immune system by supporting the gut, what should we eat? Joe 18:03-18:14 I love talking about breakfast because too many of us rely on high-carb, low-fiber options like pancakes or pastries. What would be better? Terry 18:14-18:20 We do worry about microplastics. We all have them in our bodies. Could they be triggering inflammation? Joe 18:21-18:29 Might brain inflammation be a reaction to infection? Could it lead to Alzheimer’s disease? Terry 18:39-19:09 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:54-20:57 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:57-21:46 And I’m Terry Graedon. Today, we’re learning how to calm chronic inflammation. It’s been estimated that one in three adults has inflammatory markers in their bloodstream. Inflammation contributes to conditions such as rheumatoid arthritis, lupus, psoriasis, cardiovascular disease, and metabolic conditions. Joe 21:47-22:05 We’ve been talking about the gastrointestinal tract. How does inflammation in our GI tract affect organs in the rest of our body? What’s your favorite breakfast? Do you find a bagel and cream cheese keeps you going? What about oatmeal or bacon and eggs? Terry 22:06-22:12 We should be paying attention to what’s on our plates for sure, but we should also know what to avoid. Joe 22:12-22:45 To learn more, we turn back to Dr. Tieraona Low Dog. She is a founding member of the American Board of Physician Specialties and was elected chair of the U.S. Pharmacopeia Dietary Supplements Botanical Experts Committee. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest is an e-book, “Healing Heartburn Naturally.” Terry 22:46-23:21 Dr. Low Dog, it sounds as though the inflammation that we’re talking about, chronic inflammation, is really a consequence of sort of chronically putting the immune system on alert. So not letting it relax and then jump to attention and then relax again. What can we do to help the immune system not have to feel like it’s always on patrol? Dr. Tieraona Low Dog 23:21-25:00 Well, it starts by making sure that you ensure barriers are not being disrupted. Barriers are important. In the mouth, it’s important to reduce the amount of sugar intake and to regularly get your oral cleanings. While we focus a lot on intestinal permeability, the number of diseases that are associated with high oral permeability, meaning through the gums, is also enormous. And it’s something we seldom talk about. So I do want to just note that that’s the beginning of the GI tract. So making sure you’re, you know, keeping down the sugar, you’re brushing, flossing, and you’re seeing your dentist every six months. And then when it goes to the gut, how do we maintain tight junctions? One, probably the biggest thing you can do other than cutting back on sugar, because fructose just definitely degrades that barrier, high consumption of sugars, is to increase your consumption of fiber. Fiber’s huge. And, you know, forever we’ve been telling people to increase their fiber and high fiber diets. We know they increase the health of the bugs, the microbes that are inside of our intestines, especially those that produce the food or the short chain fatty acids that are necessary for the intestinal cells to remain healthy. High fiber diets decrease intestinal permeability. That’s why, you know, we say that eating high fiber diets can help reduce the risk of colorectal cancer, can help lower cholesterol, you know, all of these amazing things. Terry 25:01-25:21 It does all those amazing things. But I think that a lot of people hear high fiber diet and they don’t really know what to eat. So Dr. Low Dog, if I were to go out to lunch today, what should I choose to make sure I’m getting a high fiber meal? Dr. Tieraona Low Dog 25:21-25:55 Absolutely. So, you know, we want both soluble and insoluble fibers, right? So, you know, how much do you need? You know, somewhere around 20 grams a day of the insoluble fibers and about eight per day of soluble. Those are the prebiotics. Those are the ones that lower cholesterol, regulate blood sugar, and help maintain those good tight junctions. So maybe this morning you got up and you had an apple with the skin on. That just gave you almost six grams of fiber and half of the soluble fiber you need for the day. One medium-sized apple, right? Terry 25:55-25:56 Okay. Dr. Tieraona Low Dog 25:56-28:24 I mean, so that’s great. If you’re going out for lunch, have your nice salad, but make sure you also put some beans on it, right? If you’re at a place where you can put, you know, garbanzo beans, black beans, a half a cup of cooked black beans is essentially seven grams of fiber, a half a cup. And almost four grams of that is soluble fiber, right? Pinto beans. I live in New Mexico. Pinto beans is another great place. A half a cup gives you five and a half grams of soluble fiber. So add some sunflower seeds. Put some walnuts on your salad, right? Make sure you’re adding more vegetables to the diet. The whole point is that all of the recommendations that we have for a plant forward diet, where we’re wanting people to increase their intake of fruits, vegetables, nuts, seeds, whole grains is because they’re rich in dietary fiber. And dietary fiber feeds the good bugs that we have inside of our gut, and it decreases intestinal permeability, which decreases inflammation. They have beneficial effects for lowering cholesterol, regulating blood sugar, you know, helping to reduce the risk of colorectal cancer. I mean, you name it. Even there’s data showing that higher fiber diets decrease the risk of respiratory infections and also increase our lives, our lifespan, our health span. So, you know, if you’re going to invest in one thing, that would be it. And for some people who are like, you know, I just, I just can’t eat that much fiber. I would say that psyllium, our old friends, psyllium seed and psyllium seed husks, which have been used forever, is a very good, you know, supplement that you can just take. It’s predominantly soluble fiber and it’s, you know, seven to three soluble to insoluble fiber roughly. And it’s the only fiber that is recommended by the American College of Gastroenterology for treating irritable bowel syndrome and chronic constipation (American Journal of Gastroenterology, Jan. 1, 2021). And the reason for that is it doesn’t tend to cause as much gas and bloating as some of the other fibers do. The FDA has actually allowed two health claims also for psyllium. It can reduce the risk of type 2 diabetes and it can lower cholesterol and reduce the risk of heart disease. So just think about that. Terry 28:24-28:34 Yeah, that’s what I was just going to jump in to say is there’s actually quite good research showing that it lowers cholesterol. And so that’s why I take it every day. Joe 28:33-29:15 Well, you know something about our favorite breakfast, as Terry will attest, my favorite breakfast is refried beans with lots of onions and peppers and, of course, olive oil. And then we put an egg on top, and it’s just fabulous. And then today we had Terry’s whole wheat bread, which, by the way, is absolutely fabulous. Terry has become the best bread baker you can imagine. And on top of that, we had avocado. So it was avocado toast and salmon. And it was just delicious. And it felt like, well, we were getting our fiber, and it tasted good, too. Terry 29:15-29:21 And I think actually salmon probably qualifies as an anti-inflammatory food too, doesn’t it, Dr. Low Dog? Dr. Tieraona Low Dog 29:21-29:33 It’s one of the most of the anti-inflammatory foods when we rank them, you know, by actually what they do in the body. So all I’m saying is me and all the other listeners are wanting to know when we’re coming over for breakfast. Joe 29:35-30:01 Come on down. But here’s the problem, Dr. Low Dog. I’ve been paying attention, as Terry will attest, to plastic for the last 50, 60 years. And, you know, when we saw the movie “The Graduate” and Dustin Hoffman is told plastic is the wave of the future, I had shivers up and down my spine. Terry 30:01-30:40 Well, Joe actually was paying attention when a grad school classmate of mine, we all got together and his girlfriend had been working for the plastic industry as a newsletter editor. And this is so long ago, back when I was in graduate school. We’re talking, you know, 1970. And she said, the industry is concerned because these compounds leach out of the plastic and into the stuff that the containers are holding. Joe 30:41-31:04 But now we even see microplastic or nanoparticles of plastic in our brains, and not just in our brains, like a lot of them, these little tiny plastic particles. But they’re in our blood vessels, they’re in our sexual organs, they’re just all throughout our body. And I can’t help but think that’s not good for us. Terry 31:04-31:06 It might even be inflammatory. Dr. Tieraona Low Dog 31:06-33:14 Oh, they’re very inflammatory. They definitely disrupt, you know, the microbiome. They alter signaling pathways. They alter immune responses. Yeah, it’s interesting because my mother never liked plastic. She would never, or cans actually, she didn’t like aluminum. She didn’t like the way cans things tasted. She didn’t like, um, she didn’t like anything in plastic. She never stored things in plastic, uh, cause she said that she could taste it. Now, I don’t know, you know, if she could taste it or not, but she certainly thought she could. And so I grew up just never having things, you know, in plastic. And, and I could never get the kids to not want to microwave in plastic when they were younger. And so I just got rid of everything that was plastic and bought glass containers for food storage. And, you know, and I learned from my grandmothers to save every pickle jar and everything else and recycle the glass, you know, and use them over and over again. But this is concerning even down to tea bags, right? Just even your brands of teas that have microplastics that you’re leaching out every morning and from your tea bags. So this is a huge issue and it’s going to be a challenge because it’s so woven into food delivery, you know, fast food packaging, food storage. But I would agree with you. And Joe, you were just way ahead of the crowd. Maybe my mom was too, just not wanting plastics. But it is very inflammatory, highly inflammatory, and they’re accumulating everywhere. And we do know that they cause neuroinflammation. So think about this with young children and a lifetime of having these microplastics in their liver driving inflammation and in their brains. And what happens when you’ve exposed a central nervous system as well as other areas of the body to 60 years of neuroinflammation? Joe 33:14-34:17 Well, speaking of neuroinflammation, you know, there is a growing theory that Alzheimer’s disease and other forms of dementia may be in part neuroinflammation. And some people are suggesting maybe a reaction to an infection, you know, like herpes simplex is reactivated, perhaps because of COVID or perhaps because of some other problem that stimulates, as we know, herpes is lingering in the brain for long periods of time. And now people are starting to look at anti-inflammatory approaches and maybe even antiviral approaches to dealing with the neuroinflammation. And what we’re hearing is that some of the medications that have been used and are so super expensive to deal with amyloid may not really be solving the problem. Dr. Tieraona Low Dog 34:17-38:01 