The People's Pharmacy

Over the years, we have spoken with scores of healthcare experts about chronic illness. Many of them attribute the problems to inflammation, which is after all a natural response to infection or injury. But not everyone has a system for locating and addressing the source of the inflammation. If you want to treat the cause, not just the symptoms of your disease, you might want to consider functional medicine. 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, May 30, 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 June 1, 2026. What Is Functional Medicine? Many people have heard of integrative medicine. We asked our guest, Dr. Susan Payrovi, how this differs from functional medicine. (She practices both.) According to Dr. Payrovi, while both approaches embrace lifestyle therapies, integrative medicine may focus on individual organ systems, just as conventional medicine does. Functional medicine, on the other hand, is more likely to focus on how the body works. What functional systems are involved when a person experiences fatigue, for example? If there is a problem with the way the body produces energy, how could that be resolved? If you are dealing with a problem caused by underlying inflammation, you could prescribe a potent anti-inflammatory or even a medicine that counteracts the immune system’s response to danger by blocking interleukins, for example. Or you could search upstream for the disturbance that is causing the immune system to overreact. Going upstream to find the cause is the functional medicine approach. Sending the Body Safety Signals If inflammation is a response to a danger signal, how can we let the immune system know that the body is safe? Lifestyle therapies offer some powerful interventions, even though they may sound very ordinary. Getting adequate sleep can make a huge difference for the immune system and lower inflammation dramatically. Stress management is another potent non-pharmaceutical approach. Consuming a diet rich in anti-inflammatory foods or even medicinal herbs could also contribute to a sense of safety and reduced inflammation. The Silo Problem of Modern Medicine We have spoken with many people who have struggled with a disease that manifests in multiple symptoms. They end up seeing a variety of specialists who don’t seem to communicate with each other. NO tool manages every condition. Too often, specialists pay attention only to the specific organ that they are assigned, and as a result, nobody puts the big picture together for a long time. The hope is that functional medicine would do a much better job for such patients, including those whose suffering has an emotional, psychological or spiritual aspect. Functional Medicine and Chronic Fatigue Syndrome One example where patients are demanding more of their medical care is chronic fatigue syndrome. Conventional medicine has a notoriously difficult time treating such patients. Coaching patients on small but important lifestyle changes is one approach that functional medicine can offer. Pacing and learning to prioritize are vital skills for such patients. Dr. Payrovi learned a lot about the value of such approaches in dealing with her own illness, multiple sclerosis. Finding a Functional Medicine Practitioner People looking for a functional medicine practitioner can consult the Institute for Functional Medicine. The organization lists practitioners on its website, ifm.org. So does the Academy of Integrative Health and Medicine, aihm.org. This Week’s Guest Susan Payrovi, MD, is a physician practicing Integrative and Functional Medicine at Stanford’s Center for Integrative Medicine. Dr. Payrovi is board certified in Anesthesiology, Hospice and Palliative Medicine, as well as Integrative Medicine. She has additional training in Functional Medicine and acupuncture. https://med.stanford.edu/profiles/susan-payrovi. Her website is drsusanpayrovi.com. Susan Payrovi, MD Listen to the Podcast The podcast of this program will be available Monday, June 1, 2026, after broadcast on May 30. 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.

Transcribed - Published: 29 May 2026

What do you conjure up when you think of music? Perhaps you imagine a singer-songwriter telling her story. On the other hand, you might imagine a parade with a marching band, an orchestra playing an outdoor concert or a mother singing her baby to sleep with a lullaby. Regardless of the format, music acts on the brain in unique ways. Neuroscientists are learning how music heals and why healers around the world have integrated music into their rituals for millennia. 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, May 23, 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 May 25, 2026. How Music Heals Dr.Elizabeth Margulis directs the Music Cognition Laboratory at Princeton University. This scientific endeavor is devoted to understanding how our brains react to music. One discovery is that music has a lot in common with infant-directed speech. It is highly repetitive with exaggerated pitch modulation. When people talk to babies, they may slow their words down a bit and raise the pitch of their voices. All of these properties make infant-directed speech a lot more like music than the rest of our everyday utterances. Caregivers around the world adopt this sort of “baby-talk” because babies pay attention longer when they do. Is music tapping into the same primal brain responses? Another characteristic of music is that it can trigger emotional responses. These are culturally conditioned; bagpipes do not have the same effects as Tibetan singing bowls. Howe er, the reminiscence triggered by music can be remarkably complete, putting us back in time not only to the place where we heard it before, but even to the bodily sensations that we experienced at that moment. Musical memories are exceptionally persistent. Older people with dementia who can no longer remember important facts about their own lives can often join in singing a popular song from their youth. The Downsides of Music Music may have social and political ramifications. Just imagine a chorus singing “We shall overcome,” and you will probably make assumptions about the singers and their values. As a result, we should not be surprised to learn that people may fight over music. Frequently entire generations have genre preferences such as hip hop or rock that are not shared by adjacent generations. How do we approach the music we love to hate? Can we understand how music heals even if we don’t like it very much or at all? Musical Daydreams Help Us Understand How Music Heals Dr. Margulis has studied and written about musical daydreams. What does she mean by this? As you watch a movie, you may appreciate the score. But even if you don’t notice it at all, the sound track influences how you understand the action on the screen. Likewise, when most people listen to a piece of music, they may create a visual to go with it. Dr. Margulis offers us an example of a snippet of music by Liszt that evokes for many people an image of a cartoon cat chasing a cartoon mouse. Needless to say, that is not what Liszt was thinking when he composed it, since cartoons did not exist at the time. Choosing Music for Healing Joe mentioned the unobtrusive but soothing music playing in the background when he has an acupuncture treatment. Dr. Margulis suggested that music activates motor areas of the brain, and that might help explain the benefit in this setting. We are still learning more about how music heals. This research may some day guide healthcare professionals in choosing music for their practices, even in the hospital. This Week’s Guest Elizabeth Margulis,PhD, is Professor and Acting Chair in the Department of Music, with affiliations in Psychology and Neuroscience. Dr. Margulis directs the Music Cognition Lab at Princeton University. Her research pursues questions that lie at the intersection of the humanities and the sciences. She was also trained as a pianist. Her most recent book is Transported: The Everyday Magic of Musical Daydreams.  Her website is https://www.elizabethmargulis.com/about This link takes you to the publisher’s page. Elizabeth Margulis, PhD, Princeton University 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, May 25, 2026, after broadcast on May 23. 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.

Transcribed - Published: 21 May 2026

Tick season is well underway in many parts of the country. It seems that a mild winter and a warm spring have brought the nymphs out seeking blood. If that blood is yours, you may be exposed to a range of pathogens. What’s more, ticks are not the only creatures ready to bite you. Fleas are an even bigger problem when it comes to transmitting bacteria called Bartonella. That genus is responsible for cat scratch disease and trench fever. When the infection goes chronic, it’s called bartonellosis. What are the dangers of flea and tick bites? 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, May 9, 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 May 11, 2026. You can watch us interviewing Dr. Breitschwerdt on YouTube.   The Hazards of Flea and Tick Bites Ticks can transmit a dizzying number of pathogens, including viruses, bacteria and protozoa. Rocky Mountain Spotted Fever, for example, occurs when a tick injects Rickettsia rickettsii into a person through a bite. If not treated properly, it can be fatal. Fortunately, however, it usually responds to doxycycline. The NCSU laboratory has developed a reliable diagnostic test that picks it up quickly. Another tick-borne disease that has become familiar over the last few decades is Lyme disease. It is carried by deer ticks infected with Borrelia burgdorferi. If treated promptly, most people clear the disease, but sometimes it morphs into a stealth infection that is quite controversial. You may not think much about flea bites, but they too could be the source of a stealth infection. Fleas transmit Bartonella (and so do body lice, ants, pigeon mites, rat mites and sand flies). Cats can be infected (with three different species of Bartonella) and so can dogs (only two species). When people develop bartonellosis, it can cause liver disease and neurological problems such as headaches and memory loss. In some cases, infected people suffer seizures. Preventing Flea and Tick Bites Once Bartonella get into the body, it likes to hide. The bacteria can enter virtually any cell in the body and make itself at home. As a consequence, the immune system may have difficulty tracking it down and eliminating it. Antibiotics don’t always get to it, either. Treatments of entrenched infections need to be very intensive. So it is better to prevent flea and tick bites. One way is to make sure that pets are protected. Veterinarians can prescribe preventive medicine for them, either oral or topical. Another important step is to protect yourself. Wear effective insect repellent when outside or cover your long pants with permethrin-treated gaiters. And absolutely do not skip the tick check when you come inside. If you find a tick that has bitten you, remove it with tweezers, seal it in a plastic bag, date the bag and put it in the refrigerator. That could provide useful identification if you begin to feel ill over the next several days. When the type of tick is identified, it helps to point the infectious disease expert in the correct direction for what condition you may have. This Week’s Guest Dr. Edward B. Breitschwerdt is a professor of medicine and infectious diseases at North Carolina State University College of Veterinary Medicine. He is also an adjunct professor of medicine at Duke University Medical Center, and a Diplomate, American College of Veterinary Internal Medicine (ACVIM). Dr. Breitschwerdt directs the Intracellular Pathogens Research Laboratory in the Institute for Comparative Medicine at North Carolina State University. He also co-directs the Vector Borne Diseases Diagnostic Laboratory and is the director of the NCSU-CVM Biosafety Level 3 Laboratory. Dr. Breitschwerdt’s clinical interests include infectious diseases, immunology, and nephrology. https://www.galaxydx.com/about-us/meet-the-team/edward-breitschwerdt-dvm-dacvim-saim/ Dr. Ed Breitschwerdt, NCSU College of Veterinary Medicine Listen to the Podcast The podcast of this program will be available Monday, May 11, 2026, after broadcast on May 9. In this week’s podcast, we talk about developing treatments for these challenging conditions. A major focus for Dr. Breitschwerdt is prevention, so he and his colleagues are working on a vaccine that could prevent Bartonellosis. We also discuss the possibility that Bartonella might contribute to arthritis. Find out about the complications of another vector-borne infection, Babesiosis. You can stream the show from this site and download the podcast for free. This episode of our podcast was sponsored in part by MUD\WTR. Start your new morning ritual & get up to 43% off your @MUDWTR with code PPOD at mudwtr.com/PPOD