Yeah. Well, you know, it is interesting. There was there was a review that was done, a meta-analysis looking at Alzheimer’s and then mild cognitive impairment, right? So looking at both. And they were looking at a variety of things. But in this case, they really found a very strong connection with oral inflammation, with periodontal disease. And those who had severe periodontal disease, you know, the risk for Alzheimer’s was almost five-fold more likely, an odds ratio of almost five. It was kind of shocking. So if we step back again and go, okay, so in the gut and in the oral cavity, when there’s this permeability, when there’s inflammation in the mouth and there’s leakage or there’s dysbiosis and there’s increased intestinal permeability, these endotoxins from these gram-negative bacteria are getting out. These are what we call lipopolysaccharides, right? So you’re going to see that word everywhere. But we know that when those are in the circulation, they degrade the blood-brain barrier and they turn on these cells, these little cells inside the brain called microglia that are normally just resting and happy and they’re there to clean up things or take care of an infection if it happens. But this turns it on. LPS, there’s little receptors for them and they turn on these microglia and we know that they drive neuroinflammation. And when you measure lipopolysaccharides in people with depression or animals with depression versus healthy animals or people that are healthy without depression, lipopolysaccharides are quite high. And so, you know, it’s, I agree, active infection, lingering infection, latent infection, but I would also have to say, step back, root cause, you know, root cause drives the inflammation down by making sure barriers, including the blood brain barrier is nice and strong. The gut barrier is nice and strong. Um, I think that for so long, so long, we keep just, you know, like that saying is we keep pulling people out of the river and keep finding new ways to, you know, dry them off and to get them on their way. But nobody’s really going upstream to figure out why they keep falling in the first place. That’s why I’m excited with the new data looking at what’s driving, what connects a bad diet, obesity, chronic stress, poor sleep, bad digestion, poor digestion. What connects all of these things to heart disease and metabolic problems and Alzheimer’s and depression and anxiety, even osteoporosis, cancer, aggravation of autoimmunity? It’s inflammation. And how do we tamp that down? And it starts with how we’re born. It starts with how we’re fed at birth. It starts with how many antibiotics we take when we’re young, the diets that we eat, the way we manage our stress, and the health of our gut. So, you know, it’s a big topic. And you all have covered so many of these subjects over the years. And I would just say, you know, all roads are sort of leading back. They’re leading back to this root cause, which is this persistent inflammation and, you know, now microplastics, endocrine disruptors in the environment. I mean, there’s just a lot of things. So we’re going to have to figure out how are we going to protect those barriers? How are we going to protect the gut and ultimately then the mind? Terry 38:02-38:37 You’re listening to Dr. Tieraona Low Dog. She’s a founding member of the American Board of Physician Specialties, the American Board of Integrative Medicine, and the Academy of Women’s Health. Dr. Low Dog has served on the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest book is “Healing Heartburn Naturally.” Joe 38:38-38:45 After the break, we’ll learn about herbs that can help fight inflammation. There are a surprising number of them. Terry 38:46-38:51 What’s the best way to get the benefits of turmeric? You know, that yellow spice in curry. Joe 38:52-39:07 It’s become one of the most popular herbs in the health food store and pharmacy. And we’ll get a golden milk recipe. That’s really terrific. Most people have never heard about golden milk in the U.S. It’s very popular in India. Terry 39:08-39:16 You do have to be a bit careful with turmeric or curcumin supplements. If you’re taking anticoagulants, there could be an interaction. Joe 39:16-39:26 Yes, it could increase your risk for bleeding. We’ll also discuss something you’ve probably never heard of, nattokinase. Why is it beneficial? Terry 39:27-39:45 We’ll also find out about other ways to calm inflammation, like meditation, massage, or magnesium supplements. You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 39:54-39:57 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 39:57-40:17 And I’m Terry Graedon. Today we’re considering calming chronic inflammation and we may need to learn about some supplements that might not be entirely familiar. You’ve probably heard of turmeric, which is a potent natural anti-inflammatory, but perhaps you’ve never heard of nattokinase derived from fermented soybeans. Joe 40:18-40:46 Our guest today is Dr. Tieraona Low Dog. She is a founding member of the American Board of Physician Specialties and was elected chair of the U.S. Pharmacopeia Dietary Supplements Botanicals Expert Committee. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and more.” Terry 40:46-41:30 Dr. Low Dog, you’ve given us all very good advice about how to keep our intestines in shape and keep those tight junctions tight and how to take care of our oral health. And what we want to do is make sure we cut back or eliminate the sugar and we increase the fiber and more fresh fruits and vegetables are going to be better along with beans and maybe some whole grains. But what about herbs? We’ve talked to you before about herbs, but I don’t remember which herbs might be most helpful for fighting chronic inflammation. Dr. Tieraona Low Dog 41:30-43:16 Oh, my gosh. There’s so many. There’s so many. So I’ll go into detail into a few. But, you know, just having that, you know, tea in the morning is good, especially green tea. Adding more spices to your diet. I think I heard you say about onions this morning. So onions are highly anti-inflammatory and so is garlic, you know, cilantro, basil, you know, cinnamons, all of these beautiful spices are so anti-inflammatory. And if Americans could just learn to cook a bit more with more culinary herbs and spices, we would begin to really start to see a shift in our inflammation. Speaking of spices, I know you know what I’m going to say. Turmeric, turmeric obviously is one of my favorite herbs and second really only to salmon when it comes to anti-inflammatory power. And when we look at turmeric, adding that to the diet, you know, putting it in your rice, adding it to your tomato soup, or for some people taking a supplement, but the data, you know, why does turmeric seem to, you know, when people eat turmeric over a lifetime, why does it seem to reduce Alzheimer’s? You know, why are studies showing that turmeric seems to help with depressed mood, you know, and memory? How can it reduce inflammation in the gut? Well, we think it’s because it’s a pretty powerful anti-inflammatory and it feeds good microbes in the gut and it reduces intestinal permeability. So turmeric does all kinds of amazing things. So I would say definitely increase turmeric. Joe 43:17-43:54 Well, hang on just a sec, because I know you’ve been to India recently, which seems like the origins of turmeric and, of course, the active ingredient curcumin. And in India, I’m guessing that a lot of people are cooking with turmeric and they’re using some ghee, some fat with that turmeric to get it to absorb better and maybe a little black pepper. You know, Americans love pills. And I keep seeing all these commercials about the best turmeric on TV. Terry 43:55-44:00 But curry tastes so much better than a pill. And probably you’re absorbing it better. Joe 44:00-44:05 Exactly. So tell us a little bit about cooking with turmeric. Dr. Tieraona Low Dog 44:05-46:10 Oh, yeah. Well, you know, we cook with turmeric probably three, four times a week. You mentioned a couple of the most important pieces, some sort of fat, right? So rather that’s your, you know, olive or coconut or ghee or butter, putting that turmeric in and letting it be absorbed with some fat. I love it. I love it in tomato soup. I love cooking with turmeric and a little black pepper saffron in my tomato soup. And of course, for many people, just making a golden milk, it’s so simple, right? You just take a little bit of ghee, [clarified butter], you know, or a little butter, and you just cook the turmeric in there for a minute or two and then add your milk or your non-dairy milk. Let that kind of simmer. If you’d like, put a pinch of cardamom, some dates, chop a date up. Cook that all up, put a sprinkle of black pepper in at the end and drink. I serve it here all the time for our classes and guests and people that visit our ranch. And they’re like, this is so delicious. So cooking, adding it to curries. One thing I would say for your listeners is that we do know that there’s been problems with lead and turmeric in the spices, right? So you do want to, Consumer Labs and Consumer Reports, there’s been a number of groups that have tested them. So just making sure that you’re buying really good turmeric to use in the kitchen. A couple that came out really good, you know, obviously McCormick is very good, which is available, but Simply Organic. Their range of spices also came in exceedingly clean. But I was concerned out of 31 different turmeric spices that were taken off the shelves around Boston, many of them exceeded all safe lead levels. So making sure you’re buying a good curry powder or a good turmeric powder to use at home with your cooking. Joe 46:10-46:36 One word of caution. We have heard from a lot of people who are taking pills, supplements, that they end up with nosebleeds or sometimes other bleeding problems, especially if they’re also taking an anticoagulant like warfarin at the same time. So apparently turmeric does have the ability to quote unquote thin the blood. Terry 46:37-46:53 Or perhaps interact with warfarin. So somebody on warfarin needs to be cautious, I would say, especially with supplements, but possibly also make sure that you don’t overdo on the curry. Dr. Tieraona Low Dog 46:53-47:13 Yeah. You know, but I would say this about warfarin just as a physician. Changing your diet in a dramatic way will affect warfarin, you know, just the way the kinetics work. And, you know, I used to tell the med students, if you have four answers and one of them’s warfarin for an interaction, always choose it because it’s so finicky. Terry 47:13-47:15 It interacts with a lot of things. Dr. Tieraona Low Dog 47:15-47:45 It interacts with a lot of things. So I would tell any listener who’s on something like a Coumadin or something like, you know, for platelet aggregation and blood clots, you just have to be very careful with even any really dramatic changes in diet or adding supplements. Make sure you’re working with your practitioner because we can always adjust your dose of your warfarin to accommodate your diet. It’s just changing your diet around a lot can be problematic. Joe 47:46-48:00 I do have a quick question that’s completely off the subject, but it has been reminded in my brain because of the conversation about turmeric as an anticoagulant in part. And that’s something called nanokinase. Terry 48:01-48:02 Nattokinase. Joe 48:02-48:20 Nattokinase. So what is nattokinase and why would it be beneficial? We heard from an internist, you know, mainstream medical doc, highly placed at one point at Duke, and he said he and his wife are now using nattokinase to prevent clots. Dr. Tieraona Low Dog 48:20-49:39 Yeah. So when you boil… natto’s made from boiled soybeans, right? You ferment them with bacteria and it creates, nattokinase is the enzyme that comes from NATTO, N-A-T-T-O, right? We looked at this when I was at the USP, at the United States Pharmacopeia, looking at it from a safety perspective, because it definitely does seem to have the ability to help with blood pressure, help prevent blood clots, etc. The problem with it is, you know, when we’re putting you on something to reduce blood clots and somebody who really has a high risk for them. We can control the dose so that we make sure you’re not under or over coagulated. That’s more challenging. It’s just, it’s more challenging. If you’re looking at something, you know, that can just kind of help with blood pressure and, you know, maybe even brain health or things like this, you know, having some of it in the diet isn’t really a problem because, I mean, there’s a food. Natto is a food. So I’d say that was fine. Where I would be cautious is if you were told you need to be on an anticoagulant because you have a high risk of throwing clots, I would say that this is not reliable because you can’t keep a steady state. Terry 49:40-50:03 Right. So for that, you need a medication. It might be warfarin or it might be one of the others. Dr. Low Dog, other approaches to calming inflammation. Is there any room for things like mindfulness meditation, massage therapy, acupuncture? What are your favorite modalities? Dr. Tieraona Low Dog 50:05-50:08 Walks in nature. You knew that would be my favorite. Terry 50:08-50:12 That is great. Tell us a little bit more about that. Dr. Tieraona Low Dog 50:14-52:28 You know, just being out wherever is like a place for you. So if it’s around a lake or near the beach or walking in a park if you live in a city, green spaces we know have a very beneficial effect on blood pressure, on mood, on our overall sense of well-being. And of course, you know, we know that when we let little kids, there were some beautiful studies done looking at little children in daycares where they’re out playing in the dirt or like planting plants. When we looked at their risk of infections, like respiratory infections, and also looked at their stool, their microbes, they are just much healthier than kids that don’t get to play outside in the dirt. So I love being out in nature. I think it’s one of the best things we can do for our health and our well-being. I do, I meditate. I meditate also when I’m walking, but mindfulness can be very powerful for reducing stress and cortisol. Remember that this high cortisol that many people have from persistent stress, cortisol, you know, also causes disruption of our gut bacteria, drives systemic inflammation. So, you know, helps us put on more weight in our tummies. So doing things that reverse that are important. Exercise can do that too, right? Physical activity, relationships, the power of connections and friends, finding ways, you know, whether that’s art or music, poetry or affirmations, things that can help connect us to meaning and purpose in our lives. All of these things not only drive down inflammation in our bodies and help our brains and help us from a physical health, but they also nurture and nourish our emotional and our spiritual selves. And when those three are in balance with each other, when we’re addressing all three of those is when we experience contentment and joy. And that’s really what’s so wonderful about being human. Joe 52:30-53:14 Many of your colleagues, Dr. Low Dog, prescribe what we would call anti-inflammatory drugs. And we’ve already talked a little bit about the non-steroidal anti-inflammatories. But as you said, the body has its own cortisol. And doctors like to prescribe drugs like prednisone or methylprednisolone. And there are certainly times for those medications. When I lost my hearing temporarily, they brought my hearing back. I loved the drugs. But Terry will attest to the fact that I wasn’t much fun to be around on big doses of prednisone. Terry 53:15-53:15 Joe gets weird. Dr. Tieraona Low Dog 53:16-53:17 So do I. Joe 53:18-53:36 And rather irritable. Yes, it wasn’t fun. How do we create our own, shall we say, more natural approaches to calming inflammation rather than relying on prednisone for weeks, months, and for some people, years, especially when it’s a condition like osteoarthritis? Dr. Tieraona Low Dog 53:37-56:40 Well, I mean, I think there’s so much that can be done. There’s so much with herbal medicines that can help with, you know, with like arthritis. And like turmeric, we just mentioned a little while ago, but there was a review done by Tufts researchers (Seminars in Arthritis and Rheumatism, Dec. 2018). They did a systematic review looking at all the studies, and they found that both turmeric and curcumin, more specifically, and Boswellia, which is also known as Indian frankincense, that both of those were very effective at relieving arthritis pain and recommended it as another way of thinking about treating osteoarthritis without having all of the side effects, right? So, you know, I think fish oil, also omega-3s, increasing your omega-3s, which, you know, trying to drive towards a higher omega-3 index, that’s something that can just be measured. A lot of my chronic pain patients. I try to increase their, you know, their omega-3 index to seven to eight percent over time so that we’re, you know, that we’re driving down inflammation and also helping with pain. But there’s a number of things that, you know, that you can do for chronic pain. I’m saddened by how many people live with persistent pain. And if you have, you know, vitamin D, can I just even throw out vitamin D? We know that when vitamin D gets too low, when those levels get too low, you know, that that actually causes pain, causes, it worsens arthritis pain and muscle pain and widespread chronic pain, like people with fibromyalgia. So making sure that people are getting adequate amounts of vitamin D is really important. Some people may, you know, may need things like, you know, CoQ10 or magnesium. Can I just share a quick story? When I had my hip replaced in 2022, I went up to the floor after my surgery and they kept coming in asking how my pain was and rating my pain. And my pain was great. And family came to visit and it was eight, 10 hours later and I saw them coming in and they were hanging magnesium with my IV. And I said, oh, was my magnesium low? And they said, no, it’s just your orthopedic surgeon likes to use magnesium during and after your surgery because he finds it reduces pain and how much opiate you need. Right now, I just had a huge surgery. I didn’t have a single opiate for more than 30 hours after having a hip surgery. Just for magnesium. So I’m fascinated by this. And so magnesium, we know, helps with migraines. It can help with a variety of things. But, you know, magnesium is another one that can relax muscles, can relax muscles in the jaw, in the neck, just so many things we can do for chronic pain. And also magnesium drives down inflammation, reduces C-reactive protein. Terry 56:40-57:59 Well, I think we’ll need to leave it there. And it sounds like there are quite a few modalities that people could use to address inflammation, to address pain. Dr. Tieraona Low Dog, thank you so much for sharing that with us today on The People’s Pharmacy. Tieraona Low Dog 56:59-57:01 Thank you. It was a pleasure. Terry 57:01-57:38 You’ve been listening to Dr. Tieraona Low Dog. She is a founding member of the American Board of Physician Specialties, American Board of Integrative Medicine, and the Academy of Women’s Health. Dr. Low Dog has served on the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest work is an e-book, “Healing Heartburn Naturally.” Joe 57:39-57:48 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 57:49-57:57 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 57:58-58:13 Today’s show is number 1,460. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 58:14-58:22 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Joe 58:23-58:52 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be so grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics interesting, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 58:52-59:31 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 59:31-59:41 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 59:41-59:46 All you have to do is go to peoplespharmacy.com/donate. Joe 59:46-59:59 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

One of the most basic pillars of health is good nutrition. A range of eating patterns might all be considered balanced diets, but in general people do better when they eat less processed foods and more whole foods. Vegetables and fruits play a starring role in at least two diets that have been studied extensively, the DASH diet and the Mediterranean diet. Americans might be healthier if we followed these eating plans, but fresh veggies can be pricey. If your doctor were prescribing produce, would your insurance plan cover it? Might this make healthful eating more of a practical possibility? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Jan. 24, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Jan. 26, 2026. Food Is Medicine: Increasingly, healthcare providers are recognizing the critical role of diet in the development of chronic disease. An entire movement is organizing around the concept of Food Is Medicine, both for prevention and for treatment of conditions like diabetes, obesity and heart failure. Scientists have shown that diet makes a difference. Studies have confirmed what many of our grandparents or great-grandparents intuited. On the other hand, translating that knowledge into action that benefits patients has been difficult. One important barrier is the cost of fresh fruits and vegetables. Doctors Prescribing Produce: People could get healthful food in a variety of ways. Past generations often had gardens and grew much of their own produce. That’s not always practical in urban settings or for families with multiple jobs struggling to make ends meet. Our guests today have tested two ways to get fresh food into people’s hands. One is a debit card that can be used to buy any WIC-approved food at more than 66,000 retail outlets across the country. WIC is the USDA supplemental nutrition program for Women, Infants and Children. WIC-approved foods include fresh fruits and vegetables with no added sugar or salt. In this model, the healthcare provider arranges for certain patients to get access to this debit card, providing $40 worth of purchasing power for healthy foods each month. They are essentially prescribing produce. The idea is to use a business model that supports good food and saves the health system money. This is termed a healthy food subsidy. The other approach is a food box. This includes vegetables and fruits, and possibly other foods, that providers decide the patients should get. In some initiatives, the person or agency deciding what goes in the food box might also take into account what is available from local farmers. The box may be distributed weekly, every two weeks or