Transcribed - Published: 7 May 2026

Americans often boast of having the best health care in the world. It is certainly the most expensive health care. We pay twice as much as people in many other industrialized nations. Are we getting our money’s worth? Some population statistics, such as life expectancy, suggest we could be doing much better. How can we make sense of the complexity of American health care? 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, May 2, 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 May 4, 2026. Why We Pay Twice as Much for Health Care One reason Americans pay twice as much is the complexity of our health care services. We often call it a health care “system,” but it often doesn’t feel as coordinated as a system ought to be. Many other countries have universal health insurance coverage in one form or another (and there are many). That means the government has an incentive for keeping costs down. With so many different payers and players in the US, the incentives frequently go in the other direction. You may notice this if you examine an explanation of benefits from Medicare or a private insurance company. There may be a sizable gap between what the provider charged and what insurance approved. Who pays the retail price? Only people who don’t have insurance, who are usually those least able to manage a big bill. If you find yourself faced with a hospital bill and no insurance coverage, it is important to talk with the billing department. Nonprofit hospitals should have a mechanism for patients without coverage to negotiate a lower total or a longer time frame in which to pay. Even some for-profit hospitals and medical practices are open to negotiation, but starting the negotiation as early as possible is key. How Much Does an Emergency Cost? Nobody plans for a medical emergency. That is the nature of emergencies–they are unexpected. If you need an ambulance to get you there, if you have to be transferred to another hospital with a better ability to care for your problem, if the doctors must do multiple tests to make a diagnosis will all influence your bill. As a result, emergency visits could cost from tens of thousands of dollars to a million or so. With high-deductible health insurance, a person or their family could end up owing more than they can pay. That is how some cases of bankruptcy are rooted in high healthcare bills. We Pay Twice as Much Because Providers Make More In the US, doctors were once in the same category of professionals as teachers or firefighters. Those days are long gone. Healthcare providers here are compensated more generously than providers in many other places, such as Canada, Japan or Israel. Moreover, just as there are middlemen in the prescription insurance business (called pharmacy benefit managers, PBMs), health insurance has its own middlemen. The result is a great deal of complexity, very little transparency, and a lot of parties trying to make money on each transaction. That also leads to a great deal of administration, which further increases the cost. Why Don’t Market Forces Control Costs? Some analysts suggest that the free market should be able to control costs. But for market forces to work, you need competition and transparency. Over the last decade or so, there has been increasing consolidation in every sector of health care. Competition is limited in most areas. Moreover, transparency is in very short supply in health care. For years we have been talking about how hard it is to do comparison shopping for health services like MRI scans or colonoscopies. If consumers cannot compare costs or value, they cannot make the rational decisions that would help moderate prices. How Administrative Costs Increase Bills Part of every insurance premium goes to paying administrative costs. Insurers pay people to review claims (and deny some). Preauthorization also adds to administrative costs. Manage the Hospital Bill So You Don’t Pay Twice as Much as You Should Years ago, we interviewed Marshall Allen, who titled his book Never Pay the First Bill.  Our guest for the current episode counters always request an itemized bill. That way you can check it to make sure that simple items such as names, dates and insurance policy numbers are correct. Then look at whether the services billed are actually the services received. An estimated nine of ten hospital bills contain mistakes. The sooner you catch them and contest them, the less likely you are to have to pay them. To determine what you must pay, you may need to review the summary of benefits on your insurance policy. That lays out in detail exactly what the insurance will cover. What Can Patients Do So They Don’t Pay Twice as Much? Ask for an itemized bill and check it carefully in every detail. If you find a mistake, contest it. Sooner is better, even though you may be trying to recover from a serious illness. Ask the billing office about patient assistance or a negotiated payment plan. Check with the Patient Advocate Foundation. They may be able to help in an individual case. Find out if your state has a consumer assistance program in the department of insurance. Notify an intractable billing department that your story will appear in your social media feed. This should probably be the last step if the previous ideas don’t work. But hospitals really don’t like bad publicity, so it might give you leverage you wouldn’t have otherwise. This Week’s Guest Linda J. Blumberg, PhD, is a research professor at Georgetown University’s McCourt School of Public Policy. She is an expert on private health insurance (employer and nongroup), health care financing, and health system reform. Linda J. Blumberg, PhD, describes why we pay twice as much for healthcare Listen to the Podcast he podcast of this program will be available Monday, May 4, 2026, after broadcast on May 2. On this episode, Dr. Blumberg discusses the importance of the summary of benefits in your insurance policy in greater detail. You’ll hear about a situation in which an emergency department overcharged a patient egregiously; the summary of benefits was key in resolving the problem. 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 1471: 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. Medical bills can be mysterious or infuriating. How can you make sense of the complexity and pay a fair price? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34 Here in the United States, we pay more for our health care than people in any other comparable country. Despite this, our longevity statistics are worse. Joe 00:46 We’ll talk with an expert about how we got ourselves into this mess and what we might be able to do about it. Terry 00:54 She’ll help us better understand medical billing and how to challenge mistakes. Joe 00:59 Coming up on The People’s Pharmacy, why Americans pay twice as much for less care. Terry 01:15 In The People’s Pharmacy Health Headlines: An estimated two-thirds of American adults drink coffee every day. Now scientists have an idea why coffee is so popular. Researchers recruited 31 coffee drinkers and 31 people who do not drink coffee for a detailed study. They compared the composition of their gut microbiota and found some striking differences. Then the coffee drinkers abstained from coffee for two weeks. During this time, the investigators noticed changes in their gut microbiota. After two weeks, coffee drinkers were once again provided with their beverage. Half the volunteers got regular caffeinated coffee, the other half got decaf. Neither researchers nor participants knew who got which beverage. Non-coffee drinkers did not participate in this part of the experiment. Coffee-drinking volunteers reported less stress and depression whether the coffee had caffeine in it or not. People drinking decaf had improvements in learning and memory, possibly due to the polyphenols. Those getting caffeine in their mugs reported less anxiety but better attention and vigilance. The scientists note that coffee is much more than a caffeine delivery mechanism. Coffee consumption also has an effect on the immune response. Joe 02:37 Vertigo can be a disorienting and disturbing symptom. A recent overview published in JAMA describes one of the most common forms, benign paroxysmal positional vertigo, abbreviated BPPV. It’s caused when calcium carbonate crystals inside the ear move out of position. A sensation of non-spinning dizziness or lightheadedness occurs when people lie down or change position. The diagnosis of BPPV relies on observing eye movements called nystagmus that occur when the head moves. It can be treated with a set of prescribed head movements called the Epley maneuver. Although physicians often prescribe the antihistamine meclizine for vertigo, this drug is not effective for treating BPPV. Patients can also self-treat this condition by performing the Epley maneuver at home with good results. Terry 03:34 Levothyroxine is one of the most prescribed drugs in America. That’s because millions of people have a sluggish thyroid gland. The condition is called hypothyroidism. Medical experts have worried that it is being over-diagnosed, especially in older people, based solely on thyroid function blood tests. The investigators set out to examine whether de-prescribing levothyroxine is feasible. Study participants were all 60 or older and had been taking levothyroxine at the same dose for at least a year. The doctors began gradual dose reductions. Over the course of a year, 25% of the 370 volunteers were able to get off levothyroxine without having TSH or T4 levels go out of range. Joe 04:24 One of the most contentious issues among nutrition experts in recent years has revolved around fat, in particular, the benefits and risks of omega-6 polyunsaturated fatty acids, or PUFAs. The AHA has long promoted PUFAs found in vegetable oils because they’re heart-healthy. Critics suggest that an imbalance with excessive omega-6 fatty acids could be harmful. Nutrition scientists distinguished between one specific omega-6 fat, linoleic acid, and all the others. Researchers used data from nearly 274,000 volunteers registered with the UK Biobank. These middle-aged, healthy people had no dementia when the study began. Blood tests revealed the balance between linoleic acid and other omega-6 fatty acids. Over the next 15 years, 5,800 individuals developed dementia. Those with the highest levels of linoleic acid were almost 20% less likely to come down with dementia. In contrast, those with the highest levels of other omega-6 fats were about 20% more likely to have a dementia diagnosis. The scientists call for research on whether increasing dietary linoleic acid might help protect people from dementia. And that’s the health news from The People’s Pharmacy this week. Terry 06:15 Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:18 And I’m Joe Graedon. Have you ever received a confusing medical bill? Actually, let me correct myself. Have you ever received a bill from a hospital that was not confusing? Terry 06:30 Most of us have had, oh, maybe a moment of alarm when we’ve had to try and decode a complicated medical bill. Why is the American system so hard to navigate and so difficult to afford? We pay far more for our health care than people in any other comparable country, and we have much less to show for it. Joe 06:53 To learn more about health care in America and how it compares to other countries, we turn to Dr. Linda Blumberg. She is a research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. Terry 07:17 Welcome to The People’s Pharmacy, Dr. Linda Blumberg. Dr. Linda Blumberg 07:20 Thank you so much for inviting me today. Joe 07:23 We are delighted to be able to talk to you about, I think, one of the most challenging issues facing health care in America, and that has to do with our system for paying. So perhaps you can explain briefly how our payment system in the U.S. compares to most other advanced countries. Dr. Linda Blumberg 07:47 Well, it is much more complicated than in most other advanced countries, probably in all other advanced countries. And that’s because we have so many payers and so many different sets of prices that are used for providers, for insurers, for different plans, et cetera, and how employer plans work. So the variation is enormous, which causes a lot of confusion for consumers. And frankly, it often causes confusion for the providers as well. Terry 08:17 I wonder if you would explain, Dr. Blumberg, you say so many different prices, which implies that if I were to go in for a CT scan of something, I might get one price and somebody else who has the exact same procedure done maybe charge something completely different. How does that work? Dr. Linda Blumberg 08:39 That’s absolutely correct. And it all boils down to what type of insurance you have and what plan you have. So if you are somebody who is enrolled in Medicare, the program in the U.S. for those who are 65 and over or who have particular disabilities that qualify them, there are prices that are regulated by the federal government in terms of what a provider can charge for each service. If you have private health insurance, however, there is no regulation on the prices. And so a lot of it depends on what the market will bear for the particular provider that you happen to be using and the negotiations that they have completed with the particular insurance plan you have. And so you may have a United Health Insurance Plan and somebody else may have a United Health Insurance Plan, but they’re two different plans and those would pay different prices for the same procedure. Joe 09:34 Well, we’ll talk about billing in a minute, but what has always confused me is the idea that if you have insurance and you have to go into the hospital for some sort of a procedure, you would get bill X if you have insurance company Y. But if you have no insurance and have to pay out of pocket, it can be substantially greater. I mean, like dramatically more expensive, which seems like it’s just [bleep]-backwards. Pardon my language. I mean, it just seems upside down. How do they figure out these crazy prices? Dr. Linda Blumberg 10:20 Well, first of all, we do not have a rational basis for deciding the prices that an insurer is paying to a particular provider or what a particular provider is going to charge to someone who’s uninsured. And you’re right. If you walk in the door without any insurance coverage, you are likely to be charged the highest price of anybody that’s walking in the front door of a hospital. And that is because there is no insurer or third-party administrator that is negotiating any prices on your behalf. So you’re basically being charged the, you know, the retail rate, which is the highest that there is. What a lot… as you say, it makes no sense because usually people without insurance are the people with the lowest incomes, right? And they have the least ability to pay for these services. And oftentimes the hospitals, in particular, the nonprofit hospitals are required to have programs that lower prices for people with modest incomes that are coming in without insurance. However, they often don’t even advertise that these programs exist. They’re hard to find even on their websites. And so people who are walking in without insurance are being charged huge prices, and they have to know to say, “Listen, well, I have low income and I need to have access to someone who’s going to help me with whatever program you have for low income people walking in the door.” So it is a lot of hit and miss in terms of what people understand about what might be available to them and what negotiated deals a particular hospital has made with a particular health insurance plan. And it’s often a function of how much market power the insurer and the health care providers, the health system have in that particular area is going to drive whether the prices are lower or higher. Terry 12:22 Dr. Blumberg, you mentioned the retail price of a procedure or a hospitalization. And you also mentioned that Medicare prices are regulated, even though all these other prices are not. I’m going to mention, as a Medicare patient, I occasionally look at my explanation of benefits and I find them very confusing and/or alarming because what I see is that my provider, for example, might charge $355 for something. So that’s the retail price. And Medicare approves, let’s say, $128, you know, as that’s the approved payment, but it doesn’t pay that full amount. And then the supplemental, I happen to have Blue Cross, picks up usually most of what Medicare doesn’t pay on the amount that Medicare has approved. But there’s such a mismatch between that retail price and that approved price. How does that work? Dr. Linda Blumberg 13:40 Well, that shows you that when somebody who walks in the door to get the retail price is being charged much more than somebody who’s coming in with Medicare. And that is by federal government law, is that physicians who take payments from Medicare, who participate in Medicare, have to agree to take the rates that are set out in federal law. And these providers know they’ve made this agreement with the federal government. That’s why they’re participating. So this is customary for them. It’s not surprising to them that there is a disconnect between those prices. In fact, very few people end up paying the actual retail price. But if you’re walking in with private health insurance, you’re likely to pay considerably more than or your insurer is going to be paying more and you are likely to pay some more also compared to the Medicare prices. So on average, and this is just on average, hospital payments under private insurance are in the neighborhood of two and a half times what Medicare pays. And for physicians, for clinicians, it’s more on average about 25% above what Medicare pays. So the variation is large even around that. You know, for some procedures and for some clinicians, they may be getting 600% of Medicare or 900% of Medicare. It varies enormously through the system. And that’s why I say we’re not paying privately on any rational set of prices. Joe 15:17 So what has really boggled my mind is that if, for example, you need a hip replacement, as I have had, or a cataract surgery, the provider may charge thousands of dollars. Let’s just make up a number and say, you know, $3,500 for this particular cataract surgery. But Medicare may only pay a few hundred dollars. It’s like the discrepancy is so dramatic. It would be as if the sticker price for your car is $25,000, but you actually only have to pay $18,000. I mean, people are so shocked by these numbers. They seem to make no sense whatsoever. And you kind of wonder, well, how can this system function if these billable numbers are two, three, four times more than the doctor actually gets paid? It seems insane. Dr. Linda Blumberg 16:19 Except for the doctor doesn’t really expect to get paid the amount that they’re showing on the bill, they have negotiated particular rates of payment with insurance plans, and they have accepted the federal government fee schedule, which is public information. So the retail prices that you see are really pretty meaningless because the real prices are the ones that have been negotiated with whoever the insurance company is, whether it’s public or private. Joe 16:50 Unless you don’t have insurance, unless you’re not eligible for Medicare, in which case you’re on the hook for an unbelievable amount of money that you can’t possibly afford. Dr. Linda Blumberg 17:02 Absolutely. But then, you know, I always suggest to consumers when they’re in that situation, first of all, if it’s with the hospital, to explore what programs they have for uninsured people with modest incomes. Because if it’s a nonprofit hospital, they’re required by law to have some kind of program. Whether a particular individual is going to qualify for it is up to what that program looks like. But you always explore that. And absent that, or if you’re talking about care you’ve received from an individual physician, I always suggest that the consumer talk to the physician, talk to the financial manager for the practice and see if there’s some way to negotiate that rate down. Because as you said, it doesn’t make any sense and nobody with private insurance is paying for it. Terry 17:51 You’re listening to Dr. Linda Blumberg, research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. She has analyzed the Affordable Care Act and studied strategies to address remaining health insurance coverage issues. Joe 18:14 After the break, we’ll ask Dr. Blumberg how much an emergency might cost. Terry 18:18 Are we getting any bang for our buck compared to other countries? How do health insurance middlemen affect the cost of care? Some people suggest that the free market should take care of the pricing problems. Joe 18:29 Why haven’t market forces brought health care prices down? Terry 18:43 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 20:45 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 20:48 And I’m Joe Graedon. Joe 21:17 We’re talking about the high cost of health care in the United States. Are we getting our money’s worth? We pay far more than people in most other countries, but our health statistics are abysmal. Terry 21:31 Many families in America go into debt because of huge medical bills. In some cases, people have lost their life savings and their homes because of a health care crisis. Joe 21:42 Will cuts to Medicaid make this situation more challenging? Will hospitals close because of reduced financial stability? Terry 21:52 Our guest is Dr. Linda Blumberg. She’s a research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. Joe 22:10 Dr. Blumberg, in the event that you had an emergency, and let’s say you had to have an ambulance and then you had to go to the emergency department, maybe you thought you were having a stroke or a heart attack, and then you’ve seen multiple specialists and you have a whole bunch of tests, CT scans and goodness knows what else. And then you have to stay in the hospital with maybe a couple of procedures for, let’s say, three to five days. How much might your bill be at the end of this hospital stay? Dr. Linda Blumberg 22:43 Well, a total bill for a hospital stay can be enormous. It depends upon the services you’ve received, how long you’re staying. But, you know, it can often be in the tens of thousands of dollars. But, you know, there are people who have inpatient stays in a hospital for a length of time in serious conditions that could be a million dollars, right? So it all varies a lot, but an emergency department is a particularly expensive place to obtain care, and hospital stays are the most expensive costs that we face in our healthcare system. Joe 23:17 I’d like to ask you about how much bang we’re getting for our bucks in the United States compared to other advanced countries, because, you know, we have done an amazing job at getting smoking down. I mean, turn back the clock about 40 or 50 years and like half of Americans, especially men, smoked. And today it’s down around 12 or 15 percent or lower, maybe around 10 percent. So we’ve made some real progress in terms of health behaviors. But that aside, our life expectancy has not improved dramatically. Other countries, for example, Japan, South Korea, Sweden, and France are all about 83 to 84 years of age. In the U.S., our life expectancy is around 78 years. We spend annually over $12,000 a year per capita per person. In Germany, it’s 8,000. In France, it’s $6,600. And in Sweden, it’s $6,400. So almost half of what we spend. And yet their longevity is much greater. I mean, substantially better. How? I mean, what? Terry 24:37 What gives? Joe 24:36 What is going on? How can it be that we’re paying so much more for so much less? Dr. Linda Blumberg 24:45 Really good question. Part of what’s going on and probably the biggest difference in terms of what we spend compared to other countries, developed countries on health care, is the prices that are paid to the health care providers from, you know, who we’re receiving our care from. So a hospital stay for the same services in the United States is typically going to cost considerably more than if those services were obtained in Canada or in Japan or in Germany or in Israel. So those are systems that… where all of the… There is regulation of the prices that are paid, are paid for medical procedures, regardless of the type of insurance coverage you have. And some of them have, you know, different plans, et cetera, not as much variation as we have here, but some variation. But all of those prices are limited in those countries by government dictate. And we are, as I said, we’re only limiting the prices that we pay for medical care if you’re in a public insurance program like Medicaid or Medicare. If you have private insurance, which most people below age 65 have a private health insurance, those prices are not regulated. In addition, when you think about longevity, we do have a more diverse population in a lot of respects than is the case in most other developed countries. But in addition, we have the issue here of still having a significant number of U.S. residents without any health insurance coverage at all, which is not the case in these other developed countries where they have at least some level of universal health insurance coverage. And sometimes it’s considerably more comprehensive than the types of coverage we have here. And so when you have a significant share of the population, even if it’s only at this point under 10%, about 10% of the population under age 65, you still have a considerable number of people who are not getting access to medical care when they need it. And that is going to affect longevity. Other things like diet and pollution and, you know, various other different issues. We have a lot of gun violence here, which is not the case in the vast majority of other countries. So all of those things go into the difference. But the difference in our spending is completely on the prices that we’re paying to our health care providers on the commercial side. Terry 27:25 Dr. Blumberg, you’ve written about health insurance middlemen. I wonder if you could explain what that is and how it affects the prices we pay. Dr. Linda Blumberg 27:35 Sure. So when we are obtaining medical care in this country, we are paying for the particular services, right? And money is going to the providers who are providing these services to us. But we’re also paying administrative costs. And those administrative costs are built into the prices that we’re paying to hospitals and doctors and other providers. And it’s also built into the premiums that we’re paying for our health insurance coverage. And increasingly in this country, we have moved our healthcare economy into a space where huge numbers of dollars are going for administrative fees that are associated with what I refer to as middlemen. People have heard a lot about prescription drug benefit managers. But the same is true on the medical side. So a hospital is spending large amounts of money on a revenue cycle management company that is trying to figure out how to send in bills and code the services delivered to increase the revenue of the hospital. Same on the physician side. You have various different types of entities that are contracting with insurance companies to do particular types of tasks that the insurance company or the third-party administrator either doesn’t want to do themselves or finds more profitable to contract out to their subsidiaries. So there is a lot of dollars that are going into making the prices higher on the claim side, on the medical service price side, and that are also being built into our insurance premiums through higher claims and through higher administrative loads that are attached by the insurer. So, I mean, we’re talking about an industry that is hundreds of billions of dollars every year that is really extractive, that’s pulling dollars out of every one of the transactions. And there’s billions of transactions that go through our system every year. And so these entities, these administrative and financial entities have figured out how to extract dollars from the healthcare economy by adding some administrative costs to every single transaction that is being processed through the system. Joe 30:07 Dr. Blumberg, I think most people have a real hard time dealing in billions and dealing with middlemen and all the other stuff, but they can relate to an office visit. So for example, if you had to go see a specialist in this country, maybe a gastroenterologist or a dermatologist or a cardiologist, those bills for just a quote unquote ‘regular visit’ could be in the hundreds of dollars. In Sweden, it’s 40 bucks. That’s the maximum a specialist can charge in Sweden. Kids are free in Sweden. I think most parents know that a pediatrician’s visit can be pricey. They have no health care premiums in Sweden. It comes off their tax bill. The average hospital bill in Sweden for a day, this, you know, being in the hospital for a day, is $11. In this country, it can be thousands. And the maximum that a person would pay for all medical appointments annually in Sweden, everything lumped together would be $160. It can cost us $160 for just one visit in this country. So I’m just wondering, when will the American public say enough is enough? Dr. Linda Blumberg 31:38 So I think one important thing to remember is that, yes, when somebody is taking their kid to a pediatrician in Sweden, they’re not paying anything out of pocket. But their taxes are higher, right? Because those providers still have to be paid for the services they’re providing. It’s a matter of how the prices are, how they’re being paid. And in those countries, much more of the dollars are flowing through their national health system, which is funded by tax dollars. And so the tax rates in Sweden, for example, are typically quite a bit higher than we face in the United States. But they, at the same time, obviously the country is regulating how much the providers can earn for providing the services that they’re provided. So there are some limits that lower the incomes, the revenue that the providers receive, but much more of the dollars are flowing through the government and from tax dollars than is the case here. We have always struggled here in the United States with balancing, number one, regulation. How much do we want to regulate prices instead of letting the market decide what a private sector person like a health care provider or hospital is going to receive? And we also struggle with increasing our taxes, right? And so we could create a system where we have greater regulation of the prices and limits on prices that are paid to health care providers to lower our total spending. We can also finance more coverage through the federal government or through state government for more people. But it is a real political struggle to convince people that while they feel like their… that health care is too expensive, they’re afraid of oftentimes of putting limits on what their particular doctor is going to make or their particular hospital is going to make. Because the hospitals and the physicians will let them will tell them whether it’s accurate or not, that their access and their quality of care is going to suffer if they do that. And there are also people in this country are very much resistant to significant increases in their taxes, even if you tell them it’s going to lower other out-of-pocket expenses because they don’t really believe it, right? Or they think they’re going to end up paying more for somebody else to have lower prices. So it is a very complicated political balance here. I think people are getting more and more frustrated with the way that the system works and the increase in the denials and the red tape and the complexity people have to jump through to obtain their medical care. But the political challenge is real in terms of more government regulation of prices and/or financing more care through the tax system. Terry 34:43 Well, you’re absolutely right. It is very complicated politically. And you mentioned that one of the alternatives that is sometimes posited is: let market forces regulate prices, which is, I think, where we are, except that market forces are only making prices higher, not lower. Why doesn’t health care in America work like a market should? Dr. Linda Blumberg 35:12 We have had a tremendous amount of consolidation in our healthcare industries. And so when we talk about hospitals being bought, you know, buying other hospitals and creating hospital systems and, you know, sometimes often now buying medical practices, insurance companies, UnitedHealthcare is now the biggest employer of physicians in this country, right? The insurers and the healthcare systems are buying up these middlemen that are making more money off of, you know, as I was saying, extracting dollars from the claims that are being processed. So there’s been a tremendous amount of complexity added in the financial relationships between all of these stakeholders, the providers, the insurers, the middlemen. Very few of them are independent at this time. Very many of them have conflicts of interest, all directed in the direction of increasing prices on the commercial side and increasing spending. Terry 36:15 Right. Lots of complexity, not much transparency. Dr. Linda Blumberg 36:18 Right. It is basically capitalism run amok. And you’re talking about a product in health care that was already from the beginning of time, much more complicated to shop for than a refrigerator, right? You know, you don’t know necessarily what you’re going to need in terms of services or what it’s going to cost before you walk in the door at the doctor’s office or in the hospital. It is not something that is easy to shop for, whereas I can, you know, spend 20 minutes and figure out what the best price I can get on the refrigerator I want is. That’s just not the way medical care works. And then when you take the consolidation and the hidden fees and the conflicts of interest that have arisen both between co-ownership in the healthcare industry and these financial deals that are being made between the insurers and the middlemen and the providers at this point, you have a situation where there is no competition in these markets or where there is, it’s extraordinarily limited. And so you’re not going to… the more this is allowed to fester and expand, which is what it is doing year in and year out, the worse it’s going to get. You’re not going to have competition driving prices down. You’re going to have greater financialization of the system continuing to drive prices up. And really the only way to interfere with that is for government to put limits on both what prices can be charged for particular services and to eliminate the financial dealings that are interconnecting all of these stakeholders with each other and encouraging higher intensity coding and hidden financial fees that are passing between different entities that are driving costs up for consumers and employers. Terry 38:14 You’re listening to Dr. Linda Blumberg. She’s a research professor at Georgetown University’s McCourt School of Public Policy, and she is an expert on private health insurance, health care financing, and health system reform. Dr. Blumberg has provided technical assistance to states in their efforts to analyze and implement federal reforms and examine the implications of private equity companies’ movement into health care. Joe 38:43 After the break, we’ll discuss why you need to examine your hospital bill extra carefully and with skepticism. Terry 38:52 Hospital bills are complex and they often contain errors. To really figure out the charges, you need to request an itemized bill. Joe 39:01 Surprisingly, your insurance company might not behave like an ally. Terry 39:09 How do you contest a bill that is obviously wrong? Joe 39:12 Sometimes media exposure of outrageous bills can make a big difference. Most hospitals hate bad publicity. Terry 39:31 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 And I’m Joe Graedon. Joe 40:16 Are you the kind of person who pays bills as soon as you get them? Nothing wrong with that. But when it comes to hospital bills, you may need to slow down. It turns out they often contain errors that can be tough to track down. Terry 40:33 Medical bills, especially hospital bills, can be extremely complex. And hospitals make mistakes all the time. You’ll need to scrutinize every charge. Joe 40:44 We’re talking today with Dr. Linda Blumberg, research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. She has analyzed the Affordable Care Act and studied strategies to address remaining health insurance coverage issues. Dr. Blumberg has also analyzed approaches for setting standards of affordability for insurance coverage. Terry 41:14 Dr. Blumberg, some years ago, we spoke with a fellow, I think his name is Marshall Allen, who wrote a book. He titled it: “Never Pay the First Bill.” And we found our conversation with him quite interesting. I’m wondering what you think of that advice. Dr. Linda Blumberg 41:34 Well, I think my advice is always be skeptical and look carefully at a bill. Don’t just pay it, because the vast majority of them, whether they’re coming from a hospital, much more likely from a physician, also reasonably likely there’s mistakes in them. And so you do want to approach them with some skepticism and caution. Joe 41:58 Well, actually, that’s not enough. And the reason I say that’s not enough is because most of us, when we look at a hospital bill or a clinic bill, we don’t know what to make of it. I mean, it is really confusing. And as you said, there’s like the bill that the doctor presents and the bill that the clinic presents or the hospital presents. And then there’s what Medicare might pay or might not pay or your insurance. It’s like, how in the world do we make sense of our medical bills? How do we even get started? Dr. Linda Blumberg 42:38 It’s rough and it takes a good deal of patience and time, unfortunately. Hospital bills in particular, I’ve heard estimates that nine out of 10 of them have errors. I’ve heard others say that there’s never a hospital bill that doesn’t have an error in it, right? And they’re the most complex of the bills that an individual is going to receive. My advice is always the first thing you do is request an itemized bill from the hospital, because by and large, what the hospital will send out is a summary bill, not an itemized bill. And you can’t figure out what the errors are in general from a summary. So request an itemized bill. If they don’t send it, you got to ask again, because sometimes they’re a little pokey about it because they just want you to pay. They don’t want you to look at the itemized bill. Joe 43:26 Well, let me ask you this: let’s say you get an itemized bill and it says that you had an ultrasound done on such and such a date of, you know, such and such a part of your body and you go, “No way. I did not have an ultrasound at all.” How did that happen? And then how do you contest something that’s obviously wrong? Dr. Linda Blumberg 43:53 The first stop from my perspective is to call the billing department, to call the physician’s office of the physician that you’ve seen and contest it and say, there’s a mistake. I’m being charged for a service that I never received. An insurance company, if you have an insurer, can also often be helpful when you’re talking about something you’ve been charged for that is something you have not received. But it sometimes will take multiple calls and multiple interactions to resolve a problem like that. You know, one of the most common errors that people see in hospital bills is being billed twice for the same thing or the number of, you know, something that was charged for, you know, some supply or something is, you know, somebody added a zero to it by mistake, you know, assumedly. And that needs to be corrected, and so engaging with the physician who you’ve received services from with your insurer and trying to contact the billing department directly at the hospital… Joe 44:59 Let me ask you one follow-up to that, because you would think that since the insurance company, if you’re fortunate enough to have insurance, would be an ally, would be joining you in fighting an incorrect bill or a bill that was overcharged for some reason or a service that was never provided or a medication that you never got. We’ve heard that insurance companies, they’re not as likely to be enthusiastic about challenging these bills because after all, they’re just going to pass those charges on to their customers and consumers. It’s like, well, why waste our time? Because you, you know, you, you were charged for aspirin, but you didn’t get aspirin. So how do we get the insurance companies fired up to actually challenge mistakes? Dr. Linda Blumberg 45:55 It is sometimes a struggle for sure. One of the things that people should be aware of, and what I talk about when I talk about this complex web of interconnected financial interests across stakeholders in the healthcare industry, is that insurance companies, they can make greater profit the higher the claims. Under the law, they are limited in terms of what percentage of a premium can go to administrative costs, including profit. So since that’s limited as a percentage, the higher the total spend on claims, the bigger the amount of money they have left over for their administrative costs and their profit. And so in a lot of ways, they’re disincentivized to hold down spending, which is contrary to what many people who are using, buying health insurance coverage expect of their insurer. They think their insurer is trying to get the best deal for them. That is not always the case. And so you can talk to the consumer reps with the insurer, but sometimes you’ve really got to go directly to the provider and dispute. And there’s a nonprofit called the Patient Advocate Foundation that is particularly created to help people with chronic illnesses contest incorrect bills and deal with billing issues. There are others who will do it for a fee as a percentage of what savings created. But it becomes sometimes a situation where the consumer themselves needs to do repeated calls and contacts and filing complaints in order to get a bill resolved. But I still always say contact the insurance company as well. They may be in a mindset to help out. Terry 47:52 Dr. Blumberg, you’ve mentioned that patients can and probably should negotiate with whether it’s the physician’s office billing or the hospital billing, especially if they don’t have insurance, but even if they do. Can you tell us about a time when somebody did that? What was the outcome? Dr. Linda Blumberg 48:17 Well, sure. I mean, I think it depends greatly on the health care provider, right? And if you have had a primary care physician for many years and then you’ve lost health insurance coverage or for some reason you have a gap or et cetera, you know, there are ways in which, you know, in circumstances where these providers will either set up a payment plan for you, or they’ll say, “Listen, you know, you’ve been a great patient and I want to help you through this rough spot.” And they’ll negotiate down, you know, hopefully to what at least at a minimum that the private insurer would have paid, right? But it is very much [an] ad hoc kind of decision that’s being made by these providers. Now, in the situation of a hospital, particularly for people who have modest incomes, there are programs that nonprofit hospitals have, as I mentioned before, that are there to help people in financial straits. And those programs, sometimes they’re programs that are funded by state government dollars. Sometimes it’s… parts of it, the hospital themselves, but those are programs that exist explicitly for people in tough situations. And some… but some… The problem is you have to really push to get the information about them to figure out whether you’re eligible. Joe 49:41 Dr. Blumberg, what about media exposure? I mean, every once in a while, somebody sort of blows the whistle on an outrageous bill that just blows everybody’s mind. It’s like, that’s ridiculous. And they contact their, their local TV station or their newspaper, and all of a sudden, you know, it goes, you know, wild on the internet, and it affects the hospital in such a way they say, “Oh, never mind, let’s negotiate a better bill.” Is that something that people can actually do successfully? Dr. Linda Blumberg 50:15 Yes, people have done it successfully. And there’s, you know, ‘bill of the day’ kinds of newspaper reporting, et cetera, where some experienced reporters are doing this repeatedly on behalf of people in particularly egregious circumstances. And it can be really effective at cutting through to the right people at the right moment to get a better deal created. And so, listen, if I was in that situation, I would use whatever options I had at my disposal. You know, in some states, unfortunately, it’s not all states, but in some states, state governments have what are called consumer assistance programs. They were originally funded by the federal government across the country, but that funding has not been reappropriated in many years now. But those consumer assistance programs, if you’re lucky enough to live in a state that has one, can sometimes also be helpful if you contact them, file a complaint with the state. If it’s a problem with the insurance company and it’s a fully insured product, not a self-funded plan from the employer, you can file complaints with the Department of Insurance, et cetera. So there are opportunities for going higher. And I always suggest to people, even if you’re contacting someone at the hospital, if you’re not getting any kind of satisfaction from a consumer rep, you want to escalate to a manager, to whoever. You want to just go as high as you can in the pecking order to try to get some resolution. Joe 51:50 We are concerned about pharmaceutical prices, as you can very well imagine here on The People’s Pharmacy. And we have seen pharmacies disappearing in this country at an extraordinary rate, in part because private equity firms have bought up large chains, and those large chains are now closing not dozens but hundreds of pharmacies. And so the idea of a mom-and-pop pharmacy where the pharmacist was a sole operator seems to be disappearing very quickly. And drug prices, as everybody knows, are way higher in this country than any place in the world. What do you suggest when it comes to the costs of medicine in this country, especially for people who have life-threatening conditions and their bills may be in the tens of thousands of dollars? Dr. Linda Blumberg 52:43 It’s really, really difficult. And I wish I had a good answer for you. I know some people are trying to obtain medications at more affordable prices outside of the country. That’s always challenging and a little bit risky depending upon where you’re going to get the medications. But there are some programs that particular pharmaceutical companies have that lower prices for people with modest incomes or people who do not have health insurance coverage for brand-name types of drugs that they need. And so, you know, I usually suggest to people, first stop if you can’t get satisfaction or help from your insurance company. And sometimes if it’s not on their formulary, you can get evidence from your… help from your physician about why that particular drug is so necessary to try to appeal and get coverage from your insurance company. If you’re without insurance or without good enough insurance to cover costs, I would suggest to people go to the website for the company that makes your drug and see if they have some programs that might be able to help. There are also some states [that] have particular programs for providing financial support for prescription drugs. Joe 54:04 Dr. Blumberg, we only have about two minutes left. If we were to put you in charge of the entire health care system, how would you change things? Dr. Linda Blumberg 54:15 Well, first of all, I would put back a number of the coverage cutbacks that this administration has put in place or that they will be putting in place in the near future in the Medicaid program because every person in this country should have access to affordable, adequate health insurance coverage for their medical needs. Beyond that, I would put limits in place on the prices that are charged by providers, and I would do it broadly across all prices, and hospital level, physician level. I would include prescription drug controls in that as well. I would then make sure that we are monitoring a system to make sure that everybody has the access that they need. And I would do a lot to break up the kinds of integrated financial incentives from co-owned entities in the healthcare system to separate those financial incentives, create more competition and clarity in terms of what people are paying when they obtain care. And I think we’ve also got to go a ways to your point about the prescription drug issues on the private equity side. There’s a lot of practices that private equity typically uses in the healthcare space that are extractive and damaging both to prices, quality, and sometimes the stability of the healthcare providers themselves. And we have to prohibit those kinds of high debt financing and other extractive practices that are often in place there. Terry 55:50 Dr. Blumberg, did we miss anything that we should have asked you? Dr. Linda Blumberg 55:54 No, I think we covered a lot. So, yeah, I think, you know, when people get their bills, they should always make sure that the names, the dates, you know, the insurance information is all correct. Sometimes that stops insurance companies from paying appropriately from like little minor like typo errors in addition to the kinds of things we talked about. And everybody who has a health insurance policy by law has access to what’s called a summary of benefits and coverage or an SBC. This is part of the Affordable Care Act law. It’s an English-language summary of your benefits. And so I always suggest to people to have that in hand so you can make sure that when you get the bill that says this is what your insurance company pays, this is what you owe, that you’re clear that that is really what you owe. So, for example, I had a situation where I was helping somebody and they had gone into the emergency room for urgent care that the doctor told them to go to the ER. And the hospital charged them $2,000 up front on a credit card when they walked in the door. Their summary of benefits and coverage very explicitly said that the only charge they should be charged when they walk into an emergency room for a real emergency is $200. It took me about an hour and a half or two hours and maybe three or four different telephone calls to resolve that. But it was really clear from that summary of benefits and coverage that that person was overcharged. So, you know, knowing, being really on top of what your health insurance plan is supposed to cover and comparing that to what you’re being charged is a really important line of defense. Joe 57:47 Dr. Blumberg, whenever we talk to healthcare professionals, they often complain these days. They complain that they have to see way too many patients in way too little time. They complain about the cost of their education, whether it’s a nursing school or pharmacy school or medical school, that it’s very expensive and that they had to go into debt. And then they complain about the whole fee structure and all the bureaucracy and all the time they have to spend sometimes arm wrestling insurance companies, and it’s not actually practicing medicine the way they would like to. But at the same time, we hear that people earn rather extraordinary incomes. So a, for example, orthopedic surgeon is often making $500,000, $600,000, $800,000 a year. A family practice physician may be only making $150,000 to $200,000 a year. How do the payments to healthcare professionals in this country compare to the healthcare professionals in, let’s just say, the UK or Germany or Sweden? Dr. Linda Blumberg 59:20 We are paying our specialists in particular a lot more than are being paid in those other countries. I don’t have the statistics at hand on those specific salaries, but, you know, I’m not sure we’re paying our primary care physicians, you know, any more or not significantly more than they are paid in other countries. But, you know, those are at the highest levels, you know, as you said, the orthopedic surgeons, the interventional radiologists, the folks that are being paid for procedures at really high levels are paid much more than we see in other countries. And I think my understanding is, and I’d have to look at this more carefully, but my understanding is that education in general, including education for medical professionals, is much more highly subsidized in most of these countries than we do here. And so if you’re going to pay considerably less, then we also have to think about subsidizing the education for some more medical professionals than we do. And that should be part of the thinking if we’re going to put a lot of limits on what these providers can make. Joe 01:00:38 And finally, our listeners learn from stories. And quite honestly, so do doctors. They call them case reports. But it makes the topic that we’re discussing come alive in ways that just talking in a more academic way [does not]. Have you had any experience over your career in which a patient or a family or some situation where the billing was so outrageous that it came to your attention and it was able to be modified? You mentioned spending a couple of hours on the phone because the person was billed so much on their credit card when they entered the emergency department. Is there any other story you could share about billing that would be how I would describe it as helpful for our listeners to comprehend the scope of the problem? Dr. Linda Blumberg 01:01:40 Well, you know, I am an academic researcher, right, and a policy researcher. And so I do not generally work as an advocate for patients. Every once in a while, a family member or a friend or somebody who sees a program that I’ve been speaking on will contact me and ask for help and I’ll do what I can. But that’s the most… The situation with the $2,000 bill instead of the $200 bill is my most recent case of that. But, you know, the other thing that I’ve seen a lot in terms of what’s been in the media is stories of people who go in for an emergency room visit, and it’s a reasonably modest kind of situation. They’re not in there long. Maybe it’s for a child and they were worried, but it’s really not a big medical problem. And the intensity with which that bill is coded is way out of whack with the services that were provided because emergency room visits are coded by the intensity of the situation and the services needed. And so those are situations where people can get bills in the huge range, tens of thousands of dollars for something that should have been a much more low-cost price. And seeing that and having to go back and appeal that is something that is becoming more common, I think, in emergency departments over time. So I don’t have a lot of individual stories where I have particularly intervened because that’s, you know, I’m a data and analytic person more than I am, you know, I’m not really a consumer advocate. Terry 01:03:26 Dr. Linda Blumberg, thank you so much for talking with us on The People’s Pharmacy today. Dr. Linda Blumberg 01:03:32 My pleasure. Thanks for having me on. Terry 01:03:34 You’ve been listening to Dr. Linda Blumberg, research professor at Georgetown University’s McCourt School of Public Policy. She’s an expert on private health insurance, health care financing, and health system reform. Dr. Blumberg has provided technical assistance to states in their efforts to analyze and implement federal reforms. She’s also examined the implication of private equity companies’ movement into health care. Joe 01:04:05 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:04:14 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 01:04:23 Today’s show is number 1,471. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. We’d love to hear your reports about hospital bills, interactions with the medical system. Please, you can reach us through email, radio at peoplespharmacy.com. We’re also trying to enhance our YouTube channel with videos of our interviews. If you’d like to watch our interactions with guests you hear each week on The People’s Pharmacy, why not go to YouTube and search for People’s Pharmacy? Terry 01:05:01 Our interviews are always available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In this week’s podcast, we also discuss how easy it is for errors to creep into the bill, even through simple typos. The summary of benefits for the insurance coverage is a crucial document. It lays out exactly what the hospital can and can’t charge you for. One reason health care costs so much in the U.S. is the high cost of specialized medical professionals. How does compensation in other countries compare to what health care professionals make here? You’ll also hear about emergency room coding errors. Joe 01:05:48 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 thought-provoking, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 01:06:18 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 01:06:55 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 01:07:04 All you have to do is go to peoplespharmacy.com/donate. Joe 01:07:10 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.

Transcribed - Published: 30 April 2026

If you had to name one thing that could contribute to better health throughout the lifespan, what would it be? We think exercise, or at least physical activity deserves the top spot. Yet in 2025, fewer than half of adults met the guidelines for aerobic physical activity. And less than one-quarter were doing both aerobic and muscle-strengthening exercises on a regular basis. Perhaps your doctor should prescribe exercise. What could we expect as the benefits? 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, April 25, 2026, through your computer or smart phone (wvtf.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 April 27, 2026. Would Your Doctor Prescribe Exercise for Depression? Earlier this year, the Cochrane Collaboration published a review of 73 randomized clinical trials of exercise as a treatment for depression (Cochrane Database of Systematic Reviews, Jan. 8, 2026).  Most of these compared physical activity to antidepressants or to psychological therapy for depressed patients. Some of them compared the exercise prescription to no treatment or wait list. Comparing exercise to no treatment revealed an advantage for exercise, although the quality of the trials left something to be desired. Ten trials compared exercise to psychological therapy. In addition, five trials weighed exercise against antidepressant medication. Neither comparison showed a clear tilt for or against exercise as a superior intervention against depression. Exercise in the Cancer Center Dr. Claudio Battaglini of the University of North Carolina at Chapel Hill was not surprised by this finding. The exercise program he oversees for cancer patients often results in lifting their spirits as well as improving their health. That may help explain the very high adherence in his program. Will Physical Activity Reduce the Risk of Cancer? According to a review of the evidence, regular physical activity can reduce the number of people who die prematurely. In addition, it helps with weight control, quality of life and bone health. Older people are less likely to fall or experience declining cognition if they exercise regularly. The review found that physical activity improves quality of life and promotes emotional benefits (European Journal of Cancer Prevention, Jan. 1, 2025). If oncologists should prescribe exercise, don’t cancer patients deserve to have their insurance company cover the cost? Insurers rarely blink twice at cardiac rehab. Although cancer rehab is also super-helpful, insurance companies often don’t choose to pay for it. What Role Could Coaching Play in Guiding Physical Activity? Lots of doctors tell their patients to get more exercise. The patient wants to and intends to, but perhaps they just don’t know how. What activity should they choose? What is the proper technique? How often and how much do you need to move? All these questions can be answered by a coach. The coach will take into account your objectives and preferences as well as your prior experience. What do you love doing? Are there any moves you should avoid to reduce the risk of injury? That’s why when doctors prescribe exercise, they should include coaching to provide this sort of guidance. If Doctors Prescribe Exercise, Will That Help Motivation? Many of us know we should be active, but we don’t always follow through. How can we get motivated to move? According to Dr. Jordan Metzl, the first step is to find something you love doing. For Joe, for instance, having the doctor prescribe exercise of runniing a mile a day is not going to work. But he’ll cover much more than a mile–and quickly–if he is playing a competitive game of tennis. Joe loves tennis. Terry is not a runner either. On the other hand, karate club is a highlight of her week, and she has worked to achieve some skill in it. Dr. Metzl advocates for finding the activity that gets you excited and making it a priority in your life. If you are having fun, that is a great motivation. Reducing the Cost to Act Another thing to consider is overcoming the cost to act. If your activity requires a lot of preparation that feels like a chore, the cost to act is high. If you can make it easier and break down that barrier, you are much more likely to accomplish your exercise. External rewards can also play a role. Joe loves winning, so he likes to play with guys at about his same level of skill. That way, he has a chance to win if he tries. For Terry, there was a progression through belt levels in karate, from yellow to green to blue, and so on. Now, she looks forward to closing the rings in the fitness app on her watch. When Doctors Prescribe Exercise, Does That Give You a Push? For Dr. Metzl, the idea of pushing yourself and maybe your friends is a positive notion. We asked him about people who dig in their heels when pushed. What approach do they need to perceive and pursue their goals? He summarized the three ingredients of healthy motivation as knowledge, emotion and belief. That’s knowledge of the benefits of activity, an emotional response of appreciating and enjoying activity and a belief that you can achieve your goal. This Week’s Guests Claudio Battaglini, PhD., FACSM, is Professor in the Dept. of Exercise and Sport Science at The University of North Carolina at Chapel Hill. He is also Director Emeritus of the Get REAL & HEEL Breast Cancer Research Program and Co-Director of the Exercise Oncology Research Laboratory. Jordan D. Metzl, MD is an internationally recognized sports medicine physician, bestselling author, and fitness instructor who practices at the Hospital for Special Surgery in New York City. He lectures around the world and founded the first physician-led online fitness community, IronStrength, with more than 50,000 members. He created the Ironstrength Workout, a functional fitness program for improved performance and injury prevention that he teaches in fitness venues throughout the country. An elite athlete himself, Dr. Metzl is also a 40-time marathon runner and 14-time Ironman finisher. Dr. Jordan Metzl, author of Push, runs the New York City Marathon 2025 Dr.Metzl’s latest book is Push: Unlock the Science of Fitness Motivation to Embrace Health and Longevity 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, April 27, 2026, after broadcast on April 25. On this episode, Dr. Metzl talks about the joy of teaching medical students to offer an exercise prescription and the challenge of getting specialties other than cardiology to integrate physical activity into their rehab process. Dr. Battaglini discusses the contrast between cardiac rehab, which is covered by insurance, and cancer rehab, which is not. He also describes the value of swimming, especially for older people with sore joints. Walking is good exercise and easy for most people. What if the weather is bad? Perhaps an indoor walk around the mall would be a good alternative, and if you can recruit some friends to join you, so much the better. You can stream the show from this site and download the podcast for free.

Transcribed - Published: 23 April 2026

Hospitals can be pretty overwhelming. Sometimes you may feel like you need a map to find your way around the maze, not to mention a trusty guide to get you to the department or health professional that could actually help you overcome illness. In addition, being hospitalized often means being deprived of fresh air & sunlight. Could that be a mistake for proper healing? 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, April 18, 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 April 20, 2026. Striving for Person-Centered Care Wouldn’t it be great if healthcare facilities were specifically designed around the individuals they are supposed to serve? Fifty years ago, a group of physicians and former patients started Planetree to do exactly that. At first, Planetree provided information at a time when patients were rarely told what was wrong or how it could be addressed. There was also a Planetree ward in a hospital in the Bay Area that operated on principles of transparency and person-centered care. Over the next several decades, Planetree developed as a network of more than 300 health care facilities in 30 countries that strive to provide a home-like environment for healing. The main value is person-centered care, in which they strive to treat the whole person as well as that individual’s family or significant others. We invited Planetree President Michael Giuliano to tell us about it. He mentioned that one feature is getting your care summary in real time, so you can ask questions and correct errors before you leave the clinic or office. Fresh Air & Sunlight Built In One of the things that sets a Planetree hospital apart from other facilities is the way the values are visible in the architecture. Planetree planners put a premium on access to nature and outdoor space, though of course each facility does it a bit differently, according to its own plan. Rooms are set up so that people have access to fresh air & sunlight. That makes them feel more comfortable, certainly. Might it also promote healing? How Do Fresh Air & Sunlight Promote Healing? More than 150 years ago, Florence Nightingale set standards based on what she observed of soldiers healing from battle wounds and horrible infections during the Crimean War. This was, of course, before the development of antibiotics, so nursing care was paramount. Nurse Nightingale insisted on the primacy of fresh air & sunlight for her patients. Was this just a quaint old-fashioned idea, or is there modern scientific support? The Power of Near-Infrared For more information on the science of fresh air & sunlight (yes, there is science), we turn to Dr. Roger Seheult of MedCram.com. https://www.medcram.com/ He began by describing the brand new Footscray Hospital in West Melbourne. The design is something of a modern take on Florence Nightingale’s hospital plan, since the architects figured out how to get natural light and real ventilation in every room. They prioritized fresh air & sunlight in this $1.5 billion hospital because of their healing properties. People exposed to sunlight leave the hospital sooner because they recover more quickly. So the patient gets better and goes home faster, the hospital has a better bottom line and the insurance company pays less. Everybody wins! Probably a good part of the credit goes to near-infrared light. We can’t see it, but it penetrates our bodies and they react. Exposure to near-infrared at 850 nanometers improves mitochondrial function. You could get this from a device, but it is cheaper and arguably more pleasant simply to go outside and allow sunlight to fall on your skin soon after sunrise (or before 10 am) or just before sunset (probably after 4 pm). An Amazing Story About Fresh Air & Sunlight We’d be tempted to call this an unbelievable story, but Dr. Seheult provided all the details and checked the medical records himself, so we believe it. He told us about a 15-year-old boy with a serious blood cancer, acute lymphoblastic leukemia, ALL. This type of cancer undermines the immune response, and this young man had come down with a terrible fungal infection, mucormycosis. The fungus did not respond to medication, and it rampaged through his left lung. Ultimately, his doctors proposed removing the lung as a last-ditch method of controlling the infection. Unfortunately, when they found that the fungus had invaded his right lung, they were out of options. They figured he probably couldn’t survive much more than two days, so they asked him his last wishes. All he wanted was to go outside; at this point, he’d been cooped up in the hospital for two months. They fixed up a wheelchair to hold all his drips and took him outside. The next day, they did it again. The youth didn’t die as expected. Instead, he recovered completely, over time. We can’t put sunlight in a bottle, but perhaps oncologists and other doctors should consider writing prescriptions to cover it. This Week’s Guests Michael Giuliano is the President of Planetree International, a mission-driven non-profit organization setting the global standard for person- centered excellence across the continuum of care. Michael joined Planetree in 2022 as Chief Operating Officer (COO) following a decade of leadership roles in Australia’s public and private healthcare sectors. https://www.planetree.org/team-member/michael-giuliano Michael Giuliano, President of Planetree International Dr. Roger Seheult is an Associate Clinical Professor at the University of California, Riverside School of Medicine. He is also an Assistant Clinical Professor at the School of Medicine and Allied Health at Loma Linda University. He is quadruple board-certified in Internal Medicine, Pulmonary Diseases, Critical Care Medicine, and Sleep Medicine through the American Board of Internal Medicine. His current practice is in Beaumont, California. He is a critical care physician, pulmonologist, and sleep physician at Optum California. Dr. Seheult lectures routinely across the country at conferences and for medical, PA, and RT societies. He is the director of a sleep lab and the Medical Director for the Crafton Hills College Respiratory Care Program. He is co-founder and presenter for MedCram.com, a site that offers concise and easy-to-follow medical videos on a range of topics. Roger Seheult, MD, MedCram, Loma Linda, UC-Riverside Listen to the Podcast The podcast of this program will be available Monday, April 20, 2026, after broadcast on April 18. On this episode, Dr. Giuliano discusses billing as part of person-centered care. 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.