every month, but the individual who is going to be eating the food does not choose what is in it. How Does a Healthy Food Subsidy Compare to Food Boxes When Providers Are Prescribing Produce? When people don’t know if they will be able to pay for the groceries they need, they are said to be “food insecure.” This complicates a range of chronic conditions, making diabetes more challenging, for example. People with food insecurity have a harder time keeping their blood pressure under control. Our guests collaborated with other colleagues on a recent comparing the food box approach to the healthy food subsidy among North Carolina resident with high blood pressure and food insecurity (JAMA Internal Medicine, Dec. 1, 2025). The study enrolled 458 individuals. Everyone in the study had a provider prescribing produce. Half the volunteers got the food subsidy debit card and half were provided with food boxes. Those getting the food subsidy had moderately lower blood pressure after six months compared to those getting food boxes. Their blood pressure was also lower after a year and a half. Food insecurity decreased in both groups over time. Tackling Food Insecurity: One of the outcomes of food insecurity is that people are more likely to need emergency department services. This costs the insurance company dearly. If improving food security and diet quality could reduce ED visits, insurers might become quite interested in the food subsidy approach. This is currently being tested for participants with heart failure. Special Populations Who Might Need Providers Prescribing Produce: During this conversation, we expressed concern about vulnerable populations that might suffer especially from cuts in government spending. We asked about school lunches and we learned about pilot programs focusing on expectant mothers. Children in foster care are especially vulnerable; a food subsidy program taking a Food Is Medicine approach could be helpful for them. This Week’s Guests: Seth A. Berkowitz, MD, MPH, is Associate Professor of Medicine at the University of North Carolina School of Medicine. He is also Section Chief for Research, General Medicine and Clinical Epidemiology. Dr. Berkowitz is a general internist and primary care doctor, studying how food and nutrition interventions can improve health. Dr. Berkowitz is the deputy scientific director of the American Heart Association’s Food is Medicine initiative, Health Care by Food initiative. He is also the author of the recent book, ‘Equal Care: Health Equity, Social Democracy, and the Egalitarian State.’ The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Dr. Seth Berkowitz of UNC promotes Food Is Medicine Peter Skillern has pursued a career dedicated to creatively and effectively addressing poverty and inequality in North Carolina and the nation. He serves as the CEO of Durham-based Reinvestment Partners, an innovative nonprofit that works with people, places and policy to foster healthy and just communities. Reinvestment Partners advocates for financial and health reforms to improve people’s lives. The agency has won numerous accolades and is considered a state and national leader in its field. In recognition of his leadership, he was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations. He holds North Carolina General Contractor and Real Estate Broker licenses. He received his B.A. from the University of California Santa Cruz with Highest Honors. A 1991 graduate of the Department of City and Regional Planning at UNC Chapel Hill, he was recognized as a Distinguished Alumni by the UNC faculty in 2020. Peter Skillern, CEO of Reinvestment Partners Listen to the Podcast: The podcast of this program will be available Monday, Jan. 26, 2026, after broadcast on Jan. 24. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1459: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of the People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy. com. Good nutrition is an undisputed pillar of health. Sadly, it seems to be out of reach for too many Americans. This is the People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:40 What if modern medicine made nutrition a priority? How would that change what we eat? Joe 00:40-00:54 The food industry has learned how to make ultra-processed food tasty and accessible, even in food deserts. But is it contributing to our epidemic of obesity, diabetes, and heart disease? Terry 00:55-01:00 How is the Food is Medicine movement changing our approach to fresh fruits and vegetables? Joe 01:01-01:06 Coming up on The People’s Pharmacy, should your doctor be prescribing produce? Terry 01:14-02:11 In The People’s Pharmacy Health Headlines: The CDC is reporting that the flu season might have peaked. Laboratory testing suggests a downward trend in flu cases. That said, this federal agency is estimating that 18 million people have caught the flu so far and 230,000 patients have been hospitalized. We’re also nearing an approximate 10,000 deaths from the flu. The CDC has classified children as experiencing high severity influenza this season and adults moderate severity. Some experts are challenging the CDC’s numbers. That’s because the data are delayed by about two to three weeks. We may still be in the early stages of this influenza outbreak. Australia’s flu season, for example, started early and lasted a long time. In the U.S., February is often our peak month for flu. Joe 02:11-02:55 A report in JAMA Internal Medicine suggests that older people who get high-dose influenza vaccines are better protected against infection. Over 300,000 Danish citizens participated in a study that randomized to either high-dose or standard-dose flu shots. The investigation covered three flu seasons. This analysis considered how well the vaccination protected against heart failure and other cardiovascular complications, as well as influenza. Those who got the bigger dose had fewer hospitalizations for cardiorespiratory problems. People with diabetes also fared better on the high-dose vaccine. Terry 02:56-03:53 Measles continues to spread at an alarming rate. Earlier this year, there was a large, long-lasting outbreak that started in Texas. While that one has calmed, South Carolina is now in the midst of a serious outbreak. Cases have doubled over the past week or so, and the total number is above 560. While most cases have been seen among children, at least two university populations are also experiencing cases. Both Clemson University and Anderson University are dealing with confirmed measles cases in the student body. There are also cases being reported in North Carolina that seem to be linked to the South Carolina outbreak. Public health authorities point to vaccination rates below 90%, which is not enough to provide herd immunity for people unvaccinated against this extremely contagious and potentially dangerous disease. Joe 03:54-04:20 Last fall, the administration warned pregnant women to avoid acetaminophen because of concerns about autism. A new systematic review in the British journal The Lancet included 43 studies. The authors concluded that there’s no evidence that taking acetaminophen during pregnancy significantly increases the risk for autism spectrum disorder, ADHD, or intellectual disability. Terry 04:21-06:17 Falls are dangerous for older people and can result in injury, limited mobility, and even death. For decades, scientists have wondered whether vitamin D might help with muscle strength and balance and thus prevent falls. The results of studies have been inconsistent. Finnish researchers took advantage of an existing study called the Finnish Vitamin D trial to investigate this question. Nearly 2,500 healthy older participants were assigned to take vitamin D3 at 1,600 international units or 3,200 international units a day or placebo. The investigators collected data on falls and injuries at baseline and at 1, 2, 3, and 5 years. Blood levels of 25-hydroxyvitamin D increased among the individuals taking vitamin D supplements. Over 5 years, just over half of the volunteers had taken a fall and 11% had sustained injuries. Those proportions did not vary much between any of the groups, including those on placebo. The scientists concluded five-year vitamin D supplementation of 1,600 international units a day or 3,200 international units a day did not affect the overall risk of falls or fall injuries among generally healthy, largely vitamin D-sufficient men and women. And that’s the health news from The People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:43 And I’m Joe Graedon. Our topic today is food. And I have to admit that I’m biased. My earliest years were spent on a dairy farm in eastern Pennsylvania. Even after we moved, visiting Uncle Leo was a highlight because of the vegetables and super fresh whole milk. Uncle Leo and my mom, Helen Graedon, lived into their 90s and prized real food. Terry 06:43-06:55 Good fresh food is a delight that’s not available to everyone. Should we also be thinking of food as medicine? If so, how could we make it affordable and accessible? Joe 06:56-07:02 We have two distinguished guests today who are at the forefront of the food as medicine movement. Terry 07:03-07:37 Dr. Seth Berkowitz is Associate Professor of Medicine at the University of North Carolina School of Medicine and Section Chief for Research, General Medicine, and Clinical Epidemiology. He’s a general internist and primary care doctor studying how food and nutrition interventions can improve health. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Food is Medicine Initiative. His book is “Equal Care: Health Equity, Social Democracy, and the Egalitarian State.” Joe 07:38-08:03 We’re also talking with Peter Skillern, CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works with people, places, and policy to foster healthy and just communities. In recognition of his leadership, Peter was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations. Terry 08:04-08:06 Welcome to The People’s Pharmacy, Peter Skillern. Peter Skillern 08:07-08:08 Thank you so much, Terry. It’s good to be here. Terry 08:09-08:12 Welcome to the People’s Pharmacy, Dr. Seth Berkowitz. Dr. Seth Berkowitz 08:12-08:13 Thank you. I appreciate the invitation. Joe 08:14-08:25 We are delighted to be able to talk about one of our favorite topics, which is food. And, you know, Terry’s grandparents were very involved with food a very long time ago. Terry 08:26-08:41 That’s true. My grandfather was the butcher in the little town in western Nebraska where they lived. And my grandmother had a huge garden and raised chickens. I mean, it wasn’t a hobby. It was just, you know, what you did. Joe 08:41-09:09 And my grandfather, at the early part of the 20th century, was a back-to-the-land kind of guy. He bought a farm in Pennsylvania, and my uncle Leo ran that farm for decades. He was a dairy farmer. And my mom and dad were always very big on gardening. They had a huge garden, and they prized their fresh vegetables. Like you would eat them in the garden because they were so delicious. Terry 09:10-09:43 Well, you know, most people today don’t have that experience. They don’t have the space. They don’t have the time to do a garden. They may not have the knowledge. So how can people get the food? What they do is they rely on supermarkets, but produce is expensive. So when budgets get tight, often what people do is they cut back on the fresh fruits and fresh vegetables