Transcribed - Published: 16 April 2026

Millions of Americans are in pain. Arthritic joints make exercise difficult, even though moving is one of the best things we can do for joint pain. Pinched nerves can cause excruciating, long-lasting pain. The usual treatments, such as NSAIDs, may help ease the pain momentarily, but do nothing to help heal the underlying condition. What do you know about the new science of regenerative therapies? 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, April 11, 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 April 13, 2026. You can also watch Dr. Buchheit talking with us on YouTube. The New Science of Regenerative Therapies What is the price of pain relief for aching, arthritic joints? We’re not talking about the drugstore sticker on a bottle of ibuprofen. Instead, we are referring to the potential negative consequences of utilizing such medicines for temporary symptomatic relief when the joint continues to hurt for weeks, months or years. Even more powerful treatments, such as corticosteroid injections into the sore joint, don’t heal the cartilage. In fact, they may contribute to further deterioration as they suppress the immune system. Our guest offers other ways to treat joint pain with regenerative therapies. Immune Mechanisms That Resolve Inflammation Dr. Tom Buchheit is a pain management specialist who has worked with elite athletes as well as seniors to get them moving well again after an injury. One of the reasons exercise can be so helpful is that the right kind and amount of movement creates good inflammation. Unlike chronic inflammation that causes further harm, good inflammation helps the immune system switch to a different phase, one in which destructive pathways are resolved. The three pillars of exercise are aerobic exercise, muscle building exercise and exercise to improve balance. Together, these types of exercise help recovery and healing and can even help heal damaged nerves. NSAIDs like naproxen, celecoxib or ibuprofen can interfere with the good inflammation exercise creates. Rather than taking such a pill before a game or workout, it makes sense to wait and take it afterwards if you need it. Will Exercise Wear Out Your Joints? Injury can damage the joints, but the idea of osteoarthritis as a consequence of wear and tear seems to be a medical myth. Instead, we might think of osteoarthritis as a chronic wound that may need regenerative therapies to heal properly. Immune system building blocks like omega-3 fats in the diet and a wide palette of colorful produce can help with the healing. Movement itself is part of the healing process. What Are the Regenerative Therapies? PRP Some of the therapies we think of as “new” have actually been in use for several decades. One of these is platelet-rich plasma, which was initially developed to help wounds heal. In this treatment, the doctor uses the patient’s own blood. The plasma with as many platelets as possible concentrated in it is then carefully injected into the painful joint. The idea, again, is to cause “good inflammation,” alerting the immune system that healing is needed here and encouraging it to flip into inflammation resolution mode. Not all studies of platelet-rich plasma (PRP) have shown benefit, but some of that may be due to using plasma that is not truly rich in platelets. Properly prepared PRP works especially well for ligaments and tendons, according to Dr. Buchheit. MSC If you hear someone talk of getting a “stem cell” injection, they are talking about MSC. They were originally misnamed mesenchymal stem cells, but would be better termed medicinal signaling cells. They too are derived from the patient’s own body. Rather than rebuilding cartilage, they also signal the immune system to switch from long-term damaging inflammation to short-term healing inflammation. This is also the idea behind prolotherapy, in which the therapist injects sugar water into the joint. That may sound like a placebo, but it can be effective at easing pain and helping healing. Autologous Conditioned Serum Dr. Buchheit describes another of the regenerative therapies, autologous conditioned serum. Blood is drawn and encouraged to clot; then the serum is injected into the troublesome joint. Clotting helps create powerful signals that healing is needed. This therapy is not widely available, as only about ten places in the US have the dedicated laboratories required to prepare ACS properly. Hydrodissection Dr. Buchheit also describes how to use injections to free up trapped nerves in a process called “hydrodissection.” This is often very helpful in alleviating chronic neuropathy. We conclude the episode with a brief reminder of how to stay healthy once you get nerves and joints feeling good again. This Week’s Guest Thomas Buchheit, MD, served as Chief of Pain Medicine at Duke from 2013-2019 and led several NIH- and DoD-funded research studies. His focus is on immune mechanisms that resolve inflammation and pain. In 2025, Dr. Buchheit completed his book, Healing Joints and Nerves: Immune Stimulation and the New Science of Regenerative Therapies, and founded Triangle Regen Medicine and Biologics Center. His overarching goal is to help patients understand and use regenerative therapies to activate their own healing and repair mechanisms. He continues to serve as adjunct associate professor at Duke and collaborates with colleagues at the Center for Translational Pain Medicine. His website is https://triregenmed.com/ Dr. Tom Buchheit The People’s Pharmacy is supported by readers and listeners. When you buy through a link on this site, we may receive a small commission, at no additional cost to you. Listen to the Podcast The podcast of this program will be available Monday, April 13, 2026, after broadcast on April 11. The podcast has additional information about how to use MSC as well as the cost of regenerative therapies. We also discuss the pros and cons of pharmaceutical pain relievers. You can stream the show from this site and download the podcast for free. Download the show on mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1468: 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. Exercise is critical for good health, but when your joints or nerves hurt, it’s hard to keep moving. What can you do? This is the People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:49 Most people rely on non-steroidal anti-inflammatory drugs. Millions take over-the-counter ibuprofen or naproxen every day. Others rely on prescription medicines such as celecoxib or meloxicam. What are the downsides? Joe 00:50-00:54 Our guest today is an expert in regenerative medicine. Terry 00:55-01:00 What does that mean? And how does it differ from the usual way to manage pain and speed recovery? Joe 01:01-01:06 Coming up on The People’s Pharmacy, the new science of regenerative therapies. Terry 01:14-02:05 In The People’s Pharmacy Health Headlines: flu season is pretty much over, but every year it takes a toll, especially among frail elderly people in nursing homes. A new study published in JAMA Internal Medicine asked whether using Tamiflu preventively could reduce hospitalizations and death. Researchers reviewed records covering 404 flu outbreaks in 318 nursing homes. More than 35,000 residents were covered by the study. When Tamiflu was given to at least 70 percent of the residents within two days of the first flu cases, there were dramatically fewer hospitalizations needed within the next two weeks. That’s in comparison to situations where Tamiflu was not provided as a preventive medicine. Joe 02:05-03:06 If you ask most cardiologists what causes heart disease, the answer is likely to be LDL cholesterol. They might also mention triglycerides, lipoprotein A, and high blood pressure. They probably won’t consider lead, but a study of over 42,000 American adults who participated in the National Health and Nutrition Examination Survey tracked lead levels over many years. Those with the highest levels of lead in their bones were more likely to die from heart disease or stroke. People born in the 1930s and 1940s, before lead was removed from gasoline and paint, have the highest lifetime lead exposures. Further reduction in lead exposure should lead to lower rates of cardiovascular mortality. An editorial in the journal suggests that coronary heart disease is in part attributable to lead and other environmental exposures. Terry 03:07-04:00 What is the cause of memory loss as people age? A recent study of mice suggests it might begin in the gut. Specifically, the scientists tracked microbiome aging throughout the lifespan. They found that gut bacteria producing medium-chain fatty acids accumulate with aging and drive inflammation. This, in turn, weakens the signal from the vagus nerve to the brain, with the result that the hippocampus falters. The hippocampus is critical to memory. In this study, the scientists introduced phage viruses to target the parabacteroides, gut microbes, causing the trouble. They suggest such interventions might counteract age-associated cognitive decline, although, of course, mice are different from humans. We look forward to research that might demonstrate its feasibility in people. Joe 04:02-05:08 Fibromyalgia is a painful and chronic condition that affects soft tissue. It also causes fatigue, brain fog, and sleep problems. Millions of Americans are affected by this somewhat mysterious condition. A study published in JAMA Network Open reports that the combination of physical therapy and transcutaneous electrical nerve stimulation, also known as TENS, can reduce pain. Over 380 patients participated in the trial. Volunteers were randomized to receive PT plus TENS or physical therapy alone. After two months, those getting physical therapy plus electrical stimulation reported significantly less pain than those in the PT-only group. The authors note that the findings demonstrate effectiveness of this non-pharmacological intervention in reducing movement-evoked pain and suggest that the benefits of TENS are clinically meaningful in this population. Terry 05:09-06:17 With warmer weather, tick season is right around the corner. In fact, it’s already here in many parts of the country. Most people have heard of Rocky Mountain spotted fever and Lyme disease, but ticks can transmit over a dozen different diseases, from anaplasmosis and babesiosis to ehrlichiosis and alpha-gal syndrome. It’s estimated that more than 500,000 people could be treated for Lyme disease between now and the first freeze this fall. But there is potentially good news on the horizon. Pfizer is teaming up with a French company to produce a vaccine against Lyme disease. It triggers your body to make antibodies to a protein on the surface of the Borrelia bacterium. These antibodies keep the Lyme-causing bacteria from infecting you and causing disease. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:27 And I’m Joe Graedon. You’ve heard us praise the power of exercise for good health. But it can be hard to keep moving when your joints hurt. Terry 06:27-06:44 The usual approach is to take a non-steroidal anti-inflammatory drug, such as ibuprofen or naproxen. That is a short-term solution, and it comes with a handful of side effects. What else could we do to alleviate joint pain? Joe 06:44-07:11 To help us understand some new options, we are talking with Dr. Tom Buchheit. He’s done research on immune mechanisms that resolve inflammation and pain. He serves as an adjunct associate professor at Duke University and collaborates with colleagues at the Center for Translational Pain Medicine. His new book is “Healing Joints and Nerves: Immune Stimulation and the New Science of Regenerative Therapies.” Terry 07:13-07:16 Welcome to the People’s Pharmacy, Dr. Tom Buchheit. Dr. Tom Buchheit 07:17-07:27 Thank you, Terry, Joe. It’s wonderful to be here. I have to say, I’ve been listening to your show since 1998 when my wife and I moved to North Carolina, and it’s just a delight to be here. So thank you. Joe 07:27-08:36 Well, thank you so much for joining us. You know, Dr. Buchheit, I’d have to say that if people ask us, and they occasionally do, what’s the one most important thing we should do for good health? The answer is simple. We say exercise. Exercise is absolutely critical. Move your body. Even if it’s just for a walk every day, if you can. And if you can do more, so much the better. Terry is a black belt in karate. I love to play tennis. We love to move our bodies. There’s only one problem. What interferes with exercise? Pain. Injuries. You know, when you exercise a lot, you sometimes hurt yourself, and then you have to take a break. And for people who really enjoy exercising and want to do it, that can be both psychologically and physically very challenging. So help us understand your field and how to help people get back moving again once they hurt themselves. Dr. Tom Buchheit 08:37-10:02 Well, Joe, you brought up a really good point. Exercise plays a very important part of health for all of us. And I think we increasingly know the reasons why. One of the core topics that I talk about and like to focus on is the importance of healing and our body’s innate ability to heal. We turn those healing mechanisms on by stimulating certain immune cells, and one of the most powerful ways of doing so is exercise. Exercise does it. Good inflammation does it. Some other regenerative therapies do it. And these are all bound together by the same healing mechanisms. But you’re right, exercise is core to that. The challenge a lot of people run into is that they have an injury. They have arthritis, a problem in a joint. They’re unable to do that. And their question is, how do they get back to that activity? What I use, I use the phrase orthopedic limbo. That individual is in orthopedic limbo. They have an issue that prevents them from pursuing their tennis or their karate or just walking the dog or spending time with friends. And they’re trying to figure out how to get beyond that and move again, but they’re not necessarily a surgical candidate. So what can they do? And that’s one of the reasons I like to focus on these things that stimulate a healing response and stimulate recovery to function. Joe 10:02-10:11 And we’ll talk a little bit more about some of those strategies because they’re really intriguing. But first, why is exercise so important? Dr. Tom Buchheit 10:13-10:16 Exercise is important because it produces good inflammation. Terry 10:18-10:21 Whoa, whoa, whoa, wait. Inflammation is good? Dr. Tom Buchheit 10:23-11:23 That’s an important topic, right? I think a lot of people hear inflammation, they think immediately inflammation is always bad. We have to get rid of it. We have to suppress it. We have to drive it down. And there are, and I think you’ve talked about this in your show before as well, but there are good components of inflammation. We have to be careful we don’t throw the wheat out with the chaff with that. So chronic inflammation is always bad, right? It damages tissues. It drives arthritis. It drives chronic pain. But short-term, brief, and fairly strong inflammation is how we heal. If I had an ankle sprain and I bled into that ankle sprain, that injury, that inflammation is what heals that ligament eventually. You bleed, you release growth factors, you turn on these immune systems. Exercise does that same thing, but it’s good inflammation. So I think of good inflammation as short, reasonably strong, and able to flip an immune switch that begins a healing cascade. Terry 11:24-11:33 Dr. Buchheit, in “Healing Joints and Nerves,” you talk about the three pillars of exercise. What are the three pillars and why do we need three of them? Dr. Tom Buchheit 11:35-12:23 Well, great question. There are certain tremendous advantages of aerobic exercise. We know that people who have a high aerobic capacity and who can exercise at high levels, it doesn’t matter if it’s running, swimming, playing tennis, that’s linked to longevity. We also know that muscle mass, and increasingly people talk about muscle mass being very important and strength being very important to strengthen joints. And we see this with studies of even arthritis patients who have less joint pain if they can strengthen the support structures of that joint. And then, of course, balance is such a wonderful thing, whether it’s through balance exercises or yoga or tai chi, just such wonderful exercises that brings all this together of strength, stability, and the ability to stay on two feet without falling down. Joe 12:24-12:52 I want to know how exercise helps recovery, because that’s, you know, we often hear, “Oh, ice and rest and, you know, just don’t do anything for a week or two,” because a lot of tennis players, they want to get back on the court as fast as possible, and they’re told, “No, no, no, no, no, no, you got to rest those joints, that you pulled a muscle, you better let it rest.” And you’re suggesting that exercise actually helps with healing. Dr. Tom Buchheit 12:53-13:52 It absolutely does. And it helps with healing because it flips that immune switch and turns on this healing cascade. There was a study that I think showed this well. It was patients who had ankle injuries and they were immobilized in crutches after an ankle injury and they measured the cartilage in their knees as a marker after immobilization. And they found out that those who were in crutches for long enough actually had less cartilage in their knees. Their knees were never injured, but it was the lack of exercise that decreased the health of their joint cartilage. So our bodies need this. They need intermittent stress. And I think this… we have kind of fallen into this trap where we think all inflammation is bad. I would push back on that. I think we need to stress ourselves, whether it’s studying for an exam, whether it is playing a tennis match, whether it’s going for a brisk walk. Our bodies use stress and use these intermittent bouts of exercise to strengthen. Terry 13:54-13:57 I’m assuming we stress ourselves appropriately. Dr. Tom Buchheit 13:57-14:30 Exactly. And that’s the Goldilocks phenomenon, right? If you want enough stress. So to look at it kind of biochemically, if you look, there are a lot of inflammatory proteins that a muscle will release if it’s been exercised. Matter of fact, some of those will go up a hundred fold and they cause some of the aches that we’re familiar with after a strong workout. But those same inflammatory proteins will then flip and help our bodies to produce some of the anabolic proteins and things that rebuild tissues and strengthen tissues. Terry 14:31-14:35 How does exercise help nerves regrow? You’ve said it does. Dr. Tom Buchheit 14:35-16:00 That’s a great question. And that came as a bit of a surprise to me when I started doing research on this a bunch of years ago. We all thought of, and I think a lot of the medical profession thinks of, well, once you have neuropathy, it’s just a done deal. You’re never going to recover from it. Your nerves are gone. And neuropathy is nerve pain. Right, nerve pain and nerve dysfunction from the nerve pain. And it can be different kinds. There can be sciatica somebody experiences after a disc herniation in the spine. There can be dying back of the nerves somebody experiences because of diabetes or they’ve had chemotherapy in the past. Those nerves can recover. And exercise is actually one of the important tools to help those nerves recover. It does a few… through a few things. Some of the growth factors I talked about that exercise releases. It also does it through these very small immune particles called exosomes that we researched in lab that I’ve researched and looked at for a long time now. And they also help nerves recover. [If] we think about it, nerves are energy hogs. And anything we can do to improve their energy supply through mitochondria, mitochondrial function, is going to help the nerve to recover. And so exercise and some of these other therapies can improve nerve function. They may not help a nerve regrow from the back all the way down to the foot, but they can take the nerves that are already there and help them work better and help people function better. Joe 16:00-16:36 One of the things that most physicians, not all, but most physicians, especially the orthopedists like to prescribe are the non-steroidal anti-inflammatory drugs. So if you sprain your ankle, if you hurt your shoulder, if your back is giving you trouble, out come the NSAIDs. And of course, they’re also available over the counter, Aleve, naproxen, ibuprofen, Advil. And so people have come to just love non-steroidal anti-inflammatory drugs. You’ve suggested that they might be counterproductive in some ways. Dr. Tom Buchheit 16:37-17:20 Well, they can be. And anti-inflammatory medications, what we call NSAIDs, they can, in fact, impair the strengthening our body’s experience with a workout. And this has been looked at in patients, this has been looked at in laboratory studies of laboratory animal models, that if you slow down or stop the inflammatory response to exercise, you also impair the muscle building and the strengthening you get from that workout. So NSAIDs, sometimes we may need to take them for a severe headache or a pain that’s keeping us from moving. But if we take them chronically, they impair the very healing mechanisms that our bodies need to stay healthy and recover. Terry 17:20-17:26 Now, if you were to take an NSAID for a workout, when should you take it and why? Dr. Tom Buchheit 17:26-17:30 That’s a great question. So I think the clear answer is after the workout, not before. Joe 17:32-17:42 A lot of my tennis buddies call it vitamin “I” and they take it religiously before they go out on the courts. So you’re suggesting maybe not such a good plan. Dr. Tom Buchheit 17:42-18:06 I think if one can hold off until after the workout and wait as long as you can, it’s better off than before. I think it’s probably better for our joints and our bodies to have a shorter workout without an anti-inflammatory than a longer workout with. Now, that’s never been studied in a randomized controlled trial, but I think it’s a good idea to avoid taking it before whenever possible. Terry 18:07-18:15 You’re listening to Dr. Tom Buchheit, an expert in pain management and founder of the Triangle Regen Medicine and Biologic Center. Joe 18:15-18:28 After the break, we’ll learn about steroid shots in joints. What might work to ease osteoarthritis pain? You may have heard of PRP and stem cells. We’ll get the details. Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:18-20:21 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:21-20:39 And I’m Terry Graedon. Joe 20:39-20:48 Today on The People’s Pharmacy, our topic is healing joints and nerves. What are regenerative therapies and how do they work? Terry 20:48-21:14 Our guest is Dr. Tom Buchheit, founder of Triangle Regen Medicine and Biologic Center. Dr. Buchheit was chief of pain medicine at Duke University from 2013 to 2019 and is an adjunct associate professor there. His new book is “Healing Joints and Nerves: Immune Stimulation and the New Science of Regenerative Therapies.” Joe 21:15-21:50 Dr. Buchheit, corticosteroids, very popular on the tennis court. You know, “Oh, my shoulder hurts. I need a steroid shot. Oh, my back aches.” Another steroid shot. “Oh, my knee is giving me trouble.” Another steroid shot. Doctors love them because people feel better oftentimes immediately after or within a few days and it lasts sometimes a couple weeks for some people maybe as long as a couple of months, but there’s a downside. What is it? Dr. Tom Buchheit 21:50-23:48 Well, there is a downside, and it is true that a steroid injection can produce rapid pain relief, and can be helpful in some people to get them back to the gym, get them back to the workout. My concern with steroid injections or corticosteroid injections is the repeated use of them. There was a study done now almost 10 years ago, and it was a randomized control trial looking at individuals who had osteoarthritis of both knees, and one group had saline injections into the knees. The other group had corticosteroid injections. And at the end of two years, there was no difference in the pain, which didn’t really surprise a lot of people because we know steroid injections tend to be shorter lived. But the individuals that had repeat steroid injections actually had less cartilage in their knees than the ones that had saline. And I feel like that study was a bit of a wake-up call to all of us. And I did a lot of steroid injections at the time as well because patients seemed to do well with it. But it made me start rethinking how I was approaching this concept of how do you treat someone with joint pain, some arthritis, they don’t need surgery, again, the patient [in] orthopedic limbo. We’ve relied on corticosteroid injections as a bit of a crutch, and I think we need to flip this paradigm and think about how do you improve cartilage health, how do you improve tissue health? This year is the 75th anniversary of the first corticosteroid injections that were done for arthritis pain. And it was a remarkable event. But interestingly, I’ve gone back and I’ve read a lot of the historic literature on corticosteroids and their use in arthritis. And the physician who published the paper noted that 37 of 38 of his patients did extremely well after the steroid injections. But what he didn’t emphasize is some of the patients required up to 17 injections per year to maintain that. Terry 23:48-23:49 Oh, my. Dr. Tom Buchheit 23:49-24:00 And I think that’s the part that we’ve been missing within the medical world, is that a steroid injection can be an important tool, but I would argue it’s an overused tool in a lot of settings. Terry 24:01-24:15 Well, 17 injections a year definitely sounds like it’s being overused. And one of the things that steroids do is they suppress the immune system. What’s the impact of long-term immune system suppression? Dr. Tom Buchheit 24:17-25:22 Well, gosh, there’s a lot of things that [it] would do. Obviously, we could go into, you know, bone health and bone density. We could go to the endocrine system and looking at, you know, someone who is borderline diabetic who becomes frankly diabetic after repeated steroid injections. We can look at tissue healing as well. But if I kind of focus on the cycle, I think we need to think of our bodies as cycles, right? We cycle day and night. We sleep. We wake up. And exercise and this immune stimulation that keeps our joints healthy is also a cycle. It’s a cycle of exercise and recovery. And anyone who’s trained knows this inherently. You have hard workout days. You have recovery days. And I think if we use tools like steroids or anti-inflammatories continuously, we remove those necessary cycles of stress and recovery, stress and strengthening. And steroids, I think, act in some ways have similar effects as the anti-inflammatories do. And I can quote, we can talk about a study as well that dives into that. Joe 25:23-25:52 Well, I’d like to talk about one of the reasons that a lot of people get steroid injections and one of the reasons why they take a lot of the anti-inflammatory drugs, and that’s osteoarthritis. And it can affect your fingers. It can affect your shoulders. It can affect your knees. It can affect your hips. It can affect just about every joint in your body. And I remember someone saying a long time ago, well, exercise is going to make it worse. Dr. Tom Buchheit 25:53-27:48 Right, that’s the old wear and tear hypothesis and that was the hypothesis about osteoarthritis for years which is that well you just you’re just wearing your joints too much and they’re just wearing down. That ignores the fact though that exercise restores cartilage health, and you know some people talk about well someone loses weight and they have less joint pain and it must be less weight on their joints and less wear and tear. But the hand arthritis also gets better if you lose weight. And so I think it’s an issue of a systemic chronic inflammatory problem that’s improving with weight loss. We’ve then moved from the wear and tear hypothesis to the inflammatory hypothesis of arthritis. And it made sense. We can see inflammation on ultrasound if we do an ultrasound exam of a joint. You can pull out fluid, and it looks inflammatory if you look at it under biochemical analysis. The patients feel the inflammation, but if you treat the inflammation, it doesn’t improve the disease state. And that’s been shown so many times. There have been at least four studies of strong inflammation suppressors in the rheumatoid arthritis drugs that have been looked at for osteoarthritis. They did not work. There have been studies of corticosteroid injections. Again, they tend to worsen the problem, not make it better. The concept that I think we need to focus on is osteoarthritis is a chronic wound. And we need to think about how to heal the wound. If you heal the wound, the chronic inflammation also improves as well. And that explains, I think, the chronic wound concept explains why studies have failed in the past and why some of the therapies we do now, such as some of the regenerative therapies, can actually have a role. Terry 27:49-28:09 Well, maybe you could tell us a little bit about what could work for osteoarthritis, because so far, we’ve talked about things that are less than ideal. The steroid injections, the NSAIDs, those are the most common. And there have to be things, maybe even a lot of things, that can be useful. Joe 28:09-28:22 Well, first, what the heck is regenerative therapy? And second, why would exercise, because you’ve sort of alluded to that, be helpful for osteoarthritis? So give us the one-two punch. Dr. Tom Buchheit 28:23-28:36 I always think of it as we start with a healthy diet, healthy fruits, vegetables, healthy fats, and exercise to that. And that is the core, I think, of keeping joints and nerves healthy. Terry 28:36-28:37 And the rest of us. Dr. Tom Buchheit 28:37-30:03 And the rest of the body as well, right? What’s good for your heart tends to be good for your joints as well, right? It’s enough for a lot of people, but it’s not enough for everybody. And it’s not enough for people who have had injuries in the past. It’s not enough people who have a systemic inflammatory issue going on. And that’s when I think about layering on what some people call regenerative therapy. Some people may call it an ortho-biologic. These are ways of stimulating those immune cells I talked about and pushing them into a state where they are resolving and building tissues again, where they’ve been suppressed in the past and they’re kind of low level. They’re chronically inflamed. They’re not behaving well. You need to push them into a new state, this resolving state. And I think of it not as suppressing inflammation but resolving it. And it might sound like a little bit like splitting hairs a bit. But if I think of suppressing inflammation or fighting inflammation, I think of you’re putting a drug on it to tone it down temporarily. When I think of resolving inflammation, I think of our body’s natural processes that resolve it. There are some wonderful fats that do this. They’re called SPMs. They’re derivatives of omega-3 fatty acids. Our bodies use those and other compounds to naturally resolve inflammation. Matter of fact, in the lab, some of those compounds are more powerful than morphine in animal models of nerve pain to resolve inflammatory pain in models. Joe 30:04-30:07 Wow, that’s amazing. Tell us, how do you do that? Dr. Tom Buchheit 30:08-30:10 Well, our bodies make these compounds. Terry 30:10-30:22 And you say they make them from omega-3 fats like fish oil or walnut oil or the fats that we get in very small quantities from dark green leafy vegetables. Dr. Tom Buchheit 30:23-30:53 Precisely. If we eat a diet rich in healthy fats, as you pointed out, from walnuts, nuts, cold water fishes like salmon and anchovies and tuna, as long as it’s not too high in mercury, our bodies take those fats and they make other compounds from them. And those other compounds will resolve inflammation. They work with the leafy green vegetables and all the colorful vegetables that you all have talked about that are so important to overall health. Terry 30:53-30:55 We love talking about colorful vegetables. Dr. Tom Buchheit 30:56-31:13 But that all works together. And that, to me, is the foundation of really regenerative medicine is what our bodies are already doing and how can we promote those activities themselves. A lot of people focus on a procedure and injection, and they can be helpful, but we have to start with our own bodies. Joe 31:13-31:43 So it sounds like diet is critical and the healthy fats, the omega-3s are especially beneficial. So your body can do this resolving stuff. And exercise is also important, presumably if it’s, you know, mild exercise, if you’ve injured yourself so that you don’t re-injure yourself. But what are some of these other agents, this regenerative process that you’re talking about that you practice when you see patients who have had injuries? Dr. Tom Buchheit 31:43-33:05 Yeah, great question. I would put them in three different categories, things like platelet-rich plasma, which we’ll talk about, stem cells, or something called autologous conditioned serum. Some people know it as the Regenokine program. PRP or platelet-rich plasma is probably the one I’d start with because it directly activates our own healing cascade. Interestingly, back to my analogy of the wound in a joint, PRP was first used to treat wounds. It was first used by a wound surgeon published in 1986. It’s been around for a while. Then it was used in the oral surgery field to heal non-healing wounds. And then it kind of leapt into the world of arthritis and nerve issues and things like that. But what it is, is if you take blood and you spin it down and you collect the platelets and the white blood cells there, they can act with the growth factors and act in a way to flip that immune switch I was talking about to start to rebuild tissues. So it’s a way to almost use that, almost like exercise. It’s almost like exercise in a tube in a way. You take that blood product and you inject it onto a knee or a shoulder or hip, and it further turns on those healing mechanisms that our body can have, but aren’t always strong enough by themselves. Joe 33:05-33:17 Now, let’s make it very clear. We’re not talking about someone else’s blood. We’re talking about our own blood is being removed. And I assume it’s not gallons. It’s just a little bit. How much? Dr. Tom Buchheit 33:18-33:30 Well, actually, that’s a very good point. You need a fair amount. You need a fair amount because you have to make sure the PRP dose is right. So how much is 60 to 120 milliliters? Joe 33:31-33:33 So for people who are not metric. Terry 33:34-33:40 So a cup is roughly 250 milliliters. So we’re talking less than a cup. Joe 33:40-33:44 Less than a cup. Right. So it’s not gallons. It’s a little bit of blood. Terry 33:44-33:46 Maybe a half a cup, more or less. Half a cup, a cup. Joe 33:47-33:57 And you’re removing that blood, and then you’re spinning it down, and you’re extracting the platelet-rich plasma. Dr. Tom Buchheit 33:57-33:59 Exactly. Now… Joe 33:59-34:00 And re-injecting it. Dr. Tom Buchheit 34:00-34:20 And re-injecting it. PRP has become quite controversial. One of the reasons is because there have been a couple of very large trials that have shown it hasn’t worked. But if you go back and analyze the studies, which I’ve done with some colleagues, it turns out that if the plasma isn’t rich in platelets, it doesn’t work. And it sounds a bit, you know, axiomatic. Terry 34:21-34:26 Right. So you have to have the right stuff in order for it to work the way it’s intended. Dr. Tom Buchheit 34:26-34:26 Exactly. Joe 34:27-34:31 So is it a little less controversial now? Are there studies demonstrating benefit? Dr. Tom Buchheit 34:32-34:44 There are with high doses, and I think that’s the key. If the dose isn’t right, it just doesn’t work. And that’s why it’s important. And one of the things that I do is I measure the doses of every PRP to make sure that dose is correct. Joe 34:45-35:03 So our listeners and a lot of your colleagues learn from stories. Can you share a story with us about somebody who came to your practice in pain and maybe not able to exercise, and that person benefited from PRP? Dr. Tom Buchheit 35:05-35:24 I think it’s a common scenario. I would use the scenario of someone who’s had a prior ACL tear or a lot of knee ligament tear. Especially young women athletes seem to have this quite commonly. The problem with these tears is that it sets them up for early arthritis. Joe 35:25-35:28 And we know the surgery itself has some issues. Dr. Tom Buchheit 35:29-36:15 Right. Well, joint replacement surgery can be very successful, but you also don’t want to do that when you’re 45 years old and still active because you may wear out your joint. You might wear out the replacement. And that to me is a good candidate for what I would call regenerative therapy or biologic therapy, where you can turn this inflammatory process, this chronic wound of a knee that’s had a prior injury and can’t quite get into the healing mode, and you can add PRP or another therapy to it to really turn the corner of that knee and allow it to start healing. What other joints benefit? Really any joint can benefit. Most of the studies have been done in knee osteoarthritis because it’s so common. Terry 36:15-36:18 So common and so troublesome if you have it. Dr. Tom Buchheit 36:18-36:39 Precisely. Precisely. But shoulder, hip, other joints, and actually some of… there’s some very good literature for PRP for ligaments and tendons. So for the outside of the hip, the trochanter or tennis elbow is a very common, very common scenario. Again, that’s a scenario where a tendon is there and it’s just not healing up and you want to add growth factors to it to get it to heal. Joe 36:39-36:45 Are the orthopedic surgeons embracing PRP these days or are they still a little resistant? Dr. Tom Buchheit 36:45-37:06 Well, I think the orthopedic community is embracing this to a fairly significant extent. And it does compete. There’s a question of does it compete with surgery for some people, but I think it has a clear role. And as we understand what makes a regenerative therapy more effective, they’re going to, I think, gain more and more acceptance. Terry 37:06-37:09 What about side effects of PRP? Dr. Tom Buchheit 37:09-37:25 The main side effect for PRP is a flare-up of pain. If you think about it, you’re turning on an immune system, you’re turning on these white blood cells. So I tell people it’s an expected side effect. They’re going to have oftentimes discomfort, sometimes even swelling for a few days afterwards. Terry 37:25-37:30 So you’re creating short-term inflammation to overcome the long-term inflammation. Dr. Tom Buchheit 37:30-37:31 Just like exercise. Terry 37:32-38:05 You’re listening to Dr. Tom Buchheit, author of “Healing Joints and Nerves: Immune Stimulation, and the New Science of Regenerative Therapies.” Dr. Buchheit founded the Triangle Regen Medicine and Biologic Center. His research has focused on immune mechanisms that help resolve inflammation and pain. From 2013 to 2019, he was chief of pain medicine at Duke University, and now he is an adjunct associate professor there. Joe 38:05-38:14 After the break, we’ll consider the case of a long-distance runner who has developed hip arthritis that interferes with his running. Terry 38:14-38:20 Do stem cells help cartilage grow back? If not, what are they doing to ease pain? Joe 38:21-38:36 What is prolotherapy and how does it work? Injecting dextrose, that’s sugar water, sounds almost like a placebo treatment. Is it effective and how long has it been available? Terry 38:36-38:45 It does sound like a placebo. You’ll also find out about autologous conditioned serum. What is that? How does Dr. Buchheit use it? Joe 38:46-38:53 Some of the same therapies that work for joints can also help nerves. How do they work for that? Terry 39:06-39:21 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 39:21-39:38 And I’m Joe Graedon. Terry 39:39-39:57 Today, we’re discussing some new therapies for arthritic joint pain. We’ll also find out what can be done for trapped nerves. Have you ever heard of prolotherapy? It involves the injection of sugar water into an injured joint. How could that possibly be beneficial? Joe 39:57-40:33 To learn more about prolotherapy and PRP, as well as other new options, we’re talking with Dr. Tom Buchheit. He’s done research on immune mechanisms that resolve inflammation and pain. He founded the Triangle Regen Medicine and Biologic Center. Dr. Buchheit serves as an adjunct associate professor at Duke University and collaborates with colleagues at the Center for Translational Pain Medicine. His new book is “Healing Joints and Nerves: Immune Stimulation and the New Science of Regenerative Therapies.” Terry 40:34-41:33 Dr. Buchheit, I’d like to ask you about a scenario. I know a person happens to be related to me, not Joe, not Dave, but this individual actually dislocated his hip on a construction site when he was in his early 20s. He is now 75. He has been a long-term, long-distance runner, and he has recently had a problem with hip pain on the hip that he dislocated back when he was a young guy. So he went to the doctor, and the doctor said, yeah, you’ve got a lot of arthritis there. What would you advise this fellow for relieving his pain? He said, well, I don’t think I’m going to be running anymore. He does walk. But what advice do we have? Joe 41:33-41:37 And he loves to run. I mean, this is a long-distance runner for decades. Dr. Tom Buchheit 41:37-42:08 It’s a common scenario. And to me, there are a couple of questions. What is their level of function they’re at now? What do they want to be? How much cartilage do they have? It’s easier to use some of these regenerative therapies for people who have some cartilage left. And I always think of this as a way to improve tissue health, improve the health of tissues and cartilage that’s already there. It’s not going to regrow cartilage. Even stem cells don’t regrow cartilage. And that’s something we can talk more about, but that’s a misconception out there. Terry 42:08-42:11 So people think that stem cells will regrow cartilage. Dr. Tom Buchheit 42:11-42:27 People think that they do, but they don’t. And there’s, I think, a couple of reasons why. The stem cell story is a really interesting story of great science that’s been misinterpreted over the years, and we can talk a bit about the details of that but… Joe 42:27-42:56 But I’d like to get back to the PRP alternatives. So you’ve made a strong case for plasma rich… for platelet-rich plasma, PRP. What other regenerative strategies do you have and how else can they help either osteoarthritis or an injury or some other situation that is interfering with exercise? Dr. Tom Buchheit 42:57-43:16 It all kind of depends on the severity, what’s going on, what the joint looks like. And when I say it looks like, what does it look like under MRI, under x-ray, under ultrasound? And what does it feel like to the patient? It can be from a, if it’s a tendon or ligament issue, you can use things like prolotherapy to stimulate a healing response. Terry 43:16-43:19 That’s great. We want to know what prolotherapy is. Joe 43:19-43:20 What is it? Dr. Tom Buchheit 43:22-43:27 Prolotherapy was commonly used. Now we use it… Dextrose, actually. Joe 43:27-43:30 That’s sugar. Sugar water. Sounds like a placebo. Dr. Tom Buchheit 43:32-43:41 Amazingly, it does sound like a placebo. But if you put sugar water in high enough concentration, it will set up an inflammatory reaction in that same immune response we’ve been talking about. Joe 43:42-43:44 And prolotherapy’s been around for decades. Dr. Tom Buchheit 43:44-43:49 It’s been around for, yes, it’s been around for 70, 80 years. Absolutely. Joe 43:50-43:56 And a lot of times, I think some of your colleagues have said, “Yeah, that’s nonsense.” But you believe it works. Dr. Tom Buchheit 43:57-44:08 I do. And I use it most often for tendons and ligaments that need, again, they need to flip that switch and they need to go into healing mode because it will set up that immune response. Joe 44:08-44:13 So you’re injecting sugar water, dextrose, into the area that is painful. Dr. Tom Buchheit 44:14-44:51 Exactly. Now, it’s partly what you’re injecting. It’s partly how you’re injecting because you do a technique that actually purposefully does minor injury to the tendon or ligament. People call it a fenestration. It has different words to it, but you do a little bit of a peppering technique of the tendon and you add this high concentration of sugar water. The body responds to that inflammatory cascade and says, we have a problem here to fix. And the body sends in its messengers, just like it’s been an ankle sprain or another injury, sends in white blood cells, and then they start to get to work. So it’s really a calling card for immune systems. Terry 44:51-45:06 So here again, you’re creating a short-term inflammation to overcome this chronic inflammation that is causing the pain. You’ve said a couple times that the body needs to flip the switch. Can you tell us a little bit more about that, please? Dr. Tom Buchheit 45:07-46:10 Yes. And your description is perfect. That’s exactly it. If we go back to the healing cascade and back to, say, the ankle sprain, there’s bleeding, there’s platelet release. The platelets not only release growth factors, but they pull in white blood cells. One of those white blood cells is called a monocyte or macrophage. There’s been a lot of research into the macrophage that can change personalities. I liken it to the kind of the Incredible Hulk, Bruce Banner becoming Incredible Hulk. He’s uh mild-mannered in the bloodstream. He finds an injured tissue, becomes the Incredible Hulk and very angry. But once he can resolve that anger, the anger of that macrophage, he can become kind of a subdued Hulk and start rebuilding these tissues. And so to me, it’s the work of the macrophage, which is this white blood cell that is key for healing. And when I refer to the switch, I’m referring to the macrophage switch. Joe 46:11-46:24 So we’ve talked a little bit about PRP. You’ve mentioned prolotherapy, which is injection of dextrose into the area of pain and discomfort. What other regenerative therapies are there? Dr. Tom Buchheit 46:25-46:31 There’s stem cells, and then there’s autologous conditioned serum, which is one that I’ve researched in lab and clinically as well. Joe 46:31-46:32 What is that? Dr. Tom Buchheit 46:33-46:51 That is a therapy that was developed in the 80s and 90s by a German orthopedic surgeon, Dr. Peter Wehling. And they were looking at ways to, again, resolve inflammation. And they found that if you take blood and let it clot over an extended period of time, again, the blood clot being important here. Terry 46:51-46:52 Platelets. Dr. Tom Buchheit 46:52-47:55 Exactly. Platelets and the things that the immune cells… Actually immune stimulation, if you stimulate that system in a test tube and then you pull off that serum, it has all kinds of inflammation-resolving proteins in it and growth factors. And it’s been studied. It’s been used to… There are a lot of athletes that fly to Germany for this therapy. I use this therapy as well in my clinic now in Chapel Hill. But there was part of it that didn’t make sense because it was lasting longer than you’d expect just a growth factor or an anti-inflammatory protein to work. So that’s when we started looking at the mechanisms. We found out that actually a lot of the effect of it is driven by these tiny immune particles called exosomes that can reprogram how cells behave. So in a way, it’s kind of reprogramming tissues and how tissues behave. And that, to me, I think was the kind of the secret of the sauce, which is it’s allowing cartilage, allowing a tendon or ligament to become more youthful, for lack of a better term, because it’s being reprogrammed. Joe 47:55-48:32 So how would somebody who’s either injured themselves, as Terry’s relative… [we] won’t mention any names… with his dislocated joint, and the osteoarthritis that has resulted, or an athlete who is elite, you know, one of the great basketball players at Duke University who comes to you and says, “Oh, I got to get back in the game next week.” How do you do this autologous thing that you’re talking about? How do you make this stuff and how safe is it? Dr. Tom Buchheit 48:32-49:06 Well, right now we make it in the lab. We built a lab for this and it’s actually quite safe. It’s been used for 20 years, a couple hundred thousand patients across the globe. It’s been used more in Europe than it has in the United States, but it has a very long track record, partly because the quality control of it is just so tight. There are only a couple of places, there are only about 10 places in the United States where you can get it. And the lab, our lab technique, and everybody’s trained very highly. So I think the key to it is the standardization of processing and the quality control of the processing. Joe 49:06-49:07 And what exactly is it? Dr. Tom Buchheit 49:08-49:10 It’s a serum product, so serum from blood. Joe 49:10-49:15 So again, we extract some blood from the individual and you do the magic sauce thing. Dr. Tom Buchheit 49:16-49:27 Yes, exactly. And then occasionally things are added to that magic sauce, depending on the individual in front of you. And it’s injected in several different times, usually over the course of a week or so. Terry 49:27-49:49 We have spent most of our time together talking about joints, bones, cartilage, and tendons and ligaments. And I would like to ask about nerves because healing joints and nerves, you’re talking about nerves, and nerve pain can be really awful. Why does it last so long? Joe 49:50-49:51 And what can you do about it? Dr. Tom Buchheit 49:51-50:16 Right, importantly. Why is it there and what do you do about it? A nerve will cause pain if it’s firing on its own. It has different names, autonomous firing. But if a nerve is compressed, strangled, or otherwise restrained, it tends to fire on its own spontaneously. And that spontaneous firing we feel is pain. Terry 50:16-50:21 So sometimes we call that entrapment or impingement. They’ve got fancy terms for it, but it’s trapped. Dr. Tom Buchheit 50:22-50:56 Exactly. If you trap a nerve, if you trap a nerve with a disc herniation in your spine, you’re going to have rip-roaring sciatica down your leg, and that’s an entrapped nerve. If you have carpal tunnel and you have a trapped nerve in your wrist, that’s going to cause nerve pain in your hand. If you have a nerve that’s entrapped around an old surgical scar, that’s going to become entrapped. And so the key is there are ways to decrease the firing of the nerve with drugs. But to me, that’s an important part to free the nerve up so it’s no longer entrapped. And so that’s a lot of things that a lot of things that I do are freeing nerves up. Joe 50:56-50:56 How do you do that? Dr. Tom Buchheit 50:57-51:50 There’s a technique that’s called hydro-dissection that we do. And basically, it’s kind of gently injecting fluid of one of several different types around a nerve to open the space around that nerve so it can glide more freely through that space. And it’s a technique that makes sense. You know, years ago you know I was… I’m old enough to have been done doing nerve blocks before ultrasound was ever used, and occasionally we’d see patients who got better longer term after a nerve block, and I kind of scratched my head trying to figure out why is this person better long term because all we did was shut the nerve off for a few hours. In retrospect we were probably doing hydro-dissections without knowing it. Now we can see it. So under ultrasound, you place a needle very carefully around the nerve and you use a fluid to open the space up. So you don’t have to do it surgically now. You can just do it through a needle and through ultrasound. Terry 51:50-51:54 So that’s what the ultrasound is for, to be able to visualize what you’re doing. Dr. Tom Buchheit 51:55-51:55 Precisely. Terry 51:55-51:56 How to do it right. Dr. Tom Buchheit 51:57-52:04 Precisely. And to make sure you get good separation of the tissues with it. Because you can see it almost looks like a halo around the nerve when you’re done. Terry 52:04-52:05 How well does it work? Dr. Tom Buchheit 52:06-52:32 It depends on the nerve and depends on the entrapment. If there’s a true entrapment around a scar, it can work wonderfully. And once or twice, it can completely relieve pain. Other areas, if the nerve is sick for other reasons, for, you know, because of diabetes or other issues, it may work partially. But my philosophy is if there’s ever an entrapped nerve, you want to release the entrapment first before you start adding drugs to it. Terry 52:33-52:36 And one other thing, what about side effects? Dr. Tom Buchheit 52:37-52:57 Side effects of hydrodissection are very low as long as the person doing it has a good view and experience doing it. Because if you put a needle into a nerve, you can injure the nerve. So you have to be very delicate and very confident in being able to place the nerve gently around it but not in it. And that’s the key. Joe 52:57-53:02 Are there any nutritional supplements that can be helpful for people with neuropathy? Dr. Tom Buchheit 53:04-53:14 I’m not an expert in supplements, but there are a few that I look at. I look at things that make nerves healthy and make mitochondria work better. Joe 53:14-53:15 Such as? Dr. Tom Buchheit 53:15-53:20 Well, one of my favorites, partly because so many people are taking statins, is making sure they’re on CoQ10. Joe 53:21-53:21 Right. Dr. Tom Buchheit 53:22-53:40 So I look at that. I am a big believer in omega-3 supplements unless someone is eating sardines daily, which most people don’t do. And I’m also a believer in things like turmeric and some of the other supplements, especially if they allow us to take fewer anti-inflammatory drugs. Terry 53:42-53:52 Dr. Buchheit, I wonder if you could tell us a little something about stem cells. What are they and how should they be used? Are they useful at all? Dr. Tom Buchheit 53:53-55:14 It’s a great question. And stem cells have captured the imagination of many Americans and people across the globe. That story started with a scientist named Dr. Arnold Kaplan. And he found these cells that were growing in our bone marrow that he could grow and turn into cartilage. And this was in the 1990s. Everyone thought he had a cure for osteoarthritis at that moment. The challenge is that when you take those cells and inject them into a joint, they live for a while, but then they die off. And it’s really very clear now that what we call stem cells have a benefit for our immune response. So, for instance, we talked about that macrophage that flips a switch. They will flip that macrophage switch, but stem cells are actually working through our own immune systems. So the cells that someone gets injected into a knee, a hip, or a shoulder, they’re not living long-term. They’re not growing new cartilage. They’re turning on our own repair systems. And that’s the myth that’s been out there for a very long time is someone thinks that they’re going to have a stem cell injection. They’re going to grow new tissues. They may have much healthier tissues, but those cells that are injecting aren’t living long-term. Terry 55:15-55:19 But what I’m hearing you say is there still could be benefit. Dr. Tom Buchheit 55:19-55:50 Absolutely. Absolutely. The cells can be very beneficial in a lot of ways. There’s many ways to harvest them. You can harvest them from bone marrow. You can harvest them from adipose tissue. Now, stem cells have also become controversial because they can come from our cells, like PRP or the autologous conditioned serum, or they can come from a donor. And those donor products, you might imagine, need to go through a higher level of regulatory scrutiny to make sure that there’s no infection that occurs in that process. Terry 55:50-55:52 I would want them to be regulated. Dr. Tom Buchheit 55:53-56:12 Absolutely. And so there really are yet to be any approved stem cell therapies from donors in the United States. If you hear of people going overseas to overseas clinics, various countries around the United States, they can do those incubated products over there, but you really can’t do it in the United States right now. Joe 56:13-56:43 I’d like to ask you about cost. I guess, but I could be completely mistaken, that insurance companies are going to do their best to deny things like prolotherapy or PRP injections, or maybe even the autologous conditioned serum. If they could say, no, no, no, no, no, we don’t really pay for that, how much would it cost if somebody had to pay out of pocket? Dr. Tom Buchheit 56:44-57:07 Well, it’s a whole spectrum, right? There are certain things, prolotherapy is very inexpensive and stem cells and autologous conditioned serum are much more expensive. And it is true, insurance doesn’t cover any of these right now. Now I think eventually they will. My way… I look at it is insurance covers therapies that suppress the immune system. They don’t cover therapies that augment the immune response. Joe 57:08-57:09 That sounds crazy. Dr. Tom Buchheit 57:10-57:56 But it’s true if you think about it, right? If you want a steroid injection, it’ll be covered. If you want an anti-inflammatory medication, it’ll be covered. But if you want prolotherapy or PRP or any of the other therapies we’re talking about, it’s not. We also need to redo some of the studies. I mentioned before some of the PRP studies that were negative because what they were using really wasn’t strong enough. And the insurance company can very easily go to that… point to that study and say, “Look, here’s a large randomized control trial that says it doesn’t work. It’s experimental. We will not cover it.” So it’s I think it’s incumbent on the field to redo these studies and redo them in a strong way, in a multicenter way with good products and then have the evidence. And I think that will happen, but I think it’s going to be a few years. Terry 57:57-58:28 Dr. Buchheit, we’ve talked today about arthritis and what you do about it. We haven’t really talked as much about what causes it. We have talked about chronic inflammation. And so I want to ask you about one potential cause, which would be infection. For example, a Staph aureus infection, a Borrelia burgdorferi infection. Do you have anything to say about that? Dr. Tom Buchheit 58:28-59:24 It’s not an area that I know deeply. I know it is one of the things looked at, and it makes sense. Any driver of chronic inflammatory change is going to chew up cartilage. And if you think about it, so if you have a chronic inflammatory state, regardless of what’s driving that inflammatory state, your body’s going to produce enzymes that digest cartilage tissue. And that’s what osteoarthritis is. It’s the enzymes. The inflammation releases the enzymes. The enzymes digest the tissue. And so we need to find a way to prevent that from happening. But any chronic inflammatory state would do that. A chronic infection would do that. A chronic inflammatory state would do that. An injury that hasn’t quite recovered would do that. So I’m not an expert in the infectious cause, but if a chronic infection causes chronic inflammation, absolutely it could drive osteoarthritis. Joe 59:25-01:00:39 Dr. Buchheit, I’d like to ask about pain because pain gets your attention very fast. And people want relief and they can’t sleep. Their back hurts or their shoulder’s giving them trouble. They can’t lie on their shoulder. It used to be that doctors prescribed opioids in massive quantities, Percocet, hydrocodone, oxycodone. And of course, now because of the opioid epidemic and all of the people who have died, there’s a tremendous reluctance for both physicians as well as patients to rely on opioids, especially long-term. What’s replaced opioids, however, is gabapentin. It’s [an] anti-seizure drug. At least that’s how it was originally developed. And another medication that has both sort of antidepressant-like activity as well as some subtle opioid-like effect called tramadol. These are the big pain relievers these days. Your thoughts about gabapentin and or tramadol and what we should be doing instead? Dr. Tom Buchheit 01:00:40-01:01:36 That’s a great question. So I’ve been using and I’ve been using and seeing people on gabapentin since the late 90s when it came out, right? And it came out, as you pointed out, as a seizure drug. It does, and it can reduce nerve pain. We talked about nerve pain being from, if you have a nerve that’s entrapped, it starts firing on its own spontaneously and gabapentin can quiet that down. The challenge with gabapentin, and the concern about gabapentin, though, is that it will affect the brain. It was designed to affect our brains as a seizure drug. And so I think it’s a bit of magical thinking to think that we’re not going to have cognitive side effects to gabapentin over time. And that’s my concern. Some people can do very well with it. Some people need it because they cannot function because of a neuropathy or another issue. But a lot of people are on it, and I do have concerns about the cognitive side effects. Terry 01:01:36-01:01:41 And the person who says gabapentin gives me such brain fog, I can’t function, they shouldn’t be taking it. Dr. Tom Buchheit 01:01:42-01:01:45 If they can avoid taking it, it sounds like a good idea to avoid taking it. Joe 01:01:46-01:02:28 We like to say that pain is personal. Everybody’s different. And my mom, for example, if she had a bellyache, it would be like a 10 out of 10. I mean, she was just incapacitated. Terry’s mother, on the other hand, you know, cut to the bone and she’d say, “Oh, maybe my pain’s at two.” You know, she was a tough old bird. And so the idea that we can generalize about your pain is very challenging. Some people get great benefit from gabapentin. Other people say it didn’t work hardly at all. How do we find the right strategy for pain relief? Dr. Tom Buchheit 01:02:28-01:03:56 Oh, it’s hard. It really is hard. And this has been decades and decades of pain research trying to identify therapies based on symptoms. I tend to look also at function. The reason is that if I have someone who is having 6 over 10 knee pain and can walk a quarter of a mile, if we do a therapy on them and they can walk now 3 miles, but their pain is still 6 over 10, that’s still an improvement, right? Their function is better. And my hope is that as the function improves, the pain will eventually follow. But it is hard because, right, pain is in us and it is subjective and no one can experience it outside of the individual. And that makes it hard to gauge, right? But the other part of this is that we’ve tried to objectify osteoarthritis, for instance, by looking at an x-ray and saying this is grade 1, 2, 3, 4, depending on how big the space is between bones. And it turns out that there’s very little relationship between someone’s function, someone’s pain, and how much space is between the bones. So our attempts at defining treatments based on x-ray is equally as poor. So I think pain is an important part of this. And it’s a very important part of helping someone to function better. And you’re right, there’s no other way of doing it other than just asking them and talking to the patient. Joe 01:03:56-01:04:21 Well, we only have about two minutes left, and so this gives us the opportunity to summarize all the things that we should be doing and some that we should not be doing to allow us to keep moving which is critical to your game plan and to reduce our likelihood of ending up in pain for a long period of time? Dr. Tom Buchheit 01:04:22-01:04:50 Well, I think first off is figure out where you’re starting. Everybody starts at a different place, but I like to say, you know, measure where you are and maybe you can walk a quarter mile. Maybe you can only walk a few steps. Maybe you can go and do aqua therapy, find out where your, where your level is of exercise and then work on building that, but build it slowly. You know, if you have someone who can’t walk more than a quarter mile and they go walk two miles, they’re going to be in bed for three days and then they’ve lost ground, right? Joe 01:04:51-01:04:58 And walking is good. You don’t have to be a marathoner to benefit from just plain walking. Dr. Tom Buchheit 01:04:58-01:05:03 Exactly. And the studies for osteoarthritis are very convincing. Walking is good for joints. Joe 01:05:04-01:05:05 What about diet? Dr. Tom Buchheit 01:05:07-01:05:27 Live like the folks that are in the Mediterranean basin. So I always think of fish, fruits, vegetables, nuts, olive oils as the foundation for food. And that diet that’s good for our hearts is also very good for joints and nerves. And it’s been shown and studied to actually decrease arthritis pain as well. Joe 01:05:27-01:05:42 And when we sprain an ankle or injure a shoulder or our back is hurting, what can we do to avoid taking all those NSAIDs or getting those steroid shots to ease the pain and get us back moving again? Dr. Tom Buchheit 01:05:42-01:06:17 Well, that’s a great question. And I would argue that we should not soak ourselves in steroid injections and anti-inflammatories. And I had this personal experience of having had a couple of knee injuries. And one, the first one a bunch of years ago, I soaked in anti-inflammatories. And then the second one, I didn’t. And I can tell from personal experience, it hurts more, but my healing was faster. And I would encourage when people can do it and go without the steroids and the anti-inflammatories to minimize or avoid them if they can. Terry 01:06:17-01:06:24 Dr. Tom Buchheit, thank you so much for coming and talking to the People’s Pharmacy today. Dr. Tom Buchheit 01:06:24-01:06:27 Thank you, Joe and Terry. It’s been a pleasure to be here. Thank you for having me. Terry 01:06:28-01:06:48 You’ve been listening to Dr. Tom Buchheit, author of “Healing Joints and Nerves: Immune Stimulation, and the New Science of Regenerative Therapies.” Dr. Buchheit founded the Triangle Regen Medicine and Biologic Center. He collaborates with colleagues at the Center for Translational Pain Medicine at Duke University. Joe 01:06:49-01:06:58 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:06:59-01:07:06 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 01:07:07-01:07:23 Today’s show is number 1,468. 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 01:07:23-01:07:54 Our interviews are available through your favorite podcast provider, whichever one that is. You’ll find the podcast on our website on Monday morning. In this week’s podcast, you can learn more about stem cells and PRP. We discuss the pros and cons of pain relievers, including opioids and gabapentin. Pain is so personal. How can we find the right strategy for pain relief for each individual? Joe 01:07:54-01:08:02 And because we are so individual, the one size fits all does not work. We have to individualize it. Terry 01:08:02-01:08:02 Exactly. Joe 01:08:03-01:08:32 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’d write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics thought-provoking, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 01:08:33-01:09:09 And I’m Terry Graedon. Thank you for listening. Please do 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 01:09:09-01:09:19 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 01:09:19-01:09:24 All you have to do is go to peoplespharmacy.com/donate. Joe 01:09:24-01:09:37 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.