and they look for food that’s cheaper, which often is more processed. Joe 09:44-10:05 And not very good for you. So let’s go back a couple thousand years to Hippocrates, who is reported to have said, let food be thy medicine, let medicine be thy food. So let’s start at the very beginning. Peter Skillern, what is the Food is Medicine movement? Peter Skillern 10:05-10:21 It’s an initiative that’s nationwide of practitioners, health care providers, insurance companies, and I think most importantly patients who are asking that the health care system assist them with their health by helping them pay for food. Joe 10:22-10:24 How did you get interested? Peter 10:24-10:49 Well, I run an anti-poverty organization, and we’re committed to helping improve people’s lives, their health, and their food security. But an important component of that is to find a business model that sustains it. We have to move beyond simply grant-based or charity. We need to find a business model where the health care system says it’s in our financial interest and in our obligations for good health care to help provide food. Terry 10:49-10:51 Tell us a little bit more about that business model. Peter Skillern 10:53-11:18 Well, ideally, we’re trying to show that we can save the health care industry money. About 80% of health care costs are created by this treatment of chronic diseases related to unhealthy food, diabetes, cardiovascular, liver disease. So if we can help show an improvement in those conditions, reducing costs, we hope that the health care system will pay for food like it pays for medicine. Terry 11:18-11:24 So going to another old aphorism, an ounce of prevention being worth a pound of cure. Peter Skillern 11:25-11:27 It’s both prevention and it’s treatment. Joe 11:27-11:56 Well, let’s turn to Dr. Berkowitz. Dr. Berkowitz, you have a medical degree and a PhD. You’re an internist. You see people with cardiovascular disease and diabetes and all sorts of other conditions. Are there any studies, any science to support what we’ll call the food is medicine movement that fruits and vegetables actually make a difference in people’s outcome? Dr. Seth Berkowitz 11:56-12:41 Yeah, I think there are a lot of studies, actually. So one of the things that we think about for food as medicine is how can we use various ways of providing healthy food resources to overcome barriers people might have to healthy eating. And as we were alluding to, there are a lot of different conditions where that might be relevant. And so there’s been a real burgeoning of studies across a number of different clinical populations that try to use food as medicine principles to improve health outcomes. That could be improving things like blood pressure or blood sugar. That could be improving things like a reduced need for emergency department visits or hospitalizations and really a number of different clinical outcomes that might be affected by food is medicine study or food is medicine intervention. Joe 12:41-12:59 It sounds like medicine is, I’ll say, rediscovering what our great, great grandparents knew, you know, almost intuitively from the time they were young kids until the time they died. It was like, yeah, food, food is essential for good health. Dr. Seth Berkowitz 12:59-13:59 Yeah. I mean, I think there’s no doubt that nutrition is, you know, a key part of health. An analogy that I sometimes like to use for food as medicine is with physical activity and exercise. So we know that physical activity and exercise are also key parts of health. They go on throughout our lives and are not necessarily connected to health care or the health system, even though they help make us healthy. But there are certain circumstances, say after an injury where you might get physical therapy or after a heart attack where you might have cardiac rehab, that physical activity and the health care system intersect to promote health. And I see food as medicine analogously. Food means lots of different things, lots of different people. It’s culture, it’s celebration, it’s nutrition. And some of that might not be in any conjunction at all with the healthcare system, and that’s totally fine. But there are certain situations, maybe with high blood pressure or with diabetes or other things, where the intersection of food and the healthcare system might produce a health benefit in a way that’s analogous to how physical therapy can produce health benefits. Terry 13:59-14:20 You’ve mentioned high blood pressure a couple times, and Joe asked about research. And we know that there is a diet that can help people lower their blood pressure. It’s called the DASH diet. Tell us a little bit more about that and the pretty robust research backing that it has. Dr. Seth Berkowitz 14:20-15:10 Yeah, so the DASH diet, I think, is one of the best studied dietary interventions. It focuses on things like having lower sodium content in the diet, higher potassium content, which generally comes from eating fruits and vegetables, using healthy fats, not having a lot of refined grains or carbohydrates, and things like that. It’s been shown to lower blood pressure in a number of randomized trials. It’s an overall healthy dietary pattern and likely has impacts on other types of cardiometabolic disease, things like heart attacks or strokes or things like that, even though it was originally designed for high blood pressure. And if there are ways to help people follow a DASH diet, then that’s likely to have very big health impacts. Also just to say, I think that’s one example of a healthy dietary pattern, but there are lots of diets that is not something that is preferred or culturally appropriate or things like that. Joe 15:11-15:43 Peter, we have all been told by every healthcare professional that we’ve ever interviewed, don’t smoke, exercise, and eat a well-balanced diet. It’s sort of like a mantra. And yet it doesn’t mean much to people. It’s sort of like, ‘Oh, yeah, okay, I’ve heard that a dozen times, a hundred times. How do I implement that in my life? How do I make that part of my real-world experience?’ Terry 15:44-15:48 Can I balance my diet with potato chips in one hand and chocolate cake in the other? Joe 15:49-16:00 So how do you make it possible for people who are on the edge sometimes in terms of their finances to be able to get really healthy food? Peter Skillern 16:02-16:20 The biggest obstacle to eating healthy for low-income people is the cost of the food. And our program in providing a $40 benefit or $80 on a card that’s restricted for healthy fruits and vegetables at almost any retailer allows them to choose and buy that healthy food. Joe 16:20-16:22 How does it work? Tell us about that card thing. Peter Skillern 16:23-16:45 Yeah, so we do a debit-restricted card that can purchase any WIC-approved fruits and vegetables at almost any retailer in the country. So it empowers people both the purchasing power, but also the choice of where they purchase it, what they purchase, when they purchase it. And that high agency that’s been given those participants leads to higher compliance with eating healthy. Terry 16:45-16:52 Now, Peter, you said WIC approved. WIC, I think that stands for women, infants, and children. What does it mean? Peter Skillern 16:53-17:03 It means that you can do produce that does not have any additives to it. So it could be canned or frozen as long as there are no salts or sugars added. Joe 17:03-17:11 So let me see if I understand this. You get a card, a debit card, and you can go anywhere? Peter Skillern 17:12-17:31 We have this particular card. It is recognized at 66,000 retail outlets across the country. So most food as medicine efforts are very locally based, perhaps food boxes from locally grown food. And what we’re trying to do is to reach the scale and impact that the health care system needs. Joe 17:31-17:32 Do people like it? Peter Skillern 17:33-17:40 They love it. We have a 95% net promoter score, which means that they would refer it to their family and friends. Terry 17:42-18:11 You’re listening to Peter Skillern, CEO of Reinvestment Partners, a nonprofit based in Durham, North Carolina, working to foster healthy, just communities. The agency is a state and national leader in its field. We’re also talking with Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. He is the author of the recent book, Equal Care, Health Equity, Social Democracy, and the Egalitarian State. Joe 18:12-18:17 After the break, we’ll find out if getting rid of the cost barrier can make people healthier. Terry 18:18-18:23 Doctors are accustomed to prescribing medications; they might not be used to prescribing produce. Joe 18:24-18:32 When you compare produce debit cards to a food box, what are the differences? And what is food insecurity and how does it affect health? Terry 18:39-18:47 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 20:37-20:40 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 20:40-20:49 And I’m Joe Graedon. The topic today is food is medicine. That’s a message we’ve been preaching for decades here on The People’s Pharmacy. Terry 20:50-20:58 Americans spend more on health care than any other nation, but we lag far behind most other developed countries when it comes to longevity. Joe 20:59-21:14 Many health professionals praise the Mediterranean diet because of its fresh produce and emphasis on real food. But many Americans find it difficult to afford fruits and vegetables. How can we change that? Terry 21:14-21:36 Peter Skillern is CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works with people, places, and policy to foster healthy and just communities. In recognition of his leadership, Peter was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations. Joe 21:37-22:00 We’re also talking with Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Health Care by Food Initiative. His recent book is Equal Care, Health Equity, Social Democracy, and the Egalitarian State. Terry 22:02-22:56 Dr. Berkowitz, I am assuming, and I should never do that, that in order for people to embrace this idea of food is medicine, you have to be able to prove it. If we want people to start eating more fruits and vegetables, we have some evidence already that eating more fruits and vegetables is good for you. We talked about the research on the DASH diet. There’s research on the Mediterranean diet. Both of those diets are very heavy on produce. So what we’ve got are barriers. And Peter has mentioned that the big barrier is cost. How do we prove that getting rid of that cost barrier can actually make people healthier? Dr. Seth Berkowitz 22:57-24:44 I think that’s a great question, and I think that’s a great way to frame it as well. I don’t think we need any more research that a healthy diet is healthy. I think we generally know what healthy foods are and what it will do for us. But the question is, how do we overcome those barriers to following a healthy diet that so many people face? Some of those barriers are knowledge-based, and so things like educational programs and things like that make sense. But as you point out, affordability is a key barrier for a lot of people in the United States. And I think that’s the key innovation of Food is Medicine programs, is there’s not only the sort of knowledge and skill building that educational programs have been providing for a while, but there’s the provision of healthy food resources that make it easier for people