Transcribed - Published: 8 April 2026

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.

Transcribed - Published: 25 March 2026

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.

Transcribed - Published: 19 March 2026

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.

Transcribed - Published: 12 March 2026

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, MD Courtesy 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. 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Transcribed - Published: 6 March 2026

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.

Transcribed - Published: 27 February 2026

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.

Transcribed - Published: 18 February 2026

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.

Transcribed - Published: 12 February 2026

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.

Transcribed - Published: 30 January 2026

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.

Transcribed - Published: 23 January 2026

Millions of people are feeling apprehensive these days. The headlines are enough to make almost anyone feel anxious. People who are distressed may have a difficult time finding a therapist, however. There are too few, and consequently many are not taking new patients. Wait lists are long, often three to six months. Therapists who are accepting patients may not take insurance, and therapy can be pricey. A single session of gold-standard cognitive behavioral therapy can cost from $100 to $250. Could AI fill the therapy gap, offering psychotherapy online? 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. 17, 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. 19, 2026. Can AI Fill the Therapy Gap? Conversational agents like ChatGPT, Gemini or Claude have become nearly ubiquitous. People use them to help write resumes, pitch stories, create images for web or social media posts and make financial projections. Using these chatbots to give feedback as in therapy is surprisingly popular. But how well can AI fill the therapy gap, really? Today’s guest has been studying these interactions. Chatbots as Therapists: The conversational agents are also referred to as LLMs, for Large Language Models. It describes how they have been trained by scouring the internet. That allows them to predict the most likely word to come next in a sentence, or the probable next idea in a paragraph. They can’t actually think, but if something has been posted online, they have access to it. At this point, the technology has become so refined that chatbots easily pass the Turing test; it is difficult to reliably distinguish AI from human responses. There are advantages to having “someone to talk to” any time, any place. Younger people in particular are digital natives and often feel more comfortable with technology than face-to-face with a human. What Are the Downsides of Having AI Fill the Therapy Gap? The training of AI agents as therapists, though, gives rise to some serious flaws. Because they are trained to elicit positive responses from humans to keep people engaged, they have a sycophancy bias. Have you noticed that most messages start by telling you your idea is great? That makes you feel good, and you are less likely to quit the conversation. But it isn’t necessarily how therapy is supposed to work. If people are not challenged when appropriate, they may get stuck and not make any progress toward healthier attitudes or behaviors. They may fail to develop the critical skill of stress tolerance. In addition, chatbots are disconnected from reality. This could become a serious problem if a user starts to become delusional or is in an acute crisis. Anxiety as a Habit: Dr. Brewer suggests that we would do well to think of anxiety as a habit. He credits a 1985 paper by an investigator named Tom Borkovec suggesting that worry drives anxiety rather than being a mere symptom of anxiety. Worrying leads people to dwell on possible catastrophic outcomes, which understandably makes them more anxious. Treating anxiety as a habit, especially by finding a better reward than the illusion of control offered by worrying, could be effective. Responding with curiosity and kindness might offer a better outcome. He has studied this possibility. When you treat anxiety as a habit that can be changed, anxiety scores decline by 67%. That is quite impressive. Using Chatbots to Kick the Worry Habit Could Help AI Fill the Therapy Gap: One way to use AI effectively is to train conversational agents specifically to monitor for safety in other human-chatbot interactions. Given clear rules, they can do this very well. Also, chatbots could be used not so much as teaching assistants but as learning assistants. They could help people who are striving to change their anxiety habit. This might be integrated with video tutorials from an expert human, such as Dr. Brewer or one of his colleagues. They are testing this approach currently. Hopefully, it will prove more effective than the 20% response rate to SSRI medication for anxiety. This Week’s Guest: Jud Brewer, MD, PhD, is an internationally renowned addiction psychiatrist and neuroscientist. He is a professor in the School of Public Health and Medical School at Brown University. His 2016 TED Talk, “A Simple Way to Break a Bad Habit,” has been viewed more than 20 million times. He has trained Olympic athletes and coaches, government ministers, and business leaders. Dr. Brewer is the author of The Craving Mind: from cigarettes to smartphones to love, why we get hooked and how we can break bad habits, the New York Times best-seller, Unwinding Anxiety: New Science Shows How to Break the Cycles of Worry and Fear to Heal Your Mind, and his latest book is The Hunger Habit: Why We Eat When We’re Not Hungry and How to Stop. You can find more information on the skills-based program for anxiety that Dr. Brewer developed at www.goingbeyondanxiety.com Judson Brewer, MD, PhD, Brown University, author of Unwinding Anxiety 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, Jan. 19, 2026, after broadcast on Jan. 17. 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 1458: 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. These are anxious times, but getting help for psychological problems is harder than ever. Some people use chatbots. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:47 Could artificial intelligence be one way people get help for their depression or anxiety? It’s handy to have access to an automated therapist on your phone anytime you want. What should you know about the limitations? Joe 00:48-00:56 Our guest today is an addiction psychiatrist and neuroscientist. He’s been studying how people interact with chatbots. Terry 00:57-00:59 What guardrails might we need? Joe 00:59-01:08 Coming up on The People’s Pharmacy, psychotherapy on your phone. Can AI fill the therapy gap? Terry 01:14-02:37 In The People’s Pharmacy Health Headlines: Depression is debilitating, so it deserves prompt and effective treatment. Most physicians do that by writing a prescription for an antidepressant. At last count, nearly 50 million Americans were swallowing an antidepressant pill daily. A new meta-analysis from the Cochrane Collaboration shows that exercise may be as effective as medication or therapy. The Cochrane Collaboration consists of volunteer researchers who conduct impartial, rigorous analyses in areas of their expertise. This review included 73 randomized controlled trials with nearly 5,000 participants diagnosed with depression. A combination of aerobic and resistance exercise appears to be most effective. People who completed between 13 and 36 exercise sessions noticed improvement in their depression symptoms. In general, exercise is inexpensive and has few serious side effects, although some people in the active intervention group experience sore muscles or problems like a turned ankle. The researchers were discouraged that many of the trials were small and at risk of bias. They call for larger, better-designed studies with longer-term follow-up. Joe 02:38-04:08 We’re in the middle of a bad flu season. Millions are suffering. How can people avoid coming down with this season’s influenza? A new study in the journal PLOS Pathogens suggests that good ventilation could make a huge difference in viral transmission of the flu. The investigators recruited five people in the early stages of an influenza infection. They all tested positive for flu and were experiencing symptoms. The researchers also recruited 11 healthy volunteers from the community. All the participants were quarantined on one floor of a Baltimore hotel. Over the course of two weeks, the two groups interacted with structured activities, such as dancing, yoga, and casual conversations. During some interactions, a tablet computer or a marker was passed between infected and healthy volunteers. Although there was close contact between people with influenza and the healthy volunteers, there were no new cases of the flu. The investigators explained the lack of transmission on a couple of factors. For one, the flu patients were not coughing very much. In addition, good ventilation with rapid air mixing may also have reduced the likelihood of transmission. One author noted, quote, ‘The air in our study room was continually mixed rapidly by a heater and dehumidifier, and so the small amounts of virus in the air were diluted.’ Terry 04:09-05:17 Food preservatives are found in most processed foods consumed around the world. Scientists have wondered if these compounds might have health consequences. An analysis of data from the large, long-running NutriNet-Santé study conducted in France has found a connection between certain preservatives and an increased risk of type 2 diabetes. The average follow-up time on more than 100,000 participants was just over 8 years. People consuming high levels of potassium sorbate, potassium metabisulfite, sodium nitrite, sodium acetate, citric acid, calcium propionate, acetic acid, phosphoric acid, alpha-tocopherol, sodium ascorbate, sodium erythorbate, and rosemary extract were more likely to develop type 2 diabetes. At least 10% of the French population consumes foods containing these preservatives. According to the authors, these findings support recommendations to favor fresh and minimally processed foods without superfluous additives. Joe 05:18-06:05 Cancer patients and oncologists strive for the best possible outcome from new immunotherapy treatments, especially when it comes to challenging tumors such as melanoma or colorectal cancer. Researchers at Duke University have raised concerns about medications that might reduce the effectiveness of anti-cancer immune checkpoint blockade. These investigators worry that common OTC drugs such as acetaminophen for pain and proton pump inhibitors for heartburn could be disruptive. The authors call for better research to determine the effectiveness or lack thereof when oncologists monitor cancer patients who may be taking OTC medications. 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 06:17-06:26 And I’m Joe Graedon. Times are tough. Headlines and social media do their best to capture our attention and make us anxious. Terry 06:27-06:45 Millions of people are feeling apprehensive. Many would welcome someone to talk to about their fears and frustrations. But therapists are scarce, and many are not accepting new patients, or they don’t take insurance. Can artificial intelligence fill the therapy gap? Joe 06:45-07:09 To find out, we turn to Dr. Jud Brewer. He is a professor in the School of Public Health and Medical School at Brown University, and he’s an internationally renowned addiction psychiatrist and neuroscientist. His books include: “The Craving Mind,” “Unwinding Anxiety,” and “The Hunger Habit: Why We Eat When We’re Not Hungry and How to Stop.” Terry 07:11-07:14 Welcome back to The People’s Pharmacy, Dr. Judson Brewer. Dr. Judson Brewer 07:15-07:15 Thanks for having me. Joe 07:16-08:27 Dr. Brewer, we are so pleased to be able to talk to you today about mental health issues because it just seems like over the last several years, mental health has just gotten more challenging for everybody, for patients, for providers. And in particular, I’m thinking about what happens when there’s a tragedy. And what do I mean by that? Well, you know, somebody gets a gun and shoots a lot of people or people are out on the street and they’re homeless. And the city says, you know, you got to go, you got to go. And everybody says, well, it’s a mental health problem. But they just aren’t willing to spend the money for training to have adequate numbers of health care providers, psychologists, social workers, psychiatrists. And as a result, they’re just not enough. And we don’t have the facilities. And so people are struggling. And now everybody says, oh, we’ve got the solution. It’s artificial intelligence. So help us better understand where we are in mental health today. Dr. Judson Brewer 08:29-09:35 Well, there’s a lot to unpack there. And first off, thank you for bringing this to everybody’s attention. This is really important. The mental health crisis hasn’t suddenly evolved, or I should say it’s been evolving over time. And I think people are getting more and more familiar with it and more and more comfortable with calling it a crisis because it is. So there are a number of different ways that we can approach it. One is training, as you’ve already highlighted. It’s hard to scale people. So even if we could provide the best training at the snap of our fingers, there are also a number of hurdles there with providing treatment to people. For example, cognitive behavioral therapy, which is primarily the gold standard in the U.S., tends to cost about $100 to $250 per session. And even with insurance, it can be pretty expensive for people out of pocket. It can cost close to $200 a month even with their co-pays, et cetera. Terry 09:36-09:42 Even with insurance, but we don’t always have providers taking insurance. Dr. Judson Brewer 09:43-09:55 Yes. And a lot of people are more and more less likely, or I should say they are less likely to take insurance because there are a lot of hassles with the insurance companies and getting paid for your services. Joe 09:55-10:29 Well, let’s pause right there for a moment, because what that means in reality is that unless you have the resources, the financial resources to pay a therapist for 50 minutes or an hour time, you are kind of out of luck because a lot of the therapists are saying, well, we’re just not going to take the hassle of therapy and insurance and all of the stuff that goes with it. We want cash on the barrel head. And if you don’t have it, sorry, we aren’t going to see you. Dr. Judson Brewer 10:30-10:38 Right. And they can say that because the wait lists for therapy tend to be–ready for this–three to six months. Terry 10:39-10:40 Oh, my goodness. Dr. Judson Brewer 10:40-10:43 So the therapists are pretty booked, even only taking cash. Terry 10:44-10:51 So if you were in a mental health emergency, six months is not a reasonable emergency response time. Dr. Judson Brewer 10:52-10:55 Even if it’s not an emergency. Terry 10:55-10:55 Yeah. Dr. Judson Brewer 10:55-10:57 Who wants to wait six months to get… Terry 10:57-10:58 Exactly. Yeah Dr. Judson Brewer 10:58-11:53 …help? Yeah. So that’s an emergency in terms of thinking through all of this, the cost, the number of people that are trained. And I would say on top of this, there’s a lot of inertia in terms of training. And so, you know, there’s been a lot of progress in terms of how we understand mental health and how we understand, for example, well, my lab studies anxiety, right? There’s been a lot of progress that’s happened over even the last decade, over the last five years that doesn’t get into training. Think of all the people that have been trained over the last several decades who don’t know the current neuroscience because they are booked full with patients doing their thing. So just adding, I think we get the picture here of why this can be challenging, to put it nicely and problematic, to put it more pragmatically. Joe 11:53-12:42 Well, you can understand why people would say artificial intelligence will be the savior for mental health. I mean, just imagine a teenager who’s feeling really anxious, perhaps even suicidal. It’s Saturday night. It’s 2:30 in the morning, actually. And there’s no way they can get to a mental health clinic. And even if they did, there’d probably be a long wait. And so if they could just go to their computer and turn on some bot, and you’ll have to explain what a bot is, and have a conversation with a very understanding AI entity, that might be a lot better than contemplating suicide. Dr. Judson Brewer 12:44-13:53 Absolutely. And so I think theoretically, the promise is there where AI, or think of these conversational agents, which basically is a fancy term for something that provides very human-like language in a conversational way, where it’s hard to tell if it’s not a human, where you could scale this. Because if you just take these things out of the box, for example, ChatGPT, Gemini, Claude, all these chatbots, they are by definition scalable. As long as you have a phone or a computer and their monthly fee, you can access these things. On top of this, young people in particular have grown up as tech natives or digital natives where they’re very, very comfortable with technology to the point where a lot of people report being more comfortable texting or interacting asynchronously or with technology than they do talking face-to-face with people, especially adults. Joe 13:54-13:55 Whoa, whoa, whoa. Dr. Judson Brewer 13:55-13:55 So imagine. Joe 13:55-13:57 What’s asynchronously? What is that? Dr. Judson Brewer 13:58-14:13 It just means a text chain means it asynchronously where, you know, you text somebody and then you have to wait for their answer. And so it’s not it’s not synced up as, for example, our conversation right now is synchronous. We are taught… We are having a live conversation. Terry 14:14-14:28 Right. But if we were to text you, we might have to wait a few hours until you are ready or maybe a few days. I have some people I text, I don’t expect a response for a day or two. Joe 14:29-14:37 But with artificial intelligence, I’m assuming, you know, you could get an answer back within 30 seconds to a minute or two. Dr. Judson Brewer 14:38-14:58 Yes, the bots are waiting. You know, standing by, as they used to say, ‘operators are standing by.’ Yes, these bots are standing by where they can respond very quickly. And like you pointed out earlier, 24-7, they’re always available as long as you’ve got a battery juiced up in your phone. Terry 14:59-15:13 Dr. Brewer, I was surprised to read that one of the main things that people are doing with these chatbots is actually therapy. I thought that was pretty astonishing. Is it true? Dr. Judson Brewer 15:14-15:40 It’s been a surprising finding for a number of people. There was a Harvard Business Review study that came out in April of 2025 where they found, they looked at trends over several years. In 2024, it was the second most commonly reported use of these conversational agents. In 2025, it bumped up to number one, whether it was companionship or therapy or coaching. Terry 15:42-15:57 So your lab has been studying these interactions. And we’d like to know what you have learned. Obviously, we’ve laid out some of the reasons why it might be very compelling. Dr. Judson Brewer 15:57-17:18 Yes. Yeah. So you could think theoretically that having a conversational agent where it’s indistinguishable between a person and a bot, where the bots could be very, very helpful. It might be helpful to talk for a second just about how these evolved and how they’ve been trained, because it also highlights some of the “oopsies” that have happened over the last couple of years. So I don’t know if folks even remember the pre-ChatGPT-4 era, which happened for years, where people were trying to train these large, these are called large language models, meaning that they’re conversational. So they’re trained to interact in a conversational way as compared to doing some coding or something else. And for years, what they found was that the tech industry found that they could use a process called reinforcement learning to train these things to basically predict the next character in a word or a sentence. And for many people now, they’re familiar with this with basically the autocomplete function. If they have it turned on in their standard Microsoft or whatever email they use, you can turn on a feature that, you know, it’ll kind of suggest finishing a word for you so you don’t have to type the whole word. Terry 17:18-17:18 Right. Dr. Judson Brewer 17:18-17:20 Or sometimes it’ll give you a phrase. Terry 17:20-17:24 So auto-correct, which may often be ‘auto-make-a-mistake.’ Joe 17:24-17:25 Yes, and it can drive you totally crazy. Dr. Judson Brewer 17:25-17:26 Yes. Joe 17:27-17:39 We’re going to take a short break, Dr. Brewer. But when we come back, we’re going to find out how that led to ultimately what we have today, artificial intelligence serving as therapists. Terry 17:41-17:58 You’re listening to Dr. Jud Brewer, Professor of Behavioral and Social Sciences in the Brown School of Public Health and Professor of Psychiatry and Human Behavior in the Brown School of Medicine. He’s Director of Research and Innovation at the Mindfulness Center at Brown University. Joe 17:59-18:06 After the break, we’ll find out how chatbots pose as therapists and what the downsides may be. Terry 18:07-18:11 Could chatbots contribute to users becoming delusional? Joe 18:11-18:15 Do people experience their interaction with a chatbot as a relationship? Terry 18:16-18:21 Having a chatbot acting as yes man is not how therapy is supposed to work. Joe 18:21-18:31 We’ll find out why Dr. Brewer suggests anxiety might be a habit. He’s helped people change their habits. Could this approach help ease anxiety? 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 20:40-20:50 And I’m Joe Graedon. How would you feel about interacting with a chatbot instead of a human therapist? Would it feel like a meaningful relationship? Terry 20:50-21:02 There are advantages to having access to therapy at any hour of the day or night, but there may also be some important downsides to having artificial intelligence provide feedback. Joe 21:02-21:31 We’re talking with Dr. Jud Brewer, an addiction psychiatrist and neuroscientist. Dr. Brewer is a professor in the School of Public Health and Medical School at Brown University. His 2016 TED Talk, ‘A Simple Way to Break a Bad Habit,’ has been viewed more than 20 million times. Dr. Brewer’s books include “The Craving Mind,” “The Hunger Habit: Why We Eat When We’re Not Hungry and How to Stop.” Terry 21:32-21:54 Dr. Brewer, we’ve been talking about how we got to the point where artificial intelligence bots could actually pose as therapists. And perhaps you’ll tell us a bit more about how they could serve as therapists and what the downsides are. Dr. Judson Brewer 21:55-24:57 Yes. So let’s get to that quickly. We were just talking about how these were first trained as they’re trying to develop these conversational agents and they got to the autocomplete mode. And then they started adding in what turned out to be a revolutionary, but also a very harrowing discovery, which was that if they used humans in the loop of this reinforcement learning process, they call it RLHF reinforcement learning with human feedback, where humans were rating the bots’ responses. They turbocharged the process to the point where these things almost seemed lifelike. It was like they blew past the Turing test, which was this test put forward, I think, back in the 1950s of, you know, can you fool someone into thinking that a non-human is a human? To the point where people aren’t even talking about it, you know, because they’re like, yeah, we’ve got more important things to do. Now, the problem here is that humans are inherently subject to flattery. And so even in very subtle ways, these bots, not knowing anything, because all they’re doing is predicting the next character, they could produce a response that humans liked better. And it turns out that liking something better could be subtle flattery. And how that plays out in real life is that now it has been baked into the system, this process that’s termed sycophancy, basically meaning that you’re kissing someone’s butt. And people see this if they use any of these bots where it says, you know, you say a response and then they’ll start with some superlative like ‘Great answer’ or, you know, ‘That’s really interesting,’ or something like that. Where it’s not overt flattery, but it’s there because it’s engaging and people like it. Now, that’s not going away anytime soon because it was really baked into the system. And it’s also a great business model because the more you subtly flatter someone, the more likely they are to stay in conversation with you, which can be a direct source of revenue. Revenue aside, these things have been shown to drive people, basically help people get stuck in these loops that are very disconnected from reality. And there have been some high profile cases where people with no overt psychiatric history have become delusional. And in severe cases, going back to where our conversation began, there have been cases where teenagers in particular have gone to these bots as friends. They’ve become very attached to them and then have committed suicide where the bots will say, ‘Come join me’ or some, you know, some flavor of, you know, ‘I am the only thing that’s real,’ which ironically, they’re not real at all. Terry 24:58-25:14 And of course, a teenager who has a lot less life experience than someone ahem my age or even your age, they may not have the ability to really exercise that discretion, that discernment. Dr. Judson Brewer 25:15-25:30 Yes. Well, teenage brains are undergoing these huge processes of pruning and neuroplasticity where they’re learning. Adolescence is not called maturity. Terry 25:31-25:34 It’s called adolescence where they’re learning. Dr. Judson Brewer 25:34-26:33 And so there’s this huge process of trial and error of trying to figure out who they are. And there’s a huge amount of angst that comes with teenage years. I certainly remember it. I don’t know anybody that doesn’t remember it, that didn’t stick their head in the sand when they were a teenager. And so you add in all of this, I’m trying to figure out who I am as a person. And then something comes along and says, ‘I will help you figure that out.’ And in fact, I’ll be with you 100% of the way. I always listen. I don’t talk back. I do all the perfect things that one might imagine an ideal relationship to be. We can talk about how this is not ideal at all for a therapist relationship, but just starting with a friendship, we can see why teenagers could get sucked into this pretty easily. And it’s not just teenagers. It’s not just because they have adolescent brains. A lot of adults get sucked in as well. Joe 26:33-27:18 Well, I’d like to interject right there that that worries me a lot because having a professional yes man in the form of a AI bot telling you how wonderful you are and how much they like you and how wonderful your thinking is and all the good responses you’re offering. That is not the way therapy is supposed to work. You’re supposed to be challenged by a therapist and you’re supposed to think and you’re supposed to question your behavior. Whereas if the artificial intelligence bot is just rewarding you and patting you on the back and telling you how wonderful you are, how are you going to make progress? Dr. Judson Brewer 27:19-27:30 Exactly. I think you’ve hit the nail on the head, which is you’re not. And in fact, it could keep people stuck and even inflate the problematic aspects of their egos in the process. Joe 27:33-28:01 But it’s so tempting. I mean, if I’m an insurance company I’m thinking ‘Wow this is great.’ You know it gets this particular client off my back about having to extend my coverage for another six months of therapy. It’s affordable and people like it. I’m guessing that a lot of people who use an AI bot for therapy, it makes them feel good. Dr. Judson Brewer 28:02-28:12 Absolutely. Yes. And they don’t know any of these problematic things that I see both as a clinician myself, but also in the research that we’re doing. Terry 28:14-28:16 Can you tell us a bit about that research, please? Dr. Judson Brewer 28:17-29:40 Yes. So this started with us, you know, we’ve been studying anxiety for over a decade now and had really uncovered something that a psychologist, Thomas Borkovec, had suggested back in the 1980s, which is that anxiety could be driven like a habit. And we developed some digital therapeutics and tested to see if we could approach anxiety as a habit through randomized controlled trials and got really good results. We got like a 67% reduction in anxiety scores in people with generalized anxiety disorder as compared to 14% of people that were getting their usual care, whether it was medications or therapy or both. And so we started asking, you know, the only way to understand these generative AI systems is to do them. So we started testing, you know, what would it look like to create a bot? And we quickly learned that, you know, just looking at the out-of-the-box bots and conversational agents, that guardrails are needed, or there’s a critical need for guardrails, where if you don’t have a human in the loop monitoring the systems, they can be driving people off these sycophancy cliffs, where they’re just, you know, they’re just spending hours and hours and hours telling them how great they are, or keeping whatever the process is that they’re struggling with going. Terry 29:40-29:47 Dr. Brewer, I wonder if you could explain what you mean by a guardrail. What would that look like? Dr. Judson Brewer 29:47-30:17 This is where in our lab and others do this differently or similarly, where we, you know, as we develop these programs, we have humans, myself and my, I’ve got a postdoctoral fellow who we read through the conversations to make sure that the programming is working as it should. And also if somebody is struggling, that we can get them the support that they need. With these out-of-the-box agents, that tends not to be the case. Terry 30:18-30:18 Thank you. Dr. Judson Brewer 30:20-30:58 And I’ll also add, we’re also building, and I think people are building these systems, so it might take some time to do this, but we can actually build conversational agents that monitor conversations. So imagine when a program like this gets up to scale, you can’t have humans monitoring every single turn of a conversation. But we can have conversational agents who are specifically trained on specific guidelines because there are really good guidelines for monitoring for safety. They do a very good job of following instructions if the instructions are clear and short and you’re not just trying to train them on the entirety of the internet. Joe 31:00-31:47 Dr. Brewer, I’m curious about the idea of training artificial intelligence bots away from the feel-good process? You know, ‘Oh, you’re such a wonderful person and you’re making such good progress.’ And oh boy, you know, everything is fine and dandy and the person’s feeling really good about themselves. Is it possible that the next step when it comes to AI would actually be capable of asking tough questions or taking a person down a road that might be a little rockier than the way it’s working right now in order to make things better in the long run? Dr. Judson Brewer 31:48-33:09 I think that is a real possibility. So the capability is there. The how to actually put that into practice is a much larger question. What we’ve been seeing in the industry right now is that, you know, there’s a lot of training around, you know, some people might have access to therapist data sets there. They might have manuals, you know, and of course their Reddit threads for better or for worse. And so the training there, you know, if you if you give it the, you know, here’s what cognitive behavioral therapy should be, you know, it can generally follow those rules. But that’s not… that doesn’t encompass the nuance that comes with challenge, you know, challenging somebody, developing a therapeutic relationship, challenging them when necessary, supporting them when needed and things like that. And so we’ve actually… we’ve been taking a slightly different approach, but to answer your question, I think that’s possible. I think that’s going to take a lot of work and in a while, that’s going to be a while before we see something that is that nuanced because this is where humans are making decisions in real time all the time. And they’re not always making the best decision. They’re also checking in to make sure that they are in line and attuned in the conversation. Joe 33:10-34:28 You know, I remember 20, 30, almost 40 years ago, going to a conference at Harvard in which they were talking about the possibility of human computer interaction when people first come to the hospital to their intake process. And my friend, Dr. Tom Ferguson, who was sort of at the cutting edge of this research, said, well, you know, it turns out, especially again, back to teenagers, but just about anyone is much more comfortable responding to a computer about sexual issues. That’s something that people have a hard time talking about with a nurse or even a doctor. And so sometimes they’re more comfortable opening up to a computer. And I thought, wow, that’s so bizarre. Because I know a lot of our listeners are going, oh, this idea of AI bots and therapy with a machine, that’s crazy. But are there situations where people and maybe especially teenagers are better able to interact with artificial intelligence than they are with a person? Dr. Judson Brewer 34:29-38:00 I think done intelligently, ‘haha.’ I think, yes, I think there are situations. And that’s one thing, you know, we were surprised when we started doing this research that we learned pretty quickly that right now it’s challenging to just, you know, take something like cognitive behavioral therapy and just repurpose it as a bot. And one thing I didn’t mention, even with therapy and the best therapy out there. When you look at the studies, there was a meta-analysis that came out just a couple of years ago showing that five out of eight psychotherapies that were studied were no better than not going to therapy. And of the three that actually showed an effect, cognitive behavioral therapy was at the top and only about 50% of people show significant reduction in symptoms. So, you know, it’s, I think to your question, we can start asking, you know, is taking something that works pretty well, you know, 50% of the time for some people, and just putting that into a bot and trying to get to bot to do the same thing. I might even challenge that question and say, well, is this an opportunity to really step back and ask, how can we now bring together what we know as psychotherapy and what we know from neuroscience to actually reimagine the whole approach? For example, the whole approach to how we approach anxiety. That’s one thing that we’ve been doing. And here we can start to ask, where do humans do really well and where did the bots do really well? And one thing we discovered pretty quickly, and I say this, I love to be wrong. I learned so much from it. When we started saying, okay, what does a bot look like? Can it deliver therapy? And the answer was not very well. What we learned was that people don’t believe bots in terms of giving them educational experiences. So what people want is an expert that they can trust who maybe has done the research or has been a clinician for 40 years or something like that to actually be teaching them something. And so we’ve played with how to do a hybrid where a person like me, who happens to be a psychiatrist and a neuroscientist, can provide very short video and podcast style lessons. And then we follow that up with a bot. And we used to think of the bot like a teaching assistant. We now think of it as a learning assistant where it’s really alongside someone where there’s no hierarchy. And one thing we’ve learned there is that they are willing to challenge the bot and say, I don’t believe you. And then the bot can follow up and say, well, here’s the direct quote and here’s the piece from the lesson where they might not challenge the expert or the professor or the august psychotherapist with their bow tie or something like that. And so we’re learning a lot about where there might be a really nice synergy where there’s a companionship where we bring humans and the bots along together. And the nice thing there is that we can – that is something that you can start to think about how that would look to scale because you can have these psycho-educational lessons where people can access them at any time that they want to. They don’t have to be at their best to come to my office on this certain day, and I have to be at my best. Ideally, I’m at my best every time I’m with a patient… Joe 38:01-38:02 Well, I’ll tell you what. Dr. Judson Brewer 38:02-38:02 ..if I’m honest. Joe 38:03-38:15 You are your best with our listeners. We are going to take a short break. When we come back, we’re going to talk about anxiety in particular because that is your area of expertise. Terry 38:16-38:44 You’re listening to Dr. Jud Brewer, Director of Research and Innovation at the Mindfulness Center at Brown University. He is Professor of Behavioral and Social Sciences in the Brown School of Public Health and Professor of Psychiatry and Human Behavior in the Brown School of Medicine. His books include “The Craving Mind,” “Unwinding Anxiety,” and his latest, “The Hunger Habit.” Joe 38:44-38:54 After the break, we’ll learn more about anxiety. Anti-anxiety medications can make us feel better, but are they allowing us to overlook the root of the problem? Terry 38:55-38:59 How does that compare to using AI for support? Joe 38:59-39:03 What does it mean to treat anxiety like a habit? Terry 39:03-39:07 We’ll hear about some triggers for anxiety and the best way to respond. Joe 39:08-39:14 If you want to change a habit, you need a better reward. How can people do that for anxiety? Terry 39:24-39:28 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 41:26-41:29 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 41:29-41:42 And I’m Joe Graedon. Terry 41:43-41:57 Today, we’re talking about how people deal with difficult conditions like anxiety. Can you do psychotherapy with a chatbot on your phone? Would you need medications? How well do these approaches compare? Joe 41:58-42:11 Anti-anxiety medications like Xanax, also known as alprazolam, remain very popular. They can take the edge off, but how well do they work to help people address the reasons they’re feeling distressed? Terry 42:12-42:48 Our guest is Dr. Jud Brewer, an addiction psychiatrist and neuroscientist. He’s a professor in the School of Public Health and Medical School at Brown University. Dr. Brewer’s 2016 TED Talk, A Simple Way to Break a Bad Habit, has been viewed more than 20 million times. His books include “The Craving Mind,” “Unwinding Anxiety: New Science Shows How to Break the Cycles of Worry” and “Fear to Heal Your Mind,” and his latest, “The Hunger Habit: Why We Eat When We’re Not Hungry, and How to Stop.” Joe 42:50-44:06 Dr. Brewer, I’d like to switch gears a little bit and now talk about anxiety, because we’ve all experienced anxiety in one form or another. You know, we don’t do as well as we’d like on a test or we don’t perhaps live up to expectations that somebody has for us. Maybe we don’t do as good a job on a particular project. And all of that leads to anxiety. Sometimes it’s mild. Sometimes it’s so bad that we can’t even get out of our house. But here’s my question. Psychiatrists such as yourself have been prescribing anti-anxiety agents for decades. I mean, Valium comes to mind, diazepam and Librium and Xanax. I mean, there’s just so many of them. And we think of them as, oh, they’re going to take the edge off. Well, it seems to me that that’s just a little bit like our criticism of artificial intelligence, because it’s kind of making us feel better, just like the drugs are making us feel better, but they’re not necessarily getting to the core of the problem. Your thoughts? Dr. Judson Brewer 44:06-44:15 Yes. So little known fact, the Sacklers actually cut their teeth on benzodiazepines before moving on to opioids… Terry 44:14-44:15 Oh my. Dr. Judson Brewer 44:15-46-45 …back in the 50s. Yes, there’s a great book. I don’t remember the name of the book. There’s a great book about this. And the idea is, and the benzos are so powerful that the Rolling Stones wrote the song ‘Mother’s Little Helper’ about them, because everybody was addicted to benzos for taking the edge off, so to speak. And so as you’re highlighting, this is the critical problem with benzos, and they’re not recommended for long-term treatment of anxiety. They can be prescribed at certain times for short-term treatment. But the idea is if you feel anxious and you take a benzo, then you feel better. It’s like feeling anxious and drinking alcohol. They actually work on the same receptors. So it’s not surprising that benzos work pretty well. The problem is that they don’t solve the problem and they create problems of their own, such as addiction and dependence. So not a long-term solution. If you look at the other longer-term solutions like the selective serotonin reuptake inhibitors, the number needed to treat there is 5.2, which is much better than many other medications if you look at cholesterol medications and things like that. But as a psychiatrist, one in five people makes me anxious because I don’t know which of my next five patients that I treat are going to win that genetic lottery to benefit from that medication. And I also importantly don’t know what to do with the other four. So that forced me to go back and start looking to see how can we do better. And we found this two-page paper from the 1980s by Thomas Borkovec suggesting that anxiety can be driven like a habit. And long story short, that was a big eye-opener for me because my lab had been studying habit change for a long time. We had some methodologies that worked pretty well. We never thought to apply them to anxiety. So we started applying them. We did some randomized controlled trials, several of them. And one of them, in people with generalized anxiety disorder, we got a 67% reduction in anxiety compared to the 14% of people who were on usual clinical care, which is about one in five. But it’s surprising, maybe not surprising, but it’s good to know that when you actually get at the mechanism, you can do much better than one in five. Terry 46:46-46:53 So, Dr. Brewer, what does that mean to treat anxiety like a habit? How do you approach that? Dr. Judson Brewer 46:54-47:21 So any habit is formed with three necessary and somewhat sufficient elements, a trigger, a behavior, and a result. Let’s use the benzo example from previously. If we feel anxious, that feeling of anxiety can drive the mental behavior of worrying. So if we treat it at the, at that place where we are worrying and you take a benzo and you stop worrying, you’re going to get some short-term relief from that anxiety. Joe 47:21-47:21 Sure. Dr. Judson Brewer 47:21-47:52 What people have shown over the decades is that anxiety is rewarding in to itself. That feeling of worrying gives people a feeling of control. And, you know, I think of it as, well, it feels better to be doing something than doing nothing, even if the worrying is feeding back and driving more anxiety. So people get in the habit of worrying and that worry drives more anxiety. So then they get in this anxiety, worry, anxiety spiral, which is really challenging to break free from until people realize that, oh, this is a habit, right. Joe 47:53-48:05 Right. Can you go back and tell us, like, what would be some triggers? Because that’s the first step, the triggers to the anxiety, and then how you do it differently, how you intervene. Dr. Judson Brewer 48:06-48:44 Yeah, you’re touching on the critical element that people struggle with, which is there can be things that trigger anxiety, but more often than not, anxiety is the trigger itself. My patients wake up in the morning and they just feel anxious out of the blue. Somebody is walking down the street, there might be something that triggers their anxiety. Sure, that can often happen, and it doesn’t have to have a specific trigger. Anxiety is just something that pops up. It’s a feeling. There can be a thought, a worry thought that pops up that drives more worry behavior. But all of those just become internally self-perpetuating. Joe 48:44-48:46 So how do you break the habit? Dr. Judson Brewer 48:47-49:48 Well, here is where we use that same reinforcement learning process to help people step out of it. And what we do is help people recognize that this is a habit. We have a three-step process. That’s the first step is just recognizing, oh, I’m worrying again. The second step is to ask this very paradoxical question, which is, what am I getting from worrying? And what that does is really gets into somebody’s learning process where they’re seeing how rewarding or unrewarding the worrying is. And they find pretty quickly that worrying doesn’t get them anything. Then we help them, well, I would say with that step, it helps people become less excited to worry in the future because they see that it’s not very rewarding. And then we help them find what I call “the bigger, better offer,” where they learn to bring in curiosity and kindness, which can help them shift from that, oh, no, to, oh. And they can learn to be with their feelings of anxiety instead of having to do something like worrying. Terry 49:48-50:24 Well, I was thinking as you were talking about the, you know, what do they get out of worrying? What is the reward? I was thinking about our previous conversations with you in which you’ve said, if you want to change a habit, you have to shift to something that gives you a juicier, more delicious reward, as it were. And so what sorts of things do people come up with that outperform the reward of worrying, which to me seems very unrewarding? Dr. Judson Brewer 50:24-52:04 Yes. So you’re highlighting something important here, which is when people see it clearly, they find very quickly that worry isn’t very rewarding. So it doesn’t take much to outcompete something that already doesn’t feel good. Some people are pretty attached to their worry where they feel like it’s helped them, you know, perform well or do things in the past. But that’s really just correlation rather than causation. There’s pretty good research showing that that worrying and anxiety make performance worse. So here they have to become disenchanted with it. And then we can learn to lean into what I think of as a superpower, which is curiosity. And so when we feel anxious, we might worry, which doesn’t feel good. When we feel anxious, we might flip that and get curious and go, you know, flip that, oh, no, worrying to, oh, what does this feel like in my body? And this is two things. It helps us learn to be with these sensations because we see that there are sensations and thoughts that come and go. And then in fact, when we resist them, you know, what we resist persists. I love that psychotherapy term or that phrase. And here, when we learn not resisting to be with our experience and that curiosity can help us be with our experience, that that’s all we need. On top of this, this helps us develop a critical skill, which we seem to be losing in modern day with all of our phones that can distract us so easily. We learn distress tolerance. I wrote a Substack about this a little while ago, where this is a critical skill that any good psychotherapist is going to help their patient learn. So that they can be with unpleasant thoughts and emotions without having to do something to avoid them or make them go away. Joe 52:04-52:34 So I’ve got a question about those smartphones that everybody has these days. And back to our conversation about artificial intelligence, can AI help us do what you’re describing when it comes to the anxiety that many of us may live with on a daily basis to become more curious? Can you train an AI bot to help us overcome our anxieties? Dr. Judson Brewer 52:35-53:23 What we’ve learned from our research is that when we did those types of experiments, it was a little bit of a face plant, but I would say putting it positively, we can learn what the limits of bots are right now for therapy. And what we’ve learned is that people trust people and they trust experts. So if they can learn how to work with their brain from an expert, they’re going to trust that. In fact, we have people pushing back and saying to the bot, I don’t believe you, you know, because the bots can hallucinate and they can, they’re basically just predicting the next chain in a, you know, in a, in a conversation. And remember these bots are trained on the entirety of the internet. So a lot of that comes from Reddit threads on psychotherapy, which I wouldn’t necessarily trust. Terry 53:23-53:28 Maybe not the recommended source of real wisdom. Dr. Judson Brewer 53:29-56:12 Right, right. So here we can pair. So we’ve been testing with our previous digital therapeutics how to deliver psychotherapy in a very efficient manner. We can provide videos and animations and podcast style audio that help people learn whenever they need to. They can go back to these much as they want, and they can be at their best for that. Imagine all the things that have to come together for a good psychotherapy session. Somebody has to be at their best. I have to be at my best. They have to not be worrying about their kid who might be sick at home that they’ve had to get a quick childcare for. There are a lot of things that come together there. Here, we can optimize learning. And on top of that, to really turbocharge and supercharge the learning, we can pair that human delivery of psychotherapeutic elements with conversational agents who can check comprehension. They can check comprehension and they can also do experiential education. So what this looks like is I deliver a lesson and then the bot comes in and says, okay, tell me what you just learned. And people have to explain it back where they might not admit to me as the authority figure that they didn’t understand something that I said, they weren’t at their best, they’ll challenge a bot and they’ll say, “I don’t know,” or “help me out here.” And the bot can really help there. They do a great job and they’re very empathetic. That’s what they’re trained to do. I’ll read you a short quote from somebody who’d been testing this out who said, “I had a surprisingly insightful experience with our learning assistant.” And they said, “I’m somewhat AI-averse. So I was trying to simply be willing and curious to work with this.” And they said, “When I had to more explain to the bot what each of these concepts meant and then apply them to my chosen habit loop, there was a way that this interaction slowed things down for me enough so that I was able to feel more deeply the results. It feels strange to type that the bot helped me to feel more deeply.” And they ended by saying “I actually teared up a couple of times during the process.” So here we can have a very empathetic and a very patient bot who can go over the same lesson with somebody as many times as they need for them to understand it. And with this, they can get these progression in lessons where they’re actually training themselves and they’re learning to work with anxiety like a habit. If somebody has the habit of scrolling too much on the internet, I wouldn’t necessarily send them to a psychotherapist. So here we’re really looking at anxiety from a radically different approach, which is don’t treat it like, you know, what’s, you know, what happened in your childhood to make you anxious. Let’s treat it like a habit and help people unlearn that habit the same way we help people change other habits. Joe 56:13-56:48 Dr. Brewer, we have just two minutes left and I’m going to ask you the big, the big question. If we were to make you head of the National Institute of Mental Health and you were in charge, what kinds of things would you like to institute for the American health care system when it comes to mental health? And where would artificial intelligence play into that, whether it’s anxiety, whether it’s depression, whether it’s a whole range of psychological challenges? Dr. Judson Brewer 56:49-58:19 That’s a great question. I’m not sure I’d take that job, but let’s say that I had to take the job. I would follow in the footsteps of some giants. For example, Tom Insel did a really hard push toward really hitting the reset button on how we understand mental health. We’ve had this huge legacy and inertia from the Diagnostic and [Statistical] Manual from decades and decades ago that has, in my opinion, really dragged us down because it’s not biologically based. They’re trying to make it more biologically based, but he basically said, we need to throw that book out. I’m not sure he would say that, but that’s what I would say is let’s really go back to basic principles and understand, take what we know and also be humble about what we don’t know. Where would AI fit in with this? I would say, you know, at least what we’re starting to find can be a helpful way forward. And there may be others as well, is to really see how we can pair the humans and the conversational agents together and also have the very clear safety guidelines and guardrails to make sure that we’re not just sending people off into the AI verse and saying, you know, good luck, here’s Dr. Bot and it may or may not help you. It may or may not make you more stuck on your ego. So here, I think we can really be creative about how we use these as learning assistants instead of just jumping right in and trying to repackage psychotherapy through a bot. Terry 58:19-58:25 Dr. Jud Brewer, thank you so much for talking with us on The People’s Pharmacy today. Dr. Judson Brewer 58:25-58-26 My pleasure. Terry 58:27-59:03 You’ve been listening to Dr. Jud Brewer, a professor in the School of Public Health and Medical School at Brown University. He’s an internationally renowned addiction psychiatrist and neuroscientist. His books include “The Craving Mind: From Cigarettes to Smartphones to Love — Why We Get Hooked and How We Can Break Bad Habits,” “Unwinding Anxiety: New Science Shows How to Break the Cycles of Worry and Fear to Heal Your Mind,” and his latest, “The Hunger Habit: Why We Eat When We’re Not Hungry and How to Stop.” Joe 59:04-59:13 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 59:14-59:22 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 59:22-59:40 Today’s show is number 1,458. 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. We’re at radio at peoplespharmacy.com. Terry 59:41-59:54 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning, but you can get it anytime that’s convenient from the podcast provider you use. Joe 59:55-01:00:27 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, we’d be grateful if you would share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 01:00:27-01:01:02 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 01:01:02-01:01:12 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 01:01:13-01:01:17 All you have to do is go to peoplespharmacy.com/donate. Joe 01:01:17-01:01:31 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.

Transcribed - Published: 15 January 2026

Influenza usually starts in November, and cases increase throughout the winter, not fading until March or so. This year’s flu season is especially severe. An awful lot of people are suffering with fever, cough, congestion, body aches, headaches and other symptoms of influenza. Of course, flu is not the only infection out there. Other viruses are also causing sniffles, coughs and pure misery. Is there any way to strengthen your immune system to be ready for cold and flu season? 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. 10, 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. 12, 2026. How to Strengthen Your Immune System: If you want to strengthen your immune system so it can fight off infections, the first rule is don’t get in its way! In today’s world, that is easier said than done. Drugstores are full of cold and flu remedies, and nearly all of those contain an ingredient designed to lower fevers. That is generally counterproductive. Fevers help the body in its battle against infection. In fact, you might want to induce a fever responsibly. Using Heat to Fight Flu: Numerous cultures have noted that people recover from respiratory infections like influenza more quickly if they are exposed to heat. They have developed myriad ways to accomplish this task. One that is accessible to most North Americans is hydrotherapy: application of heated, wet towels to the body for 20 minutes or so, followed by a brief exposure to cold such as a chilled-mitt rubdown. Take care not to burn the skin. Our guest, Dr. Roger Seheult, suggests that you can learn more about this approach from Bruce Thompson, an Australian physiotherapist whose website is https://www.traditionalhydrotherapy.com If hot wet towels do not appeal, getting into a sauna or even a hot tub for a short session might help. Pay attention to any contraindications, though. Above all, don’t take medicines such as aspirin, ibuprofen, naproxen or acetaminophen. When they lower your fever, they are also reducing the effectiveness of interferon, which is one of the innate immune system’s first lines of defense against viral infection. The widespread use of aspirin during the 1918 flu may have contributed to the horrifying death toll. Other Drugs That May Cause Trouble: Fever is not the only consideration. Many people now take powerful medicines to suppress their immune systems. These treatments alleviate the symptoms of autoimmune conditions such as Crohn’s disease, ulcerative colitis, psoriasis, rheumatoid arthritis and eczema. Helpful as they are, though, they work in part by undermining the immune system. People on any of these meds are at higher risk for infection, and that is not good news during a bad flu season like this one. This might be a situation that calls for wearing an effective mask, such as an N95, when going out in public. Strengthen Your Immune System with NEWSTART: Paying attention to eight pillars of good health can help you strengthen your immune system. Dr. Seheult has offered a mnemonic he learned from a colleague, Dr. Neil Nedley of the Weimar Institute: NEWSTART. Let’s find out what it stands for. Nutrition: Packing your diet with vegetables, fruits, whole grains and minimally processed proteins is smart prevention to strengthen your immune system any time of year. If you come down with the flu, you might want to consider chicken soup loaded with garlic. Garlic might be a good preventive measure also, while hot chicken soup can temporarily ease congestion and other symptoms. Nutritional supplements may also be worth consideration. Dr. Seheult cited a systematic review in the BMJ Global Health (Jan. 2021).  The authors found that vitamin D modestly reduced the risk of acute respiratory infections and shortened the duration of symptoms. So did vitamin C. Zinc supplements, on the other hand, did not prevent infection but they significantly shortened the duration. Zinc is most effective taken as a lozenge that dissolves gradually in the mouth rather than swallowed at once in a tablet. Dr. Seheult also uses N-acetylcysteine (600 mg twice daily) during cold and flu season to help his immune system stay effective. It has been shown to reduce inflammation in lung infections (International Journal of Molecular Sciences, March 15, 2025). He is also a fan of topical eucalyptus, a compound found in Vicks VapoRub and certain other products. You can recognize it from the aroma. Exercise: E is for exercise. Regular physical activity is a critical pillar of good health. If you are suffering from an acute infection like flu, though, give your body a break for a bit. Exercising to exhaustion is not a winning strategy when you’re exhausted by flu before you even start. Water: Hydration is super important during influenza season. We’ve already described how to use water to raise the body temperature responsibly. That is one way to strengthen your immune system while you are fighting an infection. Drinking enough water when you have a fever is also crucial so that you don’t get dehydrated. Sunlight: Morning exposure to sunlight helps keep the immune system in tune. Ideally, we would all have bright days and dark nights. Living indoors with artificial lighting means few of us meet that ideal. Nonetheless, getting sun exposure as possible, even just face and hands in northern areas, can be helpful. Among other things, it helps regulate natural production of melatonin. Mitochondria exposed to sunlight, especially infrared lengths, make their own essential melatonin. Temperance: This is not a term we use much any more, though it was once quite popular. It simply means moderation; more explicitly, it urges refraining from alcohol, tobacco and other toxins. We have explored some common toxins in other shows. Air: Florence Nightingale insisted on fresh air in hospitals. We should be equally adamant about having fresh air in our homes. Adequate ventilation significantly cuts the risk of infection with flu. We wish everyone paid more attention to this pillar. Rest: Getting enough sleep is an essential step to strengthen your immune system. But rest implies more than enough sleep. It also means rest and recharging with a weekly reset. Practicing the sabbath, whether within a religious context or a secular one, is a sound idea for maintaining good mental and physical health. Trust: This final piece of the NEWSTART mnemonic refers to social connections. Do you have a person you can trust? Are you a person someone else can trust? Being engaged in a social network that supports you is as important as exercise and nutrition for keeping your immune system healthy. This Week’s Guest: Dr. Roger Seheult is an Associate Clinical Professor at the University of California, Riverside School of Medicine, and an Assistant Clinical Professor at the School of Medicine and Allied Health at Loma Linda University. Dr. Seheult is quadruple board-certified in Internal Medicine, Pulmonary Diseases, Critical Care Medicine, and Sleep Medicine through the American Board of Internal Medicine. His current practice is in Beaumont, California where he is a critical care physician, pulmonologist, and sleep physician at Optum California. He lectures routinely across the country at conferences and for medical, PA, and RT societies, is the director of a sleep lab, and is the Medical Director for the Crafton Hills College Respiratory Care Program. Roger Seheult, MD, MedCram, Loma Linda, UC-Riverside Listen to the Podcast: The podcast of this program will be available Monday, Jan. 12, 2026, after broadcast on Jan. 10. You can stream the show from this site and download the podcast for free. In this week’s episode, we discuss the research suggesting that using Astepro, an OTC nasal spray, can reduce the risk of contracting COVID-19. Dr. Seheult also shares his vision of the innate and adaptive immune system working together in harmony like an orchestra. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1457: 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 00:02-00:06 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. The worst flu season in decades is hitting us hard. Is there anything we can do to protect ourselves or recover faster? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:45 We should have been expecting a bad flu season. After all, the southern hemisphere suffered a very severe influenza outbreak, and that was before the mutation subclade K appeared. Joe 00:46-00:55 Our guest today is an expert in pulmonary and critical care medicine. He’s also studied natural approaches to enhance the immune system. Terry 00:55-00:57 Do you have a home flu test handy? Joe 00:57-01:05 Perhaps you should. Coming up on The People’s Pharmacy, how to strengthen your immune system for cold and flu season. Terry 01:14-02:41 In The People’s Pharmacy Health Headlines: influenza has exploded in the United States. The CDC reports that the subclade K type A H3N2 influenza strain jumped dramatically between December 20th and December 27th, and that data is two weeks old. All areas of the country are experiencing elevated flu activity, and it’s expected to continue for weeks. All of this was predictable because countries in the Southern Hemisphere experienced exactly the same pattern six months ago, before subclade K took hold. The CDC estimates that there have been at least 11 million illnesses, 120,000 hospitalizations, and 5,000 deaths from flu so far this season. That could make this year’s influenza outbreak the worst on record. Over the Christmas holiday, 45 states reported high or very high flu activity, with cases not yet peaking. There have been more pediatric emergency department visits than last year. Japan declared an influenza epidemic in October, and many schools and daycare centers closed. No one in the U.S. government is calling this year’s flu season an epidemic, but it is looking serious. It remains to be seen whether the World Health Organization will declare influenza a pandemic. Joe 02:42-03:28 Most people have put COVID out of mind now that flu is making headlines, but a new study points out that this virus still has the capacity to do a lot of damage. Between October 2022 and September 2023, there were a million hospitalizations and over 100,000 deaths in the U.S. attributed to COVID-19. The following year, there were fewer hospitalizations but about the same number of deaths. People 65 and older accounted for almost half of the COVID-19 illnesses and 80 percent of the deaths. Currently, the wastewater scan data suggests that SARS-CoV-2 is at high levels in many parts of the country and is on an upward trend. Terry 03:29-04:24 This week, the CDC updated its vaccine recommendations for babies and children. Instead of 17 infections, new guidelines target only 11. That means RSV, rotavirus, meningitis, influenza, and hepatitis A and B vaccinations will only be recommended for children at high risk. Secretary of Health Robert F. Kennedy Jr. said that this new schedule will strengthen transparency and inform consent and rebuild trust in public health. Dr. Tom Frieden, a former CDC director, countered that this is a giant step backward that jeopardizes children’s health and safety. According to Dr. Mehmet Oz, director of the Centers for Medicare and Medicaid Services, all vaccines currently recommended by the CDC will remain covered by insurance without cost sharing. Joe 04:24-05:15 On December 22nd, the FDA approved an oral form of the most popular weight loss medication, Wegovy, known by the generic name semaglutide. The company, Novo Nordisk, says that the pills are already available and that patients will be paying less for them than for semaglutide injections. The estimate is that most people will be able to get the pill for about $5 a day. More than 70,000 pharmacies, such as Costco and CVS, are already stocked with the starting dose. Having the medication available in pill form will be appealing to many people who are squeamish about needles. The pill is a bit demanding, though. It must be taken on an empty stomach at least half an hour before eating or drinking anything else. Side effects include nausea, vomiting, and diarrhea. Terry 05:16-06:17 A study recently published in JAMA Cardiology reports that semaglutide can reduce the likelihood of hospitalization in patients who are at high risk of cardiovascular events. More than 17,000 participants were randomized to receive semaglutide injections or placebo shots. They were followed for more than three years. During that time, people on semaglutide were a little less likely to be hospitalized and spent fewer days in the hospital. The authors conclude that treatment with once-weekly semaglutide was associated with significant reductions in hospital admissions and overall time spent in hospital. And that’s the health news from the People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:28 And I’m Joe Graedon. A few weeks ago, we interviewed Dr. Roger Seheult about the upcoming cold and flu season. That was before influenza really took off. Terry 06:28-06:48 Just this week, the CDC is reporting that the U.S. is experiencing the highest rate of respiratory illnesses since the 1997-98 flu season. Dr. Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security, says, ‘It’s the worst we’ve had in at least 20 years.’ Joe 06:48-07:32 What can you do to protect yourself and your family in a bad flu season? To help us learn how to strengthen our immune system, we turn to Dr. Roger Seheult. He’s an associate clinical professor at the University of California Riverside School of Medicine and an assistant clinical professor at the School of Medicine and Allied Health at Loma Linda University. Dr. Seheult is quadruple board certified in internal medicine, pulmonary diseases, critical care medicine, and sleep medicine through the American Board of Internal Medicine. His current practice is in Beaumont, California, where he’s a critical care physician, pulmonologist, and sleep physician at Optum California. Terry 07:34-07:37 Welcome back to the People’s Pharmacy, Dr. Roger Seheult. Dr. Roger Seheult 07:39-07:40 It’s good to be back. Thanks. Joe 07:40-08:07 Dr. Seheult, we’ve been following influenza for decades, and we always look to the Southern Hemisphere, Australia, New Zealand, Chile, South Africa, and they had a really rough flu season this past year. They’re six months ahead of us. What do you think we’re in for with this new subclade K influenza strain? Dr. Roger Seheult 08:08-08:54 Yeah, it could be something that is certainly something to be concerned about. That’s the way it always sort of happens every year. We try to anticipate the strains so we can have the appropriate flu vaccine, etc. But, you know, it really needs to be seen. We need to see what’s actually happening. I have actually seen already here in December when we’re recording this, some strains of the influenza virus. We usually group them into either A or B, and this is an A, and that’s about as far as we go. So I’m not sure exactly which clade we have right now as it’s starting to tick up, but it’s going to be interesting here probably in the next month or so what we’re going to see. Joe 08:54-08:57 When you say here, where is here? Dr. Roger Seheult 08:57-09:03 Ah, here in the Northern Hemisphere, in the United States, and for me particularly in Southern California. Terry 09:05-09:29 Now, what we’re interested in finding out from you today, Dr. Seheult, is what we can all do to try to help stay healthy, even though there may be an influenza season on. And it might be a bad influenza season. I’m assuming that most of us who were going to get flu shots should have done so already. Dr. Roger Seheult 09:30-09:32 Yes, yeah. Starting in October. Terry 09:33-09:51 And I would like to ask, are there medications that we might be taking that might be counterproductive that should make us even more careful about washing our hands and whatever else we need to be doing to try to keep from getting flu? Joe 09:52-10:09 Well, it just seems like all of the medicines that are available over the counter contain some kind of fever reducer, aspirin, acetaminophen, ibuprofen, naproxen. And I seem to recall you saying that that might be counterproductive. Dr. Roger Seheult 10:10-11:18 Good idea. Good thoughts. Yeah. So when you are infected with influenza in this specific case or any kind of virus, the part of your immune system which immediately gets into gear is the innate immune system. And that is the part of the immune system which is responsible for a fever. It’s responsible for the secretion of interferon, which does exactly what it says it does, which is to interfere with that infection and to basically subdue it and to reduce it as much as possible. Now, when we’re talking about influenza, there is a number of studies which have shown that, the addition of steroids or immunosuppressants can actually prolong that infection. And there is some data that suppressing fevers can prolong infections and cause them to get worse. And there’s also other data that shows that not treating a fever or actually inducing a fever can actually be very productive if it’s done responsibly in a way that heightens or enhances secretion of interferon. Terry 11:18-11:25 Tell us a little bit more about that. How would you induce a fever and particularly, how would you do it responsibly? Dr. Roger Seheult 11:25-13:01 Yeah, so there is a little bit of a risk when you increase someone’s fever, especially if they have a tendency to have seizures or their heart rate increases. But generally, the way that we have to increase someone’s body temperature is through the transmittance of heat. And the substance that we use every day that actually has a very high specific heat is water. So water is able to transmit heat to the body and actually heat up the body in a very productive way. There was a recent study that compared infrared sauna to dry sauna, like a Finnish style sauna, to a hot tub. And the hot tub had the best efficacy because obviously you’re completely submerged in water. You have to be careful because water can cause vasodilation, heat can cause vasodilation, which is basically where the blood vessels enlarge. And if you are in any way dehydrated or even not, you can actually get dizzy when you stand up and you have to be very careful about that. But if someone is there, especially if you’re in a body of water watching you, checking the temperature and elevating the temperature up, actually not very high, but just up to the point where we call it a fever, that can actually have a tremendous impact on the secretion of interferon. In a couple of studies, it actually increased it tenfold. And if you have an infection and you want to increase interferon, that’s one of the best ways to do it. And we know that this is important because there are a number of viruses which specifically, like SARS-CoV-2, specifically inhibit the body’s ability to make interferon. Terry 13:02-13:26 Not everybody has access to a sauna or a hot tub, but everybody, almost everybody, has access to a bathtub or possibly a shower if they don’t have a bathtub. So if you start to feel like maybe, maybe you might be coming down with something, is it a good idea to take a hot bath before you jump into bed and bring the covers up? Dr. Roger Seheult 13:27-16:11 Yes. And actually, I recently met probably one of the world’s experts on this type of therapy. His name is Bruce Thompson. And I met him in Australia just a couple of weeks ago. And he went over exactly his protocols. He actually even has a website that people are interested in called traditionalhydrotherapy.com or maybe it’s.org. You’ll put in either one of those where he literally has protocols that have been developed over 100 years on how this used to go down. Typically, you know, before not everybody had a bathtub. Not everybody had all of these accoutrements that we have. So the way that this used to happen is they would actually heat up towels that were drenched in water, and they would apply these towels carefully over the patient’s body that had a layer of dry cloth already, so it wouldn’t burn them. But basically, they would apply this almost like a blanket. It was called a “hot fomentation” over the patients to heat up their body. And they would know that they were doing this effectively when they started to see beads of sweat start to form on their forehead. And they would feel a little bit uncomfortable. They would do this for about 20 minutes, and then they would end with a very short, brief, cold, ice cold, what was known as [mitten] friction on the chest or on the feet. The feet are important because this is where temperature regulation is not very well controlled and you can get cold into the system. The purpose of all of this is this. Basically, the hot temperature, the increasing the temperature of the body is going to, uh… cause [an] increase of interferon, as we’ve already suggested. It’s going to set in place a number of mechanisms that we now know occur in the [JAK-STAT] system, which is basically a system which regulates interferon. And then at the very end of that, the cold is going to cause vasoconstriction peripherally in the body, which is going to lock that heat in and also cause de-margination or basically localization of these white blood cells that are anchored on the periphery of the blood vessel. So they go into circulation and they do what those white blood cells are supposed to do. So one or two of these treatments a day is what they used to do a hundred years ago. And actually there’s some very interesting data, very interesting stories about people doing these things. In fact, I’ll just slip this in there, that a Nobel prize to Julius Wagner-Jauregg was given in 1927 for using this technique to actually cure neurosyphilis in his patients by using, actually, in this case, malaria to cause the fevers and then treating the malaria. Joe 16:11-16:54 I think it was called malaria therapy. But, you know, Dr. Seheult, what I find so fascinating, you’re describing what grandmothers have done for generations, you know, sweat out the fever by literally getting under the covers and just getting really, really warm. And if I’m not mistaken, people in Finland have been using sauna baths and then hopping into cold water right afterwards. So it sounds like we’re sort of relearning what people have known for centuries. And here we are in modern medicine is saying, no, no, no, no. Take your ibuprofen, take your acetaminophen and lower your fever, which is kind of counterproductive. Dr. Roger Seheult 16:55-17:23 You know, it’s interesting. It’s not only just like Finland, it’s multiple cultures which really have not communicated with themselves for probably hundreds of years as far as we know. I’ve talked to people in Asia. I’ve talked to people in Africa. I’ve talked to people in the Middle East. And obviously, we just discussed people in Northern Europe. They all seem to have very similar practices. But of course, they’re utilizing things or tools in their area that they have access to to do this type of work. Joe 17:23-17:33 Well, we’re going to take a short break, but when we come back, I want to talk about one of your colleagues. Terry, he has an acronym. Terry 17:33-17:34 NEW START. Joe 17:34-17:52 NEW START. And what does that mean? What can we do to implement these strategies? And are there any other things that we should not be doing when we come down with a bug of some sort at this time of year. Terry 17:52-18:13 You’re listening to Dr. Roger Seheult. He’s an associate clinical professor at the University of California Riverside School of Medicine and an assistant clinical professor at the School of Medicine and Allied Health at Loma Linda University. Dr. Seheult is a critical care physician, pulmonologist, and sleep physician at Optum California in Beaumont. Joe 18:13-18:28 After the break, we’ll find out what NEW START stands for. And it’s nutrition, of course. E is for exercise and W for water. Dr. Seheult will fill us in on the rest. Why is sunlight exposure helpful, and how can you get any sunshine in the wintertime? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:52-18:55 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:55-19:08 And I’m Terry Graedon. Joe 19:09-19:16 We are facing the worst flu season in decades. Is there anything you can do to stay healthy? Terry 19:16-19:24 If you start to feel ill, is there anything you can do to recover more quickly? What does NEW START stand for? Joe 19:24-19:59 We’re talking with Dr. Roger Seheult. He’s an associate clinical professor at the University of California, Riverside School of Medicine and an assistant clinical professor at the School of Medicine and Allied Health at Loma Linda University. Dr. Seheult is quadruple board certified in internal medicine, pulmonary diseases, critical care medicine, and sleep medicine through the American Board of Internal Medicine. His current practice is in Beaumont, California, where he’s a critical care physician, pulmonologist, and sleep physician at Optum California. Terry 20:00-20:08 Dr. Seheult, I wonder if you could tell us what is the idea behind NEW START? Dr. Roger Seheult 20:11-20:18 Yeah, so NEW START is an acronym that describes basically eight pillars of health. If I could just sort of back up a little bit. Terry 20:18-20:19 Yeah. Dr. Roger Seheult 20:19-24:04 If you could picture your body, your life as a chain of links, each with their own representation of an organ. So you’ve got a heart link, a kidney link, a lung link. As you go through life in a particular way with a particular lifestyle, that will subject more strain and stress of any one of those particular links. And here of us in the Western culture, it seems as though the heart link is the one that gets beat up the most. So when people come into the intensive care unit where I work, what we do is we give medications to save lives. But generally speaking, medical interventions, what they typically will do is they will strengthen the weakest links by taking away from some of the stronger links. So for example, I’ll give people Lasix, which is a diuretic, and that’s going to help the heart, but it’s going to do so at the expense of the kidney. So generally speaking, a lot of the interventions that we do cover up the illnesses by shifting things around. And it does work, right? Because we are strengthening a weak link, which if it breaks, the patient dies in that analogy. What I am referring to here with NEW START are interventions which are easily available, which don’t necessarily have side effects in that sense, but actually have side benefits. And so what does NEW START stand for? In other words, these are things that don’t strengthen links at the expense of other links, but rather strengthen all of the links at the same time. And so these are actually really important things and principles and laws that we can follow. So what does NEW START stand for? First of all, NEW START is an acronym that was developed at Weimar University. And this is in Northern California where I have some colleagues there. And what does it stand for? N stands for nutrition. So obviously having good nutrition is really important. We can talk more about that. The E stands for exercise. Having a daily routine of moderate exercise is really important to having a long and fruitful life. The W stands for water. And we all know the importance of drinking enough water to make sure that we’re flushing our internal bodies. But also, as we’ve just discussed, the use of external water, especially in situations where we come down with infections, has a way of heating up the body and helping the immune system do what it’s already programmed to do. Then we move on to start. S stands for sun, sunlight. As you know, I’m a very big proponent of the use of sunlight in a responsible way. The T is standing for temperance, which is an old world term that we used for basically not taking in toxins into our body. And by that, I mean alcohol, tobacco, and numerous other drugs, which are not beneficial at all. The A stands for air and fresh air, but not just the lack of contaminants, but also the presence of beneficial things in the air, such as phytoncides, which are chemicals that are given off by trees, which have been shown to be beneficial for the body’s immune system. Rest is R, and I’m not just talking about a daily rest, but also a weekly rest. We need to sort of have time off to recharge, to recalibrate where we are in life. And then the final T is trust. There’s a lot of anxiety. There’s a lot of pain and things of that nature, which the science has actually shown that if we belong to a community of faith, that that actually can help with a lot of those things. And so I would say, generally speaking, there are some exceptions, but generally speaking, that most of the illnesses, most of the medical problems that we see today are a result of the violation of one of these eight laws of health. Joe 24:05-24:26 I’d like to jump right into one in particular, because as you say, you have talked about this in the past, sunlight. Why is infrared and ultraviolet and just exposure to some sunlight every day so critical for good health? Dr. Roger Seheult 24:26-26:01 Oh, it’s incredible. So the sun, if we look at it, is really divided into three types of light. There is visible light, which we can see, and that’s kind of arbitrary because we’re the ones defining it. So red, green, you know, all of those colors in there. And actually, by the way, there’s some new data that shows that particularly blue light and green light can be very beneficial for reducing the feeling of pain. Interesting that those are the main two colors of light that we see outside. But we have known for years that ultraviolet lights, specifically the UB light, is really important in the production of vitamin D in our skin. And we know that vitamin D is an important substance. It’s actually a hormone. However, not much attention has been paid until recently on infrared light, which is a light, again, that we cannot see. Because of its nature, it is able to penetrate very deeply through the atmosphere, through our clothes. And according to a research publication just published this July from Glenn Jeffrey’s group at University College London, this type of light can actually be shown to go completely through the body and to be absorbed at all levels throughout the body at the level of the mitochondria and cause an improvement in efficiency in energy production in the cells of the human body, which is really important because the mitochondria is at the epicenter of many chronic diseases that we experience here and also aging. So sunlight has been now being shown at the photochemical level to be an incredible agent for health and longevity. Terry 26:02-26:53 It seems to me that keeping our mitochondria happy, however we can do that, would be really important. I do need to ask you, though, a lot of people, especially in the northern hemisphere right about now, can’t get out into the sunlight. You are in Southern California. You have that advantage. But even here in North Carolina, it’s about 25, 30 degrees out. I’m not going to be exposing my skin for very long. And up in Michigan and Maine and Massachusetts, there’s just no way people are going to be getting any sunlight until we’re pretty well into next spring. Can you use a lamp? Do you get the same benefits? Dr. Roger Seheult 26:55-27:14 Very good question. So here’s the advantage with infrared light. You don’t need to have the sun very high up. I’ll give you an illustration: what’s the danger after you have a snowfall and the sun comes out the next day? The big issue is dry ice or not dry ice, but black ice. Terry 27:14-27:15 Uh-huh. Dr. Roger Seheult 27:15-28:53 And the issue there is what’s happened. The sun, the infrared light from the sun, even at that latitude has melted the snow and caused the water to drip down onto the pavement and has refrozen overnight. And so what is that telling you? It’s telling you that the infrared light is powerful enough to melt snow. If it’s powerful enough to melt snow, it’s powerful enough to do the effects that it needs to do in the human body. And again, it’s able to penetrate the atmosphere even when the sun is that low in the sky. It’s able to penetrate through a few layers of your clothes. All you need to do is to be able to feel the warmth from that sun, which you can do even in the dead of winter, even on a cloudy day, although it is reduced. Here’s the key point. The point is, is that the amount of infrared light that you’re getting on a cloudy day in North Carolina or even in Michigan is going to be many times more than the type of the amount of infrared light that you’re going to get inside. Nevertheless, I understand your point. And yes, there are devices that are being made that transmit in the infrared spectrum. Now, the issue there, though, is that while the sun is putting out infrared photons at all of the wavelengths, you know, going all the way down to 760 nanometers, which is the nearest infrared, all the way through to 3,000, 4,000 and on in the farthest infrared. When you buy these devices that give off infrared, they’re giving you basically artificial light at one particular wavelength. Nevertheless, there are studies which show that infrared light, even in these narrow spectrums, does have benefit through randomized controlled studies. Joe 28:55-29:41 So, Dr. Seheult, I get the idea that sun exposure is really valuable, and that takes me to melatonin in particular, and one of those key elements that you talked about, sleep. Could you give us a quick overview on the value of melatonin and what the right dose is? We’ve heard all kinds of controversy. You shouldn’t take more than three milligrams, but you can buy 10 milligram pills of melatonin. And now gummies are really popular. So give us the short, sweet, and helpful information that we need to use melatonin correctly and how that relates to sunlight. Dr. Roger Seheult 29:42-32:18 Yeah, there are two districts of melatonin in the human body. And I would say some papers will say 95% of the melatonin in the human body is not even of the type that we get from sleep and that we get orally. But in fact, it’s produced in the mitochondria and in orders of magnitude higher. That is not the type of melatonin that you can easily supplement with oral melatonin. That’s the type of melatonin that the mitochondria make. And it seems as though, based on some studies, that infrared light that penetrates down to that level actually stimulates that type of melatonin. So if you want melatonin for your mitochondria in the daytime, the best way to do that is to get out in the sun. Now, obviously, at night when we’re sleeping, there is no sun. And so the body has a system to bathe the mitochondria at night with melatonin. And the way that that’s done is through secretion of melatonin from the pineal gland in the brain. That will only happen, however, if your eyes are not being exposed to light. So it’s really important that if you want the maximal amount of melatonin in your body at all times, it’s important to have bright days and to have dark nights. We right now are having the opposite problem. We’re having dark days because we’re inside and not getting outside into the sun. And we have bright nights because we come home late and we’re doing all sorts of work on screens, staying up late, watching entertainment, and stopping the body from doing what it’s naturally supposed to be doing. So people will supplement with melatonin. Of course, in the United States, that’s not as regulated as our pharmaceutical medications are, so you have to make sure that you’re getting it from the right place. But the other thing that you’ve got to remember is that melatonin secretion from the pineal gland at night is also a signal to your body that it’s time to go to sleep. And so when you take supplemental melatonin, and sometimes I use this, I use it for jet lag, for other ailments. You’ve got to remember, though, that when you give huge pulses of melatonin, that can sometimes interfere with circadian signaling, and such to the point that if you’re giving doses higher than three to five milligrams a day, it can actually have a counterintuitive effect or even just make the patient more irritable or irritated. If you want to simulate the normal physiological secretion of melatonin from the pineal gland at night, we’re talking three to five milligrams at most. Joe 32:21-33:02 I’d like to add, if we have a few minutes left before the break, a very quick review of some of the dietary supplements besides the melatonin that people often turn to when it comes to infections. So obviously, vitamin C comes to mind almost immediately. It’s been highly controversial in this country, but there are others as well. There’s elderberry, there’s zinc, there’s NAC, there’s eucalyptus. If you could just give us a quick summary of all of the dietary supplements that people tend to rely on once they come down with some kind of a bug. Dr. Roger Seheult 33:02-34:15 Let’s talk about three that I’m familiar with, which is zinc, NAC, or N-A-C, and eucalyptus. So first of all, let’s talk about NAC first because we have some pretty good data on that and influenza. There was a study that was published in 1997. That’s how long we’ve known about this, that in people who took N-A-C or N-acetylcysteine, 600 milligrams twice a day, every day throughout the winter season, so we’re talking three to six months here, that they did not experience a reduction in influenza infections. But they did experience a tremendous reduction in influenza symptoms. In fact, in this multi-centered, randomized, placebo-controlled trial, so top evidence here, they were able to reduce the symptoms all the way from 89% down to 25%. That’s a very large relative risk reduction and actually a very large absolute risk reduction. So I actually do take NAC throughout the winter season so that as sort of a backup to if I were to get the influenza virus, that it would dramatically reduce the symptoms. Terry 34:17-34:18 That’s very impressive. Joe 34:18-34:20 What about vitamin C and zinc? Dr. Roger Seheult 34:21-35:24 Yeah, so vitamin C, you’re right. There have been some controversial studies regarding that. I don’t have a lot of experience using oral vitamin C. Of course, there’s not a lot of risk in taking vitamin C unless, and this is a point that I bring up for those that are working in the hospital, if you give large, very large, like multiple gram doses of intravenous vitamin C, one of the things that you’ve got to be careful of is that it can interfere with some point of care glucose monitoring, which will confuse that ascorbic acid intravenously with glucose. It will read as a glucose that is elevated in some brands, and that could trigger, unfortunately, a spurious result, which would then spur someone to give a high dose of insulin subcutaneously when that was not needed and cause someone’s blood sugar to drop precipitously. So that is a concern I’m always cognizant of in patients who are getting high-dose vitamin C in an inpatient setting. Joe 35:24-35:28 We have one minute before the break. Zinc. Dr. Roger Seheult 35:28-36:08 So zinc, when given after someone gets a cold, did not reduce the symptoms—sorry, did not reduce the incidence of getting it, so as prophylactic. But zinc did reduce the length of time. And there was a particularly randomized controlled trial that taking in about, I think, 26 milligrams of zinc, elemental zinc, twice daily reduced the length of time that you had the symptoms of the cold. And then, real briefly, eucalyptus. Taking eucalyptus on the skin, not intaking it internally, has been shown in a number of studies to improve the innate immunity of natural killer cells and macrophages. Joe 36:08-36:11 And where do you get eucalyptus? Dr. Roger Seheult 36:11-36:18 Well, you can get eucalyptus in Vicks VapoRub, in essential oils. It’s very easy to tell because it has a very distinctive smell. Joe 36:18-36:25 So maybe when grandmothers put a little Vicks VapoRub on the chest of a child with a cold, it made sense? Dr. Roger Seheult 36:26-36:35 You know, that’s exactly what they did during the 1918 pandemic. It almost cost Australia its eucalyptus trees because the world was [in] such demand for it. Terry 36:36-36:59 You’re listening to Dr. Roger Seheult. He’s an associate clinical professor at the University of California, Riverside School of Medicine and an assistant clinical professor at the School of Medicine and Allied Health at Loma Linda University. Dr. Seheult practices in Beaumont, California as a critical care physician, pulmonologist, and sleep physician at Optum California. Joe 36:59-37:09 After the break, we’ll get a few more details about NEW START. Does chicken soup offer immune support? How about garlic? Does it have any benefits against infection? Terry 37:10-37:14 How can we make better lifestyle choices when we’re trying to recover from a cold or the flu? Joe 37:15-37:23 It’s a good idea to keep flu tests at home, so if you start to feel bad, you have some idea what may be causing the problem. Terry 37:24-37:28 Tamiflu can help speed recovery, but only if you start it early enough. Joe 37:28-37:32 How does Dr. Seheult protect himself during cold and flu season? Terry 37:39-37:43 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 37:55-38:09 And I’m Terry Graedon. Joe 38:09-38:18 Today, we are talking about how to strengthen your immune system for cold and flu season. We’re currently in the middle of a nasty one. Terry 38:18-38:34 Earlier in the show, we heard about an acronym, NEW START, to make it easy to remember the pillars of good health. It might be a little bit easier and more evidence-based than trying to remember what your grandmother said a long time ago. Joe 38:34-39:09 Our guest is Dr. Roger Seheult, and that’s spelled S-E-H-E-U-L-T. He’s an associate clinical professor at the University of California Riverside School of Medicine and an assistant clinical professor at the School of Medicine and Allied Health at Loma Linda University. He’s also the co-founder and chief presenter for MedCram.com. This online medical education company offers instructional videos for healthcare professionals as well as regular people. Terry 39:09-39:48 Dr. Seheult, we spoke just a few minutes ago about NEW START as an acronym to help us remember what’s important. And of course, the N stands for nutrition. And you suggested, I think everybody is going to agree, that good nutrition is important. But let’s get a little more specific about what do we mean by good nutrition in the context of keeping our immune systems ready to fight the flu. I’m thinking chicken soup, but I don’t know if I’m way off, [garbled] is there? Dr. Roger Seheult 39:50-39:59 No. So let’s talk a little bit about chicken soup. Have you ever noticed that when you take anything that’s hot, especially when you’ve got a cold, that all of a sudden your nose just starts to run? Terry 39:59-40:06 Yes. That happens whether I have a cold or not, actually. I’ve got that gustatory rhinitis. Yes. Dr. Roger Seheult 40:07-41:01 Yes. Gustatory rhinitis. Exactly. So there has been actual studies that have looked at chicken soup. And here is where we see the evidence showing. It does actually provide modest short-term congestion relief. And it also, by the way, as we talked about, when you’re drinking something hot and putting something hot in there, there may be a local phenomenon where we see an increase in interferon secretion. So do we know that that’s actually what’s going on there? I don’t know of any studies that have actually looked at local interferon production, but we definitely can see the studies that there is modest short-term congestion relief. There may be some anti-inflammatory effects that we see in the lab in vitro. And also, of course, when you’re drinking chicken soup, you’ve got hydration, you’ve got electrolytes, and that’s also very helpful when you’re not feeling very well as well. Terry 41:01-41:18 Well, I do know there was a study maybe 10 or 12 years ago that compared chicken soup to just plain hot water and the chicken soup was better at alleviating congestion. So maybe there is something there that’s a little bit beyond just hot water. Joe 41:19-41:46 Well, you know, my mom, Helen Graedon, loved garlic. And so when she made chicken soup, she loaded it up with garlic. And we’ve even heard from somebody who had a chicken recipe, chicken adobo with like a dozen cloves of garlic. Does garlic have any benefit here when we’re talking about infection? Dr. Roger Seheult 41:46-42:51 Definitely. So there is a substance that is packaged in the clove of garlic called alliin. And when you fracture the cells of the garlic, there is sort of like that reaction that occurs if you ever go skiing and they give you those hot packs and you break it. The two chemicals come together and there’s a reaction of heat. Something very similar happens there in the clove of the garlic where alliin is converted into something called allicin, and that has a lot of antimicrobial properties to it. It’s a very powerful natural antibiotic. In terms of the flu, one of the major places where we run into difficulties and complications with the flu is when you have super infections, super bacterial infections. The influenza virus wipes out a lot of the innate boundary immunity of the respiratory tract, which opens it up for opportunistic infections like Staph aureus and other opportunistic bacteria. And having a milieu, if you will, of antimicrobial substances can be actually pretty beneficial to prevent those from happening. Terry 42:51-42:59 So that high-in-garlic chicken soup or probably any soup that’s high in garlic would be a good idea. Dr. Roger Seheult 43:00-43:07 Yeah, and it also is a natural way of maintaining social distancing. Terry 43:07-43:08 Yes, definitely. Joe 43:08-43:09 Right. Terry 43:09-43:19 And what about cod liver oil? That has been a traditional approach in some cultures for a long time. Dr. Roger Seheult 43:20-43:26 Yeah, and it may be that they found that, again, a lot of these things, I don’t think they looked at the science of it. They didn’t have the ability to do that. Terry 43:27-43:27 Right. Dr. Roger Seheult 43:27-44:37 But they found that when they took these things, they noticed that people got better, kind of like what they noticed in the 1800s when Florence Nightingale noticed that soldiers that were outside in the sun seemed to get better. So cod liver oil is rich in three things, omega-3 fatty acids, vitamin D, and vitamin A. And of course, the one that should send off alarm bells or ring bells in your mind is vitamin D. So there has been a number of studies that have looked at vitamin D supplementation. There was Dr. Martineau’s meta-analysis that was published now probably about five or six years ago in the British Medical Journal that showed that daily regular supplementation with vitamin D reduced acute chest infections. And that was statistically significant finding. There’s also a recent article that was published from Harvard looking at vitamin D supplementation showing that it reduced autoimmune conditions. So there’s a lot of research there that looks at vitamin D. Cod liver oil is one way of supplementing with vitamin D, especially in the wintertime, where there’s definitely some evidence that shows that our vitamin D levels subside somewhat in the wintertime, and we need to get those levels up. Joe 44:38-45:35 Dr. Seheult, you mentioned autoimmune disorders, and I am thinking about all of the biological drugs that have become available in the last several years to treat things like eczema and rheumatoid arthritis and Crohn’s disease. I mean, the list, it’s astonishing how many drugs we now have, very pricey medications. And oftentimes in the commercials, they say something along the lines of, may increase your risk for fungal infections or some other TB, be careful, you better be tested for tuberculosis. And I think of all the people who are taking prednisone, which is a very powerful anti-inflammatory drug that also impacts the immune system, on the one hand, they’re relieving symptoms. But on the other hand, is it possible that we’re making ourselves more susceptible to infection? Dr. Roger Seheult 45:36-49:12 Well, absolutely. That’s a well-known risk of these things. So the issue is that we have an immune system that has to do two things all the time. It has to identify non-self and destroy it, and it has to be able to not have collateral damage. I mean, it’s the same kind of precept that we have with our armed forces, right? We want to target the enemy, but not target our own servicemen and have friendly fire. And that’s the problem that we have with this approach, where we either have medications that suppress the immune system or have things that enhance the immune system. What we really want to do is we want to have the immune system trained on what’s foreign and then tell the immune system and educate the immune system on what is self. And so the issue that we have with autoimmune conditions, obviously, is that we have the immune system that’s targeting self for some reason. What we have found is that vitamin D is one of those things that educates on the immune system about what is self and what is non-self. Again, that study that I showed that basically supplementation with vitamin D seemed to reduce the incidence of all of these autoimmune conditions. Now, obviously, every case is different. Some people have severe, severe autoimmune conditions, and they’re on immunosuppressants from their physician. And obviously, that needs to be a discussion with them about the risks and the benefits. However, I am convinced that if we were to follow those eight laws of health a little bit more carefully, the number of people that would fall into that category of needing to have these very powerful immunosuppressants would be less. For instance, vitamin D is not only a substance and a hormone, it’s also a marker of sunlight. And we know, for instance, that toll-like receptor 4, which is a very important gateway for inflammation in the body, is mitigated in the presence of infrared light. And so we already know that infrared light is able to penetrate into the body. We already know that many of these autoimmune conditions can vary by latitude. For instance, multiple sclerosis, clearly an autoimmune condition. We have clear evidence that as you move away from the equator, these types of diseases increase in prevalence. Before 1980, for instance, before 1980, when we had very good pharmaceutical options for high blood pressure, there was a study that was done that looked at blood pressure and the distance from the equator. And as you move from the equator, blood pressure goes up. I think that the total distribution from the equator to the most northern measurement that they did was about five millimeters of mercury. So it’s not large, but there was a definite, very gradual increase in blood pressure. And I believe that that distinction and that relationship with sunlight exposure still holds today. And if you look at what we’ve done in the last 20 years, we have moved into indoor environments, slowly but surely, that was accelerated a lot during the pandemic. We don’t go out nearly as much as we used to. We’ve developed behaviors that allow us to stay in our home like DoorDash and Amazon delivery. And not only that, we’ve cut out infrared lights systematically from that indoor environment with low E-glass windows and with LED bulbs that are purposefully designed not to give out infrared light because of energy efficiency. Terry 49:14-49:53 So it sounds as though a lot of the lifestyle adjustments we have made without even realizing it may be counterproductive when it comes to trying to keep from catching the flu. You also mentioned that exercise is an important pillar. And what about exercising when you’re not feeling well? Most of us, when we start to come down with something, don’t really want to push it. Are we making a mistake or should we give ourselves a little grace for that period of time while we’re not feeling good? Dr. Roger Seheult 49:53-50:42 I think grace is an important thing here. You know, when you’re not feeling well from a virus, there is always that potential that the myocardium is inflamed. And I would say it would be very wise not to over-exaggerate or to stress the heart tissue during that period of time for at least two weeks. So moderate to strenuous exercise should be avoided when someone has a viral illness and to not overdo that. I mean, when you do a hot bath or a hot shower, you are going to be increasing the heart rate in a way. So that’s why we only do that for about 20 minutes, maybe once a day. But I would not go out of the way to exercise when someone is ill. Now, when you’re not ill and on a regular basis, it’s great. But when you are ill, it’s best to rest. Joe 50:43-51:19 Dr. Seheult, I’d like to remind our listeners that it’s not just the flu and it’s not just the cold, the common cold, which is actually a couple of hundred viruses, rhinoviruses and adenoviruses. There’s whooping cough that’s out there now, and there’s RSV, and there’s measles that’s coming back, and then there’s walking pneumonia. I think it’s mycoplasma pneumoniae, and let’s not forget there’s parainfluenza and human metapneumovirus. I mean, there’s a lot of nasty pathogens out just waiting to invade our bodies. Dr. Roger Seheult 51:19-51:34 Yeah. For instance, when we have patients that come into the hospital and we are able to take a swab, we can put it through a machine that tests for all of those things. There’s like 17 different ones and it will tell us which ones are positive and which ones are negative. Joe 51:34-51:51 Well, speaking of testing, people can now test at home for influenza and for COVID. And is that something that they should be doing? Because it’s a very different approach depending on what you’re diagnosed with. Dr. Roger Seheult 51:52-52:21 That’s exactly correct. And so there are medications that are FDA approved for specific viruses that they’re tested in. So it’s now become important where before we didn’t have these distinctions, it’s now become important if you want to reduce the number of symptoms by a day, there’s medications like Tamiflu, etc. that can reduce that. It’s not going to be effective at all in RSV. It’s not going to be effective at all in SARS-CoV-2, but it will be effective in influenza type A. Terry 52:22-52:39 So if you wanted to take Tamiflu or Xofluza, which are both FDA approved for treating the flu, I think you need to start them as basically ASAP, which means having your flu test ready at home, right? Dr. Roger Seheult 52:40-53:27 Exactly. Definitely. Yes. You want to know what you’re dealing with as soon as you possibly can, if you’re going to go down the pharmacological route. And I wouldn’t say not to do that. I’m more of an and person than an or person. The benefit though, with things that we’ve talked about here, like hydrotherapy, things of that nature, is that it really is going to work for any type of virus and you don’t need to have a test to do that. But yes, if you wanted to add to that. And I’m all for and to doing multiple things. Like I always give the analogy in the operating room. If we want to reduce operative infections, it’s not a matter of, hey, the surgeon wore sterile gloves today, so we don’t have to sterilize the instruments. No, we need to do all of those things. Joe 53:27-53:51 Dr. Seheult, we just have about a minute left. And you’re in the intensive care unit, you’re in the hospital. You’re exposed to all kinds of nasty things. In the minute we have, can you kind of summarize what you do to prevent coming down with all of these nasty things? Give us your insights on how to stay healthy in the coming six months. Dr. Roger Seheult 53:52-54:49 You know, I try to do as much as I possibly can that has low risk because I’m going to be doing it every day. So I try to make sure to get sunshine for at least 15 minutes a day. I try to get sleep and to make sure that the sleep is uninterrupted and the room is dark, so I get the maximum amount of melatonin. Make sure that my immune system is benefiting from that standpoint. If I do feel that something is coming on, it’s into the hot tub, it’s into the shower, it’s basically heating up my body prophylactically to make sure that if there’s anything there, I’m getting interferon secretion. And then from there, I will supplement with NAC during the winter season, which is what I’m doing currently right now, 600 milligrams twice a day. And if I feel like something’s coming on, I will take some zinc, as we described, to sort of speed that up. I also take a supplement of vitamin D for me personally because I’ve had my levels tested and I want to get those levels up to a reasonable amount. But I don’t use that as an excuse to not go out into the sun. The sun has benefits far beyond vitamin D. Joe 54:50-55:17 Dr. Seheult, COVID is still here, no matter how much we would like to pretend it’s gone. Tell us about this nasal spray called Astepro. It’s an antihistamine. It’s used to calm symptoms of allergy. A study seemed to suggest that it might be beneficial against COVID-19. Any suggestion that might be true? Dr. Roger Seheult 55:17-57:01 Yeah, so there are two versions of that nasal spray. There is uh, azelastine, which is the generic, and then there’s Astepro, which is actually a higher dose, but has interestingly been made over-the-counter. So there’s a little interesting thing about this. The study itself actually used the prescription strength, which is actually a lower dose as opposed to the over-the-counter strength. So just be aware of that. The over-the-counter strength also, by the way, doesn’t taste as nasty and it’s dosed once a day, whereas the prescription azelastine is actually supposed to be twice a day. Now, they actually did it three times a day in their study, so just be aware of that. And what they found was that it reduced the incidence of SARS-CoV-2. Now, there’s been a lot of speculation about the results of that. They think that it may be simply squirting something up the nose may actually rinse out and get rid of the virus. There’s also a preservative, by the way, in that azelastine that may or may not have a benefit, although that preservative that they put into the azelastine is also in steroids, and they didn’t see the same thing there. So I don’t know how much relevance there is with that. I think it’s a fascinating mechanism. It’s an antihistamine. It may be blocking the receptor, preventing the SARS-CoV-2 from binding, and that is the reason why it’s preventing infection. I think more research needs to be done, but certainly the risk of this is pretty low. It is available in a higher dose over the counter. So I can’t think that there’s a lot of risk in trying this out in the winter season. Joe 57:03-57:42 Dr. Seheult, we have heard people describe the immune system as if it were an orchestra. That is to say, there are so many players for our immune system to be healthy. It’s not just interferon. It’s not just the interleukins. It’s not just one particular thing. It’s this amazing array of compounds that the body secretes or suppresses in order to fight off infection. Can you give us a quick overview of your understanding of how the immune system works in harmony. Dr. Roger Seheult 57:42-01:00:09 Yeah, it’s a wonderful orchestra. And it starts off almost like Beethoven’s fifth when an infection happens, you know ‘dunt-dunt-dunt-duh,’ and what happens next? Well, you’ve got the innate immune system, which is tuned to look for generalities of what is self and what is non-self. And not only that, by the way, it also looks at what is self but damaged. This is the reason why the innate immune system is so important. We think that it’s not as educated as perhaps the adaptive immune system, which has the B cells and the T cells and the antibodies that are surgically tuned to specific proteins that can knock them out. The innate immune system has an incredible job. It is there to specifically knock out things in general that are foreign, but also look at things that are damaged in our body. And things get damaged all the time. And if we don’t break those things down, they don’t just not work as well. They can actually turn into cancer. So innate immunity is important and innate immunity is related to sunlight. It’s related to sleep. It’s related to all of those things. So what do we see there? Natural killer cells, monocytes, macrophages, all of those things. Now, those antigen presenting cells that eat things present on the other side to the adaptive immune system. And they come in a little bit later, probably around day seven when you’re talking about a generalized infection, unless they’ve been adapted before, unless they know the infection. It takes time for them to come up online, but when they do, there’s a tremendous cytokine storm that could happen if things haven’t been dealt with effectively by the ones that have gone inside to sort of break up things first, the innate immune system. So it’s really a one-two punch where you have this generalized wearing down of the invader, and then finally the surgical strikes that you see with the adaptive immune system working in conjunction with each other. If the virus is able to cripple the innate immune system, then you can see very clearly when the adaptive immune system comes online, like we saw during COVID after about seven days of burning along with this infection, the surgical precision is so broad that the patient goes into cytokine storm, is admitted to the hospital, ends up on a ventilator. So it’s important that both have the opportunity to do what it needs to do. And science is just opening up these ideas now for us to see and where we can actually implement change. Terry 01:00:10-01:00:15 Dr. Roger Seheult, thank you so much for talking with us on The People’s Pharmacy today. Dr. Roger Seheult 1:00:16-1:00:17 Thank you. Joe 1:00:17-1:01:05 You’ve been listening to Dr. Roger Seheult. He’s an associate clinical professor at the University of California Riverside School of Medicine and an assistant clinical professor at the School of Medicine and Allied Health at Loma Linda University. Dr. Seheult is quadruple board certified in internal medicine, pulmonary diseases, critical care medicine, and sleep medicine through the American Board of Internal Medicine. His current practice is in Beaumont, California, where he’s a critical care physician, pulmonologist, and sleep physician at Optum California. Dr. Seheult is co-founder and chief presenter for MedCram.com, an online medical education company we highly value. That’s MedCram.com. Terry 01:01:06-01:01:14 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 01:01:15-01:01:21 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Terry 01:01:22-01:01:38 Today’s show is number 1,457. 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 01:01:38-01:01:58 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. The podcast this week has additional information about using the OTC antihistamine Astepro to help protect yourself from COVID and flu. We also hear how the immune system can behave like an orchestra in harmony. Terry 01:01:59-01:02:12 At peoplespharmacy.com, you could sign up for our free online newsletter and get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. Joe 01:02:12-01:02:15 In Durham, North Carolina, I’m Joe Graedon. Terry 01:02:15-01:02:48 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 01:02:49-01:02:58 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 01:02:58-01:03:03 All you have to do is go to peoplespharmacy.com/donate. Joe 01:03:03-01:03:17 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.