to overcome that affordability barrier. But also, as you say, overcoming the affordability barrier means that there’s going to be an input of financial resources into the health care system or through the health care system to an organization like Peter’s to run programs and those kinds of things. And so people are going to be looking for strong evidence that doing that really will improve people’s health. And that’s a lot of the work that I do. So I’m a physician by training. I’m a practicing primary care doctor. But I also do research. Some of that is observational research, but a lot of it is interventional research, randomized clinical trials, evaluations of interventions that are being done across our state in North Carolina and really across the country now, and looking for that evidence that shows, all right, this is the right interventional approach in the right population for the right duration of time to make it a truly covered benefit in the same way we might say that, oh, if you have a certain type of infection, you don’t just need antibiotics broadly. You need some type of antibiotics in a certain dose for a certain period of time. And that’s what turns it into a real medical intervention that can be covered through insurance benefits or things like that. And similarly, there’s a body of research that’s being built around food as medicine interventions to do that same kind of thing. Joe 24:45-25:50 Well, Terry said that everybody knows that food as medicine is good for you and making the right choices. But I would actually take an exception to that because I think our grandmothers great-grandmothers knew that. I’m not sure that everybody recognizes how powerful food is, especially, and I hate to say this, Dr. Berkowitz, your colleagues, because a physician is trained, let’s be honest, to write a prescription. They’re trained to look for double-blind, randomized, placebo-controlled trials in the New England Journal of Medicine or fill in the blank journal. And so the idea of spending any time at all with a patient talking about food choices seems like a waste of time. You know, I’m busy. I’ve got 10 minutes to see this person. Let me just write a prescription for, I know, atorvastatin. That’s the answer, because it’s got science behind it. Terry 25:50-25:55 And possibly the physician is assuming that the patient knows how to eat. Joe 25:56-26:13 There are a lot of assumptions that are made. So, you know, how do you, as a health care provider, help your colleagues begin to embrace the idea that, you know, you could perhaps help people lower their blood pressure with a food-as-medicine approach? Dr. Seth Berkowitz 26:14-27:39 I think that’s a very fair question. I think your description of the constraints that people are facing in practicing medicine is very accurate. I think there are these time constraints. I think there is a historic focus on pharmaceutical treatments and, you know, surgical interventions and those kinds of things, but for what physicians are doing. But I don’t think that means that the healthcare system overall is not able to do this. For example, you know, we have professionals who have a lot of expertise in doing exactly what you’re saying, registered dietitian nutritionists. And I think we could be doing a lot more to bring those folks into the care team even more than they already are. Expand the number of situations in which they’re being used. But I do think physicians need to recognize the importance of diet for both preventing and managing chronic disease. And I think there are gains being made in that area, but it’s not exactly where we want it to be. I also think we need to recognize the complementarity between a lot of these different interventional approaches. I think we’re fortunate to have the amazing science that we have that has brought medications that can lower cholesterol or lower blood pressure or lower blood sugar. But we also are fortunate to have the science that is proving that there are ways to use diet to do similar things. And it’s not an either-or situation. You’re probably even better off, at least in the appropriate circumstances, using both approaches to get as much benefit as possible. Terry 27:40-27:54 Well, let me ask. You all have recently collaborated on a couple of publications showing your research. Would you tell us about that, please? Dr. Seth Berkowitz 27:58-28:38 Sure. I’m happy to start and let Peter join in. So there have been two recent, you know, sort of studies that I think are worth talking about. One is a randomized trial where we compared two different types of food as medicine approaches. One approach used a food subsidy provided by reinvestment partners and compared it to the delivery of a food box and looked at whether one was better than the other in terms of lowering blood pressure. And we found that people in both groups had their blood pressure go down from baseline. But the food subsidy had blood pressure, the people in the food subsidy group, I should say, had blood pressures that went down even more than in the food box group. Joe 28:39-28:45 Let me ask you to pause there. Peter, tell us the difference between these two groups because a food box, I don’t understand. Peter Skillern 28:46-29:04 A food box is typically put together with the provider determining what goes in the box, produce or meats, proteins, dairy or not. Maybe it’s just the produce. And it’s typically whatever is in season at the time in that region. And then they deliver that to the client. Terry 29:04-29:08 So it’s a little bit like your CSA box. Joe 29:08-29:09 Which stands for? Terry 29:10-29:41 Community Supported Agriculture. And that is a program in which you pay the local farmer up front. You pay him $100, $200, and every week for the next four or five weeks during the season, you get a box of whatever it is he or she has grown. But what you’re saying is for this food box, it isn’t whatever the farmer has available, which is how the CSA usually works. It’s whatever the doctor says you need to have, huh? Peter Skillern 29:41-29:42 No, actually, I’m not saying that. Terry 29:43-29:43 Okay. Peter Skillern 29:43-30:16 Ideally, you would have kind of a detailed nutritional prescription for which vegetable, for what diagnosis, for what dosage, for what duration, for what demographic, and it’s very specific. A food box is typically an anti-poverty, anti-hunger program where it’s also trying to support local farmers and local food system. Even if all the food is bought from a retailer, someone else other than the participant is making the decisions. So the recipient receives collards or cauliflower or lettuce or whatever vegetable they may or may not choose. Terry 30:16-30:25 I was going to say, I can already see that there could be some problems with that, because if you get collards and you don’t like collards, it doesn’t help. Peter Skillern 30:26-30:34 And so the card, the food subsidies, allows and empowers the participants to choose which produce they want them to buy. Joe 30:34-30:45 Okay, so we’ve got the food box and we’ve got the card that allows me to make the decision what I’m going to buy. It’s a debit card, basically. What’s the result of the study again? Dr. Seth Berkowitz 30:45-31:06 Yeah, so again, we found that blood pressure went down in both groups. So both interventions, or at least people who received both interventions, had lower blood pressure by the end of the study. But it went down even more amongst people who had the card, the food subsidy, suggesting that maybe that element of choice and being able to match your preferences for what you’re getting could be providing some extra benefit. Joe 31:06-31:10 And how did you feel about the results of the study, Peter? Peter Skillern 31:10-32:33 You know, I never felt like the comparison between food boxes and the card were the essential element. The essential element was, are we reducing hunger? Are we improving blood pressure? Are we able to do that at an affordable rate that makes sense for the healthcare sector? And I think that’s what was so powerful about this study was that our initiative reduced blood pressure of 5.4 over 6.8, which is very significant. It reduced hunger. Both interventions reduced hunger by 40%. And, you know, we were able to do that for about $40 a month. The benefits lasted beyond the intervention. And so while we provided the food for six months or 12 months, it would last 18 months. You know, the comparison I would offer is what is our traditional medical interventions, such as blood pressure, how could this complement those pharmaceutical interventions? How can we help change behavior with this so that people aren’t needing blood pressure medicines? So those are some of kind of the bigger opportunities and questions. To the extent that we’re helping address people’s food needs, let’s give them either source of food, boxes or cards that’s available that there’s support for. But if we’re looking to have it prescribed as an intervention, then we need to look at it for it to work across all requirements. Joe 32:33-32:37 And it sounds like you’ve made a really good first step. Peter Skillern 32:38-32:47 I think very significant first step. Dr. Berkowitz’s research which is unparalleled, and having it published in JAMA is kind of building the body of evidence. Joe 32:48-32:50 And what do your colleagues say, Dr. Berkowitz? Dr. Seth Berkowitz 32:50-33:31 I think people are excited about these findings. I mean, one of the reasons I got into this line of work or this line of research as a primary care doctor is seeing the problems that unhealthy diets cause, seeing the problems that lack of affordability of healthy foods cause, people who want to make changes to improve their health but are just unable to, but feeling like I didn’t have a lot of clinical tools to offer. And a lot of my colleagues feel the same. So now, you know, as we’re seeing, well, hey, maybe there are some interventional programs that can make a difference, that can address these issues, that can address both hunger and food insecurity, along with improving the clinical outcomes and reducing the numbers and those kinds of things. And I think people are very excited about that. Terry 33:32-33:35 Let me ask you, what do you mean by food insecurity? Dr. Seth Berkowitz 33:36-34:09 It’s a great question. So food insecurity is uncertain access to the food needed for an active, healthy life. It’s considered a leading public health indicator. So up until recently, at least, it’s been tracked in the United States every year annually for the last 25-ish years or so. And it’s a way to look at what percentage of people in the population in the U.S. have a secure, a stable source of food and aren’t worrying about where their next meal is coming from or whether they’re going to be able to put food on the table at the end of the month. Terry 34:09-34:11 What are the outcomes associated with food insecurity? Dr. Seth Berkowitz 34:12-34:56 Food insecurity is associated with a large number of negative outcomes very consistently across a very large body of research. So it’s associated with greater prevalence of diet-related diseases like more diabetes, more high blood pressure, more heart attacks. It’s associated with more complications of those conditions once you have them. So not only might it lead to diabetes, but it might lead to diabetes that’s out of control and results in, say, an amputation or needing to go on dialysis. It’s associated with worse mental health because it’s a very aversive condition. So stress, depressive symptoms, anxiety. It’s associated with worse learning outcomes in children. So you can think of lifelong impacts there. Essentially, almost any condition you can think of adding food insecurity into the mix just makes things worse. Peter Skillern 34:57-35:30 One of the key indicators is the usage of the emergency room services, which is expensive for both the hospital and the insurers. We did a study with Atrium Health, which showed that with our intervention, the odds of high utilizers, visitations of three times more in six months, was reduced by 36 percent. You know, that’s a better health care outcome. That’s a better financial outcome. And it’s a better quality of life for the health of those individuals who aren’t spending their time in the ER. And almost all of that is directly related to food insecurity. Wow. Joe 35:30-36:08 Well, emergency department usage is unbelievably expensive. I mean, if you had to pay out of pocket for a visit to the emergency room, it would be very challenging. And it’s not good care in the sense that if you could prevent that emergency room visit, you’d be way ahead. So you’re actually suggesting, am I hearing this right, that food security and good choices can reduce emergency department visits? Is that even possible? Peter Skillern 36:08-36:31 That’s what our study found, but other studies as well. I think most importantly was a study that Dr. Berkowitz did on the Section 1115 Medicaid waiver, Healthy Opportunity Pilots, where food was provided to Medicaid members. And he evaluated the health outcomes and savings and found that there was significant savings primarily in the ER usage. How do your colleagues feel about that? Joe 36:31-36:36 I mean, that’s, you know, reducing the number of visits to the emergency room. That’s huge. Dr. Seth Berkowitz 36:37-37:21 Yeah, I think it’s a really important indicator of people being in better health when issues like food insecurity are addressed. There’s very strong evidence that food insecurity is associated with more acute health care utilization, emergency department visits, hospitalizations, higher health care spending. On average, someone who has food insecurity, their health care spending will be something on the order of $1,500 per year, more than a similar person who was food secure. And we now have interventional evidence that programs that address food insecurity and other health-related social needs like housing and transportation barriers can have exactly these impacts that Peter is talking about. Fewer emergency department visits, fewer inpatient hospitalizations, lower spending on health care services. Joe 37:21-37:29 You would think that health insurers would be totally on board with this project because they’re trying to cut costs. Peter Skillern 37:30-38:26 Well, the particulars matter. You know, for which population do we need to provide this service to? What other related services need to go with it? What diagnosis are we trying to treat? So as an example, we’ll be running a randomized clinical trial with Duke Health to look at those who have cardiovascular failure and have recently been admitted to the hospital. That’s a very specific population. They have a very high cost associated with their treatment, and we believe will be very sensitive and responsive to a healthier diet. So those are the types of questions. I think we have to, more broadly, food is medicine, more specifically, for whom? Underneath what conditions? With what additional services? Gets us to the health care outcomes that help us to save money in our system. We can’t really afford to continue our current trajectory on health care costs. And this is a new, innovative approach to help us solve a bigger problem. Terry 38:29-38:57 You’re listening to Peter Skillern, CEO of Reinvestment Partners, a nonprofit based in Durham, North Carolina, working to foster healthy, just communities. The agency is a state and national leader in its field. We’re also talking with Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Food is Medicine Initiative. Joe 38:58-39:07 After the break, we’ll talk about some of the highly processed foods that also seem highly addictive. How does the idea of food as medicine combat that? Terry 39:08-39:13 When we look at cutting government spending on food programs, we wonder how that affects children in particular. Joe 39:13-39:15 Will it affect school lunches? Terry 39:24-39:43 you’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. and I’m Joe Graedon there used to be a Joe 39:43-39:49 potato chip commercial that challenged viewers with the slogan, betcha can’t eat just one. Terry 39:49-39:55 Nobody says that about apples or carrots, but chips can be addictive. Joe 39:56-40:10 Ultra-processed foods are designed to be tasty and affordable, but not particularly nutritious. What is the Food is Medicine movement doing to counteract the appeal of junk food? Terry 40:10-40:42 We have two guests today who have worked together on some important projects. One is Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Healthcare by Food Initiative. Our other guest is Peter Skillern, CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works to foster healthy and just communities. Joe 40:44-42:04 This is a question for both of you because the food industry has spent an awful lot of time, money, and research into making foods addictive. And I’m talking about snack foods. I’m talking about this vast majority of foods in the middle of the supermarket that is so tasty that you just want more and then more still. And a lot of those foods have chemical names that you couldn’t possibly pronounce or understand. And they’re high in salt and they’re high in sugar and they’re high in all kinds of seed oils, which is a particular issue for us because we’ve just recently talked to some experts who say those seed oils may be pro-inflammatory and therefore increase the risk for heart disease and diabetes and maybe even cancer. So in a sense, you’re fighting this massive and very successful food industry that has packaged foods to taste great. And we, as people, are always susceptible to yummy tasting foods, even if they’re not good for us. How do you combat that with the food is medicine idea? Dr. Seth Berkowitz 42:05-44:23 So I think this is a great question, and I think it’s worth thinking about both the problems and the solutions at multiple levels. A lot of what we’ve been talking about in food as medicine I see as essentially treatments, things that come in after the fact, after people are already existing and have lived maybe a lot of their lives in an unhealthy food environment, in a society where economic resource distribution is not very equal, and so they experience food insecurity and things like that. And you’re trying to use food as medicine interventions to treat the consequences of that, or at least mitigate them to the extent you can. And these are effective treatments for that. But as you said earlier, you know, we all know that prevention is probably better than treatment. And so then you get into this higher level question of how do you sort of create a system of social relations, a structure of society, so that people are in environments that promote their health. You know, we focus, I think, too much in medicine on individual solutions. The individual should resist with willpower those tasty treats or those kinds of things. And to a certain extent that that can happen. But I think we also need to think structurally. Why is it that those foods, which have a lot of different labor inputs and other things like that, why are they more affordable than foods that seem simpler to produce in some ways, right? You know, an apple or grapes or something like that. Why is it that so many people are, you know, struggling to make ends meet and really have to choose, you know, to get their 100 calories through soda rather than 100 calories of broccoli, because it’s a lot cheaper to get your calories through soda than it is through broccoli. And so then these structural questions, I think, really get at bigger questions around social policy and how you might use social policy to promote people’s health overall. And that will involve an element of programs that, what you might call incomes policy, distributing resources so that people have income they need to be healthy. That will involve elements of policies that target what you might call the commercial determinants of health, the ways that food industry and other industries will create products and affect people’s health in that way, and I think really is a bigger picture question that’s ultimately the really important question to be asking for what you might call population health, the overall health of the American people. Joe 44:25-44:26 Peter, thoughts? Peter Skillern 44:26-45:19 What problem are we solving here? Are we solving the commercial production of food and how that’s regulated and distributed? Or are we looking for this particular food as medicine about helping to address people’s individual health and then scaling that up so that it can affect our population health? That we’re using the health care system for payment, for enrollment, for treatment. And that’s a really more narrow problem to solve. And I think that one of the challenges our food is medicine movement faces is there are so many interrelated challenges that we have. We’ve got to stay focused on what are we solving today for this type of initiative. So through providing a food is medicine food subsidy, we’re enabling individuals at scale and millions of folks to be able to make better choices. But we still have to make their… they have to make those choices and the industry has to respond. Joe 45:20-45:21 And who’s paying? Peter Skillern 45:21-45:44 Well, so in the publicly insured healthcare space, it’s Medicaid and Medicare and the Veterans Administration. But the majority of people are covered by commercial plans through their employers or through the American CARES Act. So that’s kind of different payers all have different standards for who will pay for this, underneath what conditions. Joe 45:45-46:01 Because you kind of could imagine an insurance company saying, you know, if I can keep people out of the emergency department, I’m going to save money. And if it’s what, $40, $50 a month, is that how much you said for your debit card? Peter Skillern 46:01-46:01 That’s right. Joe 46:02-46:23 That’s a huge investment. But I’m also wondering about the government. You know, we’re continuing to hear, well, we need to slash these programs. And what will happen when that is implemented, especially with a food is medicine type program like yours? Peter Skillern 46:23-47:07 Yeah. We say that we’re trying to meet the business regulatory and health care requirements of the health care sector. We also have to meet the political requirements, which is a broader issue. We think that this intervention addresses some concerns around efficient use of resources, emphasizing individual choice, showing greater returns. And as this research, it’s evidentiary that it’s making a difference. This food is medicine movement is not a simple task. It is a cultural change. It’s a political change. It’s a technology change. It’s a medical practice change. It’s an individual change. And so let’s recognize the complexity of it and stay focused on those things that we can affect through this strategy. Joe 47:08-47:37 What about kids? Because, Dr. Berkowitz, you said prevention. And prevention is always better than trying to catch up and deal with treatment. I think a lot of school lunches are, you know, what are tasty, you know, pizza, macaroni and cheese. Maybe the broccoli is not as popular. How do we begin to get kids involved in the food is medicine movement? Dr. Seth Berkowitz 47:37-49:38 I think getting kids involved is very important, but I’ll actually point to the National School Lunch and School Breakfast Program as an area where we’ve made a lot of improvements, actually. So throughout the 2010s, there’s been a change in the nutritional standards for school meals. Again, anytime you’re cooking at large scale for lots of people on, you know, very tight budgets, things might not be, you know, exactly what everyone would want. But a lot of studies show that the meal that kids get at school is often the healthiest meal of the day they get compared with home cooking. And the bigger picture point, even though I think there is still room to improve, is that there has been real progress there. And so it’s been a win in a lot of ways and points to the fact that if we do make a concerted effort to change these things, we can improve the nutritional quality of the food that’s being provided. And I think there’s a lot that the food is medicine movement can learn from the way that policy has been used in the national school lunch and school breakfast program. But to your larger point of, you know, should be should kids be involved in food is medicine programs? I think there’s a lot of potential for that. However, the evaluation of it, I think, needs to be a little bit different for an adult with heart failure, or someone who is currently on dialysis, their short-term consequence of eating an unhealthy diet is very high. And so the healthcare costs associated with that in a couple months span is very high. And so if you’re doing a study that follows people for a few months, you’re likely to be able to see a difference between a healthier diet and a less healthy diet. Kids, you’re talking about years, are really preparing them for adulthood and maybe their older age and things like that. And so if you use the same standards and say, well, I want to, you know, if I’m going to, you know, choose the adult program over the child program because the adult program saves me money in six months, but the child program doesn’t, you’re going to, you know, not take advantage of what could be a very large long-term impact because you’re being a little bit short-sighted about it. So very important to include children in food as medicine interventions, but you also have to think about the specifics and the nuance of the situation when you’re evaluating it. Peter Skillern 49:39-49:55 One area that we found is we did a pilot with Atrium in Mecklenburg County with expectant mothers, you know, and the response that mothers gave as far as the impact of food security on themselves and their newborns, you know, it was pretty tremendous. Terry 49:57-50:10 And this is a wonderful place to do an intervention because expectant mothers mostly are very interested in doing whatever they can to promote the health of their growing fetus. Peter Skillern 50:10-51:01 And it’s a particular area where the insurance is involved, right, with medical experience. Another population of youth are those in foster care who are often covered by Medicaid insurance underneath the behavioral health sections. That’s a Medicaid expense. 70% of young women 13 to 21 become pregnant underneath the foster care system, right? Food insecurity is extremely high among foster care children. There’s an area for where we can provide Medicaid-provided food assistance that will help the direct health outcomes of foster care children. So there are different ways of looking at this problem of how can we intersect between the health care sector, insurance, the providers, and the patient. You know, it’s got to work for all three, and I think we can solve those problems. Terry 51:01-51:19 Dr. Berkowitz, I’m wondering how the food is medicine movement would compare or compete or possibly complement the conventional pharmaceutical approaches to problems like you have diabetes, you want to get your A1C level down, or how about GLP-1s? Joe 51:22-51:25 Explain GLP-1s, Dr. Berkowitz. Dr. Seth Berkowitz 51:25-52:07 Sure, yeah. So GLP-1s are a group of medicines that work in receptors for a hormone called incretins–the hormone is called incretin–and they have a lot of effects on the body, but in particular, they have large effects on appetite and satiety and tend to result in a large amount of weight loss, and for people with diabetes, large drops in the blood sugar. And so have been a really important category of medicine over the last decades or so, the last about a decade, and really kind of taking off in the last few years for use beyond people with diabetes, but also as a weight loss medication. Terry 52:08-52:17 And so the question is, food is medicine. How does it interact with the use of these potent pharmaceuticals? Dr. Seth Berkowitz 52:17-53:31 Yeah, I think there’s a lot of complementarity to it. And there are a few issues involved. The GLP-1 medicines are very powerful, but they’re sort of blunt appetite suppressants. And so the quality of what you eat, even though you’re eating less overall, is still very important. And if you only use GLP-1s but don’t pay any attention, let’s say, to the quality of what you’re consuming, you know, maybe you’re only having 1,200 calories a day, but it’s only a milkshake or something like that, then that’s going to have bad health impacts, even though there might be some benefits from the weight loss overall. The actual components of what you’re consuming will have health impacts in other ways. And so I think there’s complementarity in using food as medicine interventions for people who are on GLP-1s to promote better diet quality for the foods that people are eating. A number of people have side effects with GLP-1s and so can’t tolerate them long-term. And so food as medicine interventions might be an alternative. And a lot of people may want to stop taking a GLP-1 at some time. They might have lost the amount of weight that they’re looking to lose and would like to sort of stay at that weight or, you know, slow the regain of weight to the extent possible. And so food is medicine interventions can be helpful in that situation as well, I think. Joe 53:31-53:57 I’d like you both to look into your crystal ball and say, okay, if we were in charge, if they gave us a lot of money to make food is medicine kind of the primary way that both the public as well as health professionals would look at this whole process, what would the future look like for you and how would you implement it? Terry 53:57-53:59 And you each have one minute. Joe 54:01-54:03 Starting with you, Dr. Berkowitz. Dr. Seth Berkowitz 54:03-55:03 Okay. Well, maybe this will be my curveball. So I think food as medicine programs are very important and I think it’s important that they have a place in the healthcare system. But I really don’t think that we can lose sight of the question of why are food as medicine programs needed for so many people. And so if I really have a lot of control and everything, though, so if I really have the control that you’re giving me, while one aspect of that would be making sure that evidence-based food as medicine interventions are available as insurance benefits for people, another piece would be to really sort of question, well, why is it that, you know, so many people find it so difficult to follow a healthy diet? And are there things that we can do to address income and resource distribution in the U.S.? Are there things we can do to address commercial determinants of health? Are there things that we can do to address the reasons that people find it difficult to follow a healthy diet so that maybe they don’t even need a food as medicine intervention in the first place? But if they need it, I do want it to be there. Joe 55:04-55:04 Peter? Peter Skillern 55:06-56:22 Again, I focused around where the health care sector aligns with food support, around the health outcomes, around the financial incentives. You know, as a person who’s trying to address poverty at scale, I certainly support a broader safety net, right, to help people purchase that. But within that, where does health care find its motivation? And it’s motivated by patients asking for it from providers like the clinicians saying this is needed. There is research that shows it’s impactful. And for health insurers to say we have an incentive to do this at scale. And it may not be for everyone. Even a small population as a percentage, when you scale it across all of America and our population, we serve millions of people. Those with uncontrolled diabetes or cardiovascular failure or even smaller issues. It makes a difference at an enormous level. So I’m not looking for the revolution. I’m looking for the incremental difference that we can make in people’s lives, but do it at a systems level across this country. So I think food is medicine has huge potential for both political and practical reasons. Terry 56:22-56:30 Peter Skillern, Dr. Seth Berkowitz, thank you both so much for talking with us on The People’s Pharmacy today. Peter Skillern 56:31-56:33 Thank you so much for having us. Dr. Seth Berkowitz 56:33-56:34 Yeah, it was great to be here. Thank you. Terry 56:35-57:04 You’ve been listening to Dr. Seth Berkowitz. He’s Associate Professor of Medicine at the University of North Carolina School of Medicine and Section Chief for Research, General Medicine, and Clinical Epidemiology. Dr. Berkowitz is a general internist and primary care doctor studying how food and nutrition interventions can improve health. He’s also the author of the recent book, “Equal Care: Health Equity, Social Democracy, and the Egalitarian State.” Joe 57:05-57:30 You’ve also heard Peter Skillern, CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works with people, places, and policy to foster healthy and just communities. In recognition of his leadership, Peter was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations. Terry 57:30-57:40 Lyn Siegel produced today’s show, Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 57:40-57:47 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Terry 57:48-58:05 Today’s show is number 1,459. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Joe 58:05-58:13 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Terry 58:13-58:34 At peoplespharmacy.com, you could sign up for our free online newsletter, and that way you get the latest news about important health stories. When you subscribe, you also get regular access to information about our weekly podcast. We’d be grateful if you’d write a review of the People’s Pharmacy and post it to the podcast platform you prefer. Joe 58:35-58:38 In Durham, North Carolina, I’m Joe Graedon. Terry 58:38-59:14 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 59:14-59:24 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 59:24-59:29 All you have to do is go to peoplespharmacy.com slash donate. Joe 59:29-59:42 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.