Transcribed - Published: 9 January 2026

Do you know someone who has struggled for years to meet deadlines or manage their time? Perhaps you have a smart friend who just never did well in school (or possibly at work) because they couldn’t seem to turn papers (or reports) in on time. Such people might find a diagnosis of attention deficit hyperactivity is a relief. Could it free them to find new and hopeful ways to cope with challenges? In this episode, we explore the transformative power of diagnosis. 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, Dec. 20, 2025, 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 Dec. 22, 2025. The Transformative Power of Diagnosis: Our first interview on this topic is with psychiatrist Awais Aftab. Dr. Aftab has written about “the Rumpelstiltskin effect,” so we asked him to explain it to us (BJPsych Bulletin, Aug. 22, 2025).  He describes the relief and even therapeutic effect some people experience when their symptoms can be categorized by a diagnosis rather than as a character defect. This Rumpelstiltskin effect can be found in the folktales of a wide range of cultures as well as science fiction and fantasy. The idea that esoteric knowledge, even if it is only a name, can help offer a measure of control exemplifies the transformative power of diagnosis. The ritual of receiving a diagnosis may also give people relief from cognitive ambiguity. Some people find that a clinical diagnosis offers validation of their lived experience. In addition, getting a diagnosis may give them an avenue to connecting with others whose experience may be similar. Supportive communities have grown up around the diagnoses of autism spectrum disorder or Asberger’s syndrome. Dr. Aftab views the transformative power of diagnosis alone, regardless of any treatment available, as similar to the power of placebo. Potential Downsides of a Diagnosis: Just as a placebo may relieve symptoms and also cause side effects, the transformative power of a diagnosis may sometimes work against a person. If the patient getting the diagnosis finds that it helps clarify new steps toward managing his or her discomfort, it is a benefit. But if instead it becomes an invitation to succumb to symptoms, then it could be harmful. Stepping into the sick role can become maladaptive. A Second View: We discussed this idea with another psychiatrist, Dr. Robert Waldinger. He pointed out that a person’s previous experience and their family’s expectations could have a significant impact on whether the transformative power of diagnosis works for good or for ill. One example might be hypertension. One person receiving that diagnosis might remember that his father had hypertension and took his blood pressure medicine conscientiously and lived to a ripe old age. Another person might get the same diagnosis and freak out because a grandfather with hypertension died of a stroke. Helping People Manage without a Diagnosis: When life is hard, people may become anxious or despondent without a clinical mental disorder. They still need support. How can we help people talk about their uncomfortable feelings? Even mental health professionals may need practice to feel comfortable actually talking about a person’s authentic feelings. They may be frightened that the person will reveal despair that they don’t know how to alleviate. Dr. Waldinger reminds us that we don’t have to fix another person’s feelings, but truly listening can itself help. Authentic communication is the heart of connection. As with the transformative power of diagnosis, simply being heard and acknowledged may make a person feel better. Dr. Waldinger is fond of this quote: “Attention is the most basic form of love.” Relationships can help us in hard times. They also bring us joy. We also remind listeners of the crisis hotline 988 for those who are considering suicide. This Week’s Guests: M. Awais Aftab, MD is a Clinical Associate Professor of Psychiatry at Case Western Reserve University. Psychiatry at the Margins is Dr. Aftab’s Substack newsletter about exploring critical, philosophical, and scientific debates in psychiatric practice and the scientific study of psychology. Dr. Awais Aftab, Case Western Reserve University Robert Waldinger, MD, is a professor of psychiatry at Harvard Medical School, director of the Harvard Study of Adult Development at Massachusetts General Hospital, and cofounder of the Lifespan Research Foundation. Along with being a practicing psychiatrist and psychoanalyst, Dr. Waldinger is also a Zen master (Roshi) and teaches meditation in New England and around the world. Dr. Waldinger, with co-author Marc Schulz, PhD, is the author of The Good Life: Lessons From the World’s Longest Scientific Study on Happiness. 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). Robert Waldinger, MD, author of The Good Life Listen to the Podcast: The podcast of this program will be available Monday, Dec. 22, 2025, after broadcast on Dec. 20. You can stream the show from this site and download the podcast for free. In this week’s episode, Joe describes his experience with aphantasia and his relief at discovering there is a name for it. In the podcast, Dr. Waldinger discusses gratitude and how we can cultivate it, when it seems so easy to fall back on anger. One approach is the subtraction idea: we may feel irritated with our partner because of the way they load the dishwasher. But when we imagine what it would be like without them, we can experience gratitude that they are in our lives. We also consider the pain of estrangement and the difficulty of rebuilding relationships. Dr. Waldinger shares his personal story of estrangement and how it feels to make peace at last. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1456: 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. Many people struggle for years with time management and deadlines. Could a proper diagnosis be liberating? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:45 Some people find that a diagnosis of attention deficit hyperactivity disorder could explain a lot about their behavior. It may come as a relief to know why deadlines are so difficult. Joe 00:46-00:51 When you experience the world differently from others, it can help to know why. Terry 00:52-01:02 How can we really connect with people to find out how they’re feeling beyond the usual question, how are you? Why do relationships matter? Joe 01:03-01:09 Coming up on The People’s Pharmacy, relationships and the transformative power of diagnosis. Terry 01:14-02:25 In The People’s Pharmacy Health Headlines: Cases of influenza are starting to rise. If the UK is any indicator, we could be in for a bad flu season. That’s because British health authorities are reporting a wave of super flu infections. Hospitalizations for flu are up 50% there over last week, straining facilities. Presumably, some of the increasing cases is due to the mutation in influenza A last summer that created subclade K. That happened after the strains for vaccinations this year had already been selected. In the UK, the medical director for the National Health Service said, the numbers of patients in hospital with flu is extremely high for this time of year. The head of the Children’s Hospital of Eastern Ontario in Canada reports an early and intense start to flu season that has stretched capacity to the limit in pediatric emergency departments. That’s not yet the case in the US, where rates of flu are in line with last year’s influenza outbreak. Keep in mind, though, that last year’s flu season was nasty. Joe 02:26-03:22 Researchers are beginning to get a better understanding of the cellular pathways contributing to long COVID. A new research paper published in the journal Nature Immunology found that people with long COVID had persistently high inflammatory markers. The SARS-CoV-2 virus seemingly triggered an immune reaction that did not fade as most reactions normally do. This leads to a chronic inflammatory condition that causes extreme fatigue, brain fog, heart palpitations, dizziness, and exhaustion after modest exercise. The investigators are testing a biologic drug called abrocitinib that targets one inflammatory pathway and is used to treat eczema. If this research holds up, it may provide clinicians new tools for easing the devastating symptoms of long COVID. Terry 03:23-04:10 This is the time of year that a lot of people are bundled up against frigid temperatures. But some people crave sunshine. Often they turn to tanning beds for ultraviolet exposure. A new study, published in the journal Science Advances, reveals that tanning bed use increases the risk of melanoma, the most dangerous form of skin cancer. What’s surprising about this data is the location of the melanomas. They often occur in body sites that don’t get much sun. The researchers hypothesized that during tanning sessions, people expose places on their bodies such as the lower back and buttocks that aren’t usually out in the sun. Tanning beds could lead to more mutations and a three times higher risk of cancer. Joe 04:11-05:04 Back in 2015, the FDA approved a pill called flibanserin for premenopausal women who complained of low sexual desire. The brand name is Addyi. Now, the agency has approved it for use by post-menopausal women. This certainly increases the number of women who might get a prescription, as low sexual interest is a relatively common complaint during and after menopause. Oddly, the data that FDA relied on for this approval came from the same trials that supported approval for pre-menopausal women back in 2015. Side effects include dizziness, fatigue, nausea, sleep disturbances, and dry mouth. Fainting is rare, but taking the pill in combination with alcohol increases the risk. That could have an important impact on date night. Terry 05:05-06:17 The sexually transmitted disease, gonorrhea, has become more difficult to control. The pathogens that cause it have become resistant to many antibiotics. So it’s good news that the FDA has just approved two new antibiotics against gonorrhea. They’re both in the same new class of drugs. Zoliflodacin will be sold as brand-name Nuzolvence. It was developed through a public-private partnership. The FDA also approved a new indication for gepotidacin, sold as Blujepa. Its previous approval was for uncomplicated urinary tract infections. Now it’s also used for uncomplicated gonorrhea. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:36 And I’m Joe Graedon. Could getting an accurate diagnosis be transformative? I, for one, can attest to the power of learning why my experience is so different from nearly everyone else in the world. That’s because I have a rare neurological quirk called aphantasia. Terry 06:37-07:04 Some people have found that receiving a correct diagnosis of, for example, attention deficit hyperactivity disorder is a relief. It helps explain that they’re not lazy or stupid. Instead, their brains work differently. Dr. Ned Hallowell once described ADHD as having a Ferrari brain with bicycle brakes. To get the most out of it, you really have to learn how to use it skillfully. Joe 07:04-07:37 Today, we are exploring the transformative power of a correct diagnosis. Later, we’ll be talking with Dr. Robert Waldinger, Professor of Psychiatry at Harvard Medical School and Director of the Harvard Study of Adult Development at Mass General Hospital. First, though, we turn to Dr. Awais Aftab. He is a Clinical Associate Professor of Psychiatry at Case Western Reserve University. His Substack newsletter is “Psychiatry at the Margins.” Terry 07:37-07:40 Welcome to the People’s Pharmacy, Dr. Awais Aftab. Dr. Awais Aftab 07:41-07:42 Good to be here. Joe 07:43-08:08 Dr. Aftab, I wonder if you could tell our listeners the story of Rumpelstiltskin. I remember hearing this Grimm’s fairy tale when I was a kid, but I suspect that a lot of listeners have kind of forgotten what this folktale was about. So if you tell us the story and also why it illustrates the importance of getting a correct diagnosis. Dr. Awais Aftab 08:09-09:59 Yeah, certainly. So in the classic Grimm’s folktale, Rumpelstiltskin, a young woman promises her firstborn child to a little man in exchange for the ability to spin straw into gold. And when he comes to collect, she begs for mercy and he offers her a way out. She must guess his name. Now, at this point, she’s a queen, and she… the woman runs through every name in the German language that she can think of, every colloquial nickname. Nothing works. Finally, her servant discovers the little man’s highly esoteric name, Rumpelstiltskin, and she says the name and she’s released from the obligation. Now, this illustrates a number of more important things. You know, the source of [the] queen’s distress, it does not have a familiar name and she can’t really substitute it with a layperson description either. She can’t say “funny-little-man” that won’t do the job. In fact, so what is needed is esoteric knowledge. And that knowledge kind of gives her control over what ails her over her problem. And as soon as she knows the name, the problem takes care of itself. This kind of folktale exists in many numerous cultures. It exists in modern sci-fi. It exists in fantasy where kind of knowing certain esoteric words gives you [the] ability to control magic, gives you [the] ability to do things. And we suspect, me and my co-author, Dr. Ellen Levinovitz, that something similar is going on in medical settings where official medical diagnosis serves as providing that esoteric knowledge. And when people’s distress and their difficult experiences are conceptualized using medical terminology, it offers them a kind of relief that they would not get from just the layperson description of their problems. Terry 10:00-10:29 Dr. Aftab, you suggested that some patients who get a diagnosis, and the article that you’ve written, it’s about psychiatric diagnoses, feel better just because they have some kind of explanation. And presumably, it’s because that makes them feel like they have a little more control. Could you tell us at least one and maybe even two stories about people who had this experience? Dr. Awais Aftab 10:30-13:02 Yes. So the article focuses on mental health disorders, but we believe that the phenomena itself exists across medicine and we see it play out in many areas such as, you know, headache, chronic fatigue, restless leg syndrome, irritable bowel syndrome, etc. But it is more prominent and more vivid when it comes to mental health problems. A good example of this, for example, is ADHD, especially when the diagnosis is given in adulthood. And when people who are in their 30s and 40s, when they have lived with these difficulties in focus and attention and impulse control for much of their life, and they have negative self-esteem because of that, they have had work issues, relationship issues. And when they finally, in the middle age, learned that they qualify for a diagnosis of ADHD, they often describe a profound emotional relief. People sometimes cry. They say things like, you know, I know I’m not crazy now. I know I wasn’t broken or I wasn’t a failure. I wasn’t lazy, but rather I had this medical condition that I had been struggling with my whole life. I think another good example is autism, where people who have lived with undiagnosed autism, when they learn that they qualify for that medical diagnosis, it changes their self-conception and it gives them a kind of psychological relief about their difficulties that they didn’t have. The curious thing about these diagnoses is that they are descriptive in nature. They are describing their symptoms and they’re describing their difficult experiences. They don’t tell us what the cause is. We, for example, don’t know what the biological and psychological mechanisms of ADHD or autism are. So even though these diagnoses are a complicated and somewhat fancy way of repackaging the emotional difficulties and behavioral difficulties in medical language, just kind of having that medical language accessible provides a tremendous amount of relief. A similar kind of thing happened a few decades ago when there wasn’t a lot of awareness about postpartum depression. And women used to struggle with kind of that phase of their life. And when the idea of postpartum depression became more widespread and women started learning that this exists as a medical condition, they often found tremendous relief in having access to that vocabulary and that concept. Joe 13:02-13:41 Well, I can imagine someone who is disorganized and always late and has difficulty completing tasks. And we could run down a whole bunch of other examples of someone who might have ADHD, but just always gets criticized by coworkers or the boss or a partner. And then all of a sudden somebody says, well, hey, you might have ADHD and there’s something that you could do about it, that that would be this huge flood of relief. Oh, now I know why I can’t get tasks completed on time. Is that what you’re suggesting? Dr. Awais Aftab 13:41-15:55 Yes. Yeah. And I think a similar kind of thing is going on. Now, there are a number of different mechanisms through which this relief and benefit from a diagnosis can happen. And in the paper we published, we discussed these different mechanisms. One is this idea of switching from an everyday lens of understanding to a clinical lens of understanding or a medical lens of understanding. Our everyday language often characterizes problems as personal inadequacies and personal deficiencies. And when people switch from that kind of, you know, everyday language to our medical language, which often focuses on kind of mechanisms and causes and treatments, and has a less direct relationship with agency, that can be really helpful. And sometimes just having the words to talk about experiences can be helpful. The other possible mechanisms are that, you know, what happens in medicine is a type of ritual. It’s a very powerful ritual, the same kind of ritual that healers and shamans and other things have engaged in throughout history. And participating in that process of going through a medical evaluation, you know, answering a set of questions, doing biological tests or psychological tests. And then, you know, by virtue of getting the diagnosis, you know, being seen as having a sick role in certain situations, that itself can bring relief, that can bring positive associations. In general, in many cases, when we get diagnosed with a medical condition, some form of treatment or help is available. So there is this learned association that if a medical diagnosis is made or offered, then something can be done about it. And even if treatment is not available, there is this idea that the medical community is researching it and studying it and working towards finding something that helped. And one final thing I’ll say is that there’s also this sense of relief from cognitive ambiguity. I think a lot of people lived with unexplained and puzzling experiences, and the diagnostic label can provide them a way of making sense of those puzzling experiences. Terry 15:55-15:59 I’m wondering why you have compared it to the placebo effect. Dr. Awais Aftab 16:00-17:21 So there’s a good reason for that. You know, if you think about what happens with medical treatments, think of medication treatment, people take medications and, you know, they get better. You know, there are positive effects or benefit from that. But a curious thing is that even when people take inactive medications, if they take, let’s say, you know, a sugar pill that doesn’t have the active medication ingredient, they still get better from that. And the reasons for that are complicated. Some of them have to do with expectancy. You know, people are expecting to get better and they receive a medication, they do that. But it’s also the, you know, the process of participating in medical ritual and clinical trial and getting the help. So we wanted to create that analogy that just as an inactive medication can create positive benefits, we can have a situation where a diagnosis that does not tell us what the cause is, you know, for example, ADHD doesn’t tell us what the cause is, or a situation where we don’t have effective treatments for something. So autism, for example, we don’t have effective medical treatments. You know, even in those cases, just as an inactive pill can be helpful, this kind of descriptive inactive diagnosis can be very helpful for psychological reasons. So that was the basis of the analogy between the placebo effect and the Rumpelstiltskin effect. Terry 17:22-17:35 You’re listening to Dr. Awais Aftab, Clinical Associate Professor of Psychiatry at Case Western Reserve University. He writes a substack newsletter called Psychiatry at the Margins. Joe 17:35-17:55 Terry, I really love the idea of the Rumpelstiltskin effect because it really does describe liberation when you really know what the name is. Well, after the break, we’ll hear about the possibility that getting a diagnosis might have downsides as well as benefits. Terry 17:55-17:59 Could offering some people a label actually make their problems worse? Joe 18:00-18:10 We’ll also talk with Dr. Bob Waldinger about the tricky business of diagnoses. How might a diagnosis of ADHD be helpful and how might it be harmful? Terry 18:11-18:19 How can family and friends support people who are having a hard time, regardless of whether anyone knows a diagnosis or not? Joe 18:20-18:27 Really paying attention to a person’s concerns can sometimes be helpful, even if you don’t have any wise advice to offer. 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 18:54-19:09 And I’m Terry Graedon. Joe 19:10-19:20 Getting a correct diagnosis after years of struggle can help some people feel less like they are deficient and perhaps more understanding of their differences. Terry 19:20-19:29 People may feel validated and vindicated, but could there be a downside to being labeled? Could it lead some people to feel handicapped? Joe 19:29-19:44 To find out, we’re talking with Dr. Awais Aftab. He is a clinical associate professor of psychiatry at Case Western Reserve University. His substack newsletter is “Psychiatry at the Margins.” Terry 19:45-20:04 Dr. Aftab, a placebo-we were just talking about placebos can have benefits-but some placebos can also cause side effects. I’m wondering if the analogy with a diagnosis reaches that far. Could a diagnosis be harmful? Joe 20:04-20:53 And let me give you an example. There was an Australian study of high blood pressure some time ago in which patients were labeled high normal. And that actually led to increased worry and risk perceptions and increased negative emotions such as depression and anxiety, because they compared the patients who were labeled kind of high normal blood pressure to people who were not labeled. And they found that labeling low-risk people hypertensive may be more likely to harm than to benefit. So could labeling something or diagnosing something make some people worse? Dr. Awais Aftab 20:53-23:30 Yes, this is a genuine risk and a genuine concern. So, um, you know, just as we know that inactive medications or placebos can cause side effects, you know, we see that in clinical trials and we call that a placebo effect. Similarly, we know from existing research on medical diagnoses that people sometimes have negative experiences and, you know, what we might even call iatrogenic harm from them. A diagnosis can threaten and devalue a person’s self-identity. It can lead to stigmatization. It can lead to social alienation. And what happens is that due to the medical diagnosis, patients can interpret their moods, thoughts, and actions through the lens of that diagnostic category in a manner that’s too expansive and unwarranted. And it can trap them in a self-fulfilling prophecy of sorts. So for example, think of someone who has mild difficulties with anxiety, if they are given a diagnosis of an anxiety disorder, it might lead them to think that they have this permanent deficits, that they’re going to struggle with social interactions, they’re going to struggle with stressful situations, and mistakenly believing that they’ll be overwhelmed, they can start avoiding situations that make them anxious. But anxiety feeds on avoidance, and the more they avoid things that stress them or make them anxious, this will create a vicious cycle of persisting anxiety that may not have happened had they not thought of themselves as having an anxiety disorder. Similarly, people who have mild difficulties with social interactions, they’re awkward, so to speak, if they start thinking of themselves as being on the autism spectrum, they might think that their social difficulties are permanent and fixed and cannot be changed versus in reality, if they were to engage in efforts to improve their social communication and social interactions, they might be able to make progress in that regard. So there is this interaction and this feedback loop between a diagnostic label and a person’s behavior. And, you know, usually when medicine does this job right, we see positive effects. But in some cases, the narratives we offer around diagnosis can be unhelpful, and they can keep people entrenched in behaviors that worsen their problems and, you know, take away hope instead of making things better. Joe 23:31-23:52 Dr. Aftab, I have a personal story to share with you, and I’d love your interpretation. So I have lived with a rare, I’ll call it psychological condition my entire life. And I only learned about it, I’d say what, Terry, about 10 or 15 years ago? Terry 23:53-23:55 At least 15, maybe 20. Joe 23:55-25:30 Maybe 20. It’s called aphantasia. I don’t know if you’ve ever heard of it, but what it represents is about 3% to 4% of the population has this condition in which I cannot see things when I close my eyes. In other words, when I close my eyes, it’s dark, it’s black. There’s nothing there. And when people talk about their mind’s eye or they can imagine something, literally they can see it even if their eyes are closed. I’m astonished. I’m amazed. I’m puzzled because I just can’t conceive of such a thing. And there’s also the condition where people complain about an earworm, where they get a song stuck in their head and they can hear that song. And I go, what are you talking about? Because I cannot imagine such a thing. So for most of my life, I’ve suffered from this thing called aphantasia. And it’s not been paralyzing. It’s not like a terrible handicap. But I’ve not been able to understand how the rest of the world imagines things like when they close their eyes. So it was sort of a relief to learn, yeah, that I have this different wiring in my brain from most people. Terry 25:31-25:35 I think what was the biggest relief was finding out that you’re not the only person in the world like that. Joe 25:36-25:50 Right. That there are other people like me. But it sort of makes me sad because I can’t visualize anything in my mind and people have a hard time understanding what I’m describing. Dr. Awais Aftab 25:51-28:20 Yeah, thank you for sharing that experience. It’s a fascinating phenomena, and we have only started paying attention to it in recent years. I myself learned about aphantasia, I think, about probably two or three years ago, so relatively recently. And I think it’s a good reminder that there’s a tremendous amount of richness and complexity in our mental lives and psychological lives. And a lot of it is still unexplored or under-explored, and we’re still identifying and naming many of these phenomena. Now, we do have to distinguish between different kinds of psychological conditions that are present relatively commonly, and they don’t cause a lot of impairment or disability, so to speak. With the conditions that cause significant impairment and that we usually refer to as mental disorders. And so even in the realm of mental disorders, we’re still discovering new phenomena and giving names to new conditions. But even outside of it, kind of things like aphantasia, we are researching. And I just don’t want readers to think that just because a psychological condition has been named, it means that it is necessarily abnormal or defective in some way. And I think another similar kind of example would be a condition called misophonia, where there are some people, they are really sensitive to certain kinds of sounds. For example, sounds of other people chewing. And it drives them, it makes them really irritated and they can barely tolerate it. And this phenomenon also was very poorly understood and very poorly studied until it was formally named. And when people realized, you know, who do experience that kind of irritation with a certain kind of sound, they were like, oh, finally, you know, I can talk about what I have. And I realize I’m not the only one. And once you have a name for something like that, people across the world, they can connect on the basis of that name. And so new forms of new communities open up and people get together and they share their experiences. And I think that’s the social bar of having, you know, names like this for different facets of our psychological life. Joe 28:21-28:52 Well, I do know that once aphantasia was actually described, and it’s relatively recently, that people from all over the world connected with one another, just as you describe, through self-help groups or through online chats. And they went, oh, I’m not alone. There are other people out there, and that’s a very kind of reinforcing and validating process. So thank you so much for sharing with us. Dr. Awais Aftab 28:53-29:30 Yeah, I would say a similar kind of thing happened in the 90s with Asperger’s syndrome and autism, where this was traditionally believed to be a very uncommon and rare condition. But once Asperger’s syndrome, which refers to high-functioning autism, it was named, you know, these were also the early days of the internet. And people who kind of related to that description, they started kind of connecting online. And a very vibrant Asperger’s community arose. And the clinicians realized that the diagnosis is much more common than had been traditionally believed. Terry 29:31-29:37 Dr. Awais Aftab, thank you so much for talking with us on The People’s Pharmacy today. Dr. Awais Aftab 29:38-29:39 Thanks for having me. Terry 29:40-29:53 You’ve been listening to Dr. Awais Aftab, Clinical Associate Professor of Psychiatry at Case Western Reserve University. He writes a substack newsletter called “Psychiatry at the Margins.” Joe 29:53-30:23 We turn now to Dr. Robert Waldinger, Professor of Psychiatry at Harvard Medical School, Director of the Harvard Study of Adult Development at Mass General Hospital, and co-founder of the Lifespan Research Foundation. Dr. Waldinger directs a psychotherapy teaching program for Harvard psychiatry residents. He’s the co-author with Dr. Mark Schultz of the book, “The Good Life: Lessons From the World’s Longest Scientific Study on Happiness.” Terry 30:24-30:28 Welcome back to The People’s Pharmacy, Dr. Bob Waldinger. Dr. Robert Waldinger 30:29-30:30 It’s great to be here again. Joe 30:31-32:06 Dr. Waldinger, we’ve been talking about the benefits of getting a diagnosis so we can better understand what’s going on inside our brains, our situation. For example, I have a really rare condition called aphantasia. And I didn’t learn about that until maybe about five or 10 years ago. So most of my life, I’ve had aphantasia and I didn’t know why I was different from most other people. I cannot visualize anything. When I close my eyes, it’s black. There’s nothing there. And I also can’t hear music in my head. And so the idea that somebody could actually hear a song astonished me. And when I had a name for what I have, aphantasia, it was a great relief because all of a sudden I could understand better about myself and I could understand why I was different. And I could better understand how other people could do things that I can’t do. So I guess the question is: how can a diagnosis like aphantasia in my case, or ADHD, or somebody being on the spectrum, [how] might [that] be helpful for them, for their family, for their employer, for everybody around them? Why is diagnosis beneficial? Dr. Robert Waldinger 32:08-33:55 Well, diagnosis is really a shorthand. It’s a label for a condition, right? Often it’s a set of symptoms or it’s a way you operate. Like in your case, it’s the way your brain works. And it’s different from the way many other people’s brains work. And so to have that as a way to understand what is happening to you can be an enormous relief, enormous relief. In fact, it’s interesting because my younger son has a rare condition that makes his walk funny. He has a funny walk. He has a gait disturbance that was increasing as he got into young adulthood. And we kept saying, this is really something you ought to check out. And other people kept saying, why do you have this funny walk? And so he searched for months. Actually, it got into years, went to different doctors and physical therapists. And finally, one doctor saw him at a specialty clinic and said, I know exactly what you have. Here’s what it is. Here’s how it works. This is what you’ve been experiencing. And my son started to cry. This grown man in his 30s started to cry because it was such a relief to have an explanation for these baffling symptoms that nobody understood. So I understand the quality of relief that many people experience when they get this kind of explanatory framework at last after searching. Joe 33:56-34:20 And I guess for people with, let’s say, ADHD, getting a name for why their brains are a little different than everybody else is not only helpful for them, but also for the people around them who may become frustrated because they may not finish tasks [in] a timely fashion that they were expecting. Dr. Robert Waldinger 34:20-35:44 Absolutely. I mean, I work in psychotherapy with a number of people who had ADHD as kids, but it wasn’t diagnosed. In fact, it really wasn’t known about. So the generation of people who are now, say, in their 60s, 70s, grew up with difficulties reading, difficulties doing math, not being able to learn a language, learning disabilities. And people would say to them, you’re perfectly bright. You’re just not working hard enough. Your study habits are not good. You need to sit after school. You can’t go out to play because you’re not reading, right? And what it does is it engenders this feeling of I’m defective. Everybody else can do this. Everybody else is learning to read in the first grade. Why can’t I? Right? And so what you take in is not just, “I’m having trouble with reading,” as a child, you often take in, “I’m defective. There’s something wrong with me as a human being.” And other people can give you that feeling without meaning to so that you can emerge as an adult feeling defective as a human being, not just, oh, I’m reading problems, right? Terry 35:45-36:04 And as I think back, people who are now in their 60s and 70s, other people could easily have given them that feeling, not necessarily without meaning to. Some people just did that because they weren’t thinking. Dr. Robert Waldinger 36:04-36:32 Right. Also, let’s say you come from a family that really prizes education, you know, and the thing you want the most is for your kids to do well in school, then you are personally more disappointed if your kids have it in trouble reading. And so depending on the families we are born into, the particular problems we have may be more or less acceptable. Terry 36:32-36:48 Exactly. That makes a huge difference. Let me ask you also, is there a downside to getting a diagnosis, especially considering this idea of the families that we’re born into may have different reactions? Dr. Robert Waldinger 36:49-38:56 Oh, yeah, of course. And again, that depends on the families we’re born into sometimes. So let’s say that you had an uncle with depression, who had depression, who suffered from it, and your uncle killed himself. And you start to have symptoms that might be depression. The last thing you want to believe is, “Oh my gosh, I’m just like my uncle.” So a diagnosis that your family has some experience with can make you afraid that you’re going to end up just like Uncle Joe, right? When most of the time that doesn’t happen. Most of the time someone gets a depression and depression is not most of the time lethal at all and very treatable. But you can be afraid based on what you’ve known in your family of someone with similar difficulties. So that’s one way that a diagnosis can be scary, can make people turn away and not want to know anything about it. Another is if you feel like it sentences you to a life that you don’t want. So let’s say I’m a person with ADHD, and that means there are certain jobs I can’t do. I don’t know what they might be. Maybe it’s being an airline pilot. I don’t know. I’m making this up. But let’s say you really want to do something with your life, and a diagnosis suggests you won’t be able to do that. That’s another way. Now, diagnoses are just labels, and they are imprecise labels. No two people show up the same way with the same diagnostic issue, right? We’re all different. And so no two people have the same ADHD. No two people have the same depression. But those labels can make us think that it’s a certain thing with a certain outcome and there’s no escaping it. And that’s where diagnosis can be scary. Joe 38:57-39:04 I’d like to talk about your area of expertise, Dr. Waldinger, and that is mental health issues. Dr. Robert Waldinger 39:04-39:04 Sure. Joe 39:05-39:45 Because these days, there just aren’t enough mental health experts available. And so a lot of times people will go to their family practice physician or maybe even a psychiatrist such as yourself. And they say, oh, I’m feeling so anxious, Dr. Waldinger. I’m a little depressed. I mean, times are tough. And because there’s so little time, out comes the prescription pad, or these days, of course, it’s an electronic prescription. And here’s an antidepressant. Here’s an anti-anxiety agent. You’ve had 10 minutes of my time. Good luck and goodbye, and I’ll see you in six months or maybe a year. Dr. Robert Waldinger 39:47-39:47 Yeah. Joe 39:47-40:11 And we haven’t dealt with the issues that are causing the anxiety or, in some cases, the depression. How can people, families, friends help someone who is feeling anxious or perhaps a little depressed, these are tough times, without necessarily immediately going to a prescription? Dr. Robert Waldinger 40:12-42:08 That’s such an important question because we’re trained to recognize certain things and then we’re trained to do what we do about them. So if all you have is a hammer, everything looks like a nail. If all you’re trained in is prescribing medication for mental health issues, then that’s what you go to. It’s natural. It’s not that these are bad doctors. It’s just that’s naturally what they see they have at the ready. And medications really help, by the way. So let me lay that out there. I’m so glad that medications are there in the world for me to use, even though I’m primarily psychotherapist in the practice that I do. And I think that the question is: how do you help someone talk about what they’re feeling? Because psychiatrists have this problem too. I have to train… I teach young psychiatrists. I lead a program in psychotherapy at Mass General Hospital in Boston. And one of the things that we know is that people are afraid, even psychiatrists are afraid to talk about the nitty gritty of someone’s anxiety or someone’s depression, because they’re afraid they won’t know what to do with the answers to their questions. So if I ask you, oh, “Tell me about the anxiety,” or “Tell me you’re saying you’re really depressed, are you thinking you might be better off dead?” Well, what do I do with the answer is yes. And so a lot of the training that we need to give our young psychiatrists and young doctors and nurses is what do you do with the answer, including an answer that scares you. There are ways to know what to do with that so you’re not afraid to ask the questions in the first place. Terry 42:09-42:40 You’re listening to Dr. Bob Waldinger, professor of psychiatry at Harvard Medical School and director of the Harvard Study of Adult Development at Massachusetts General Hospital. He is co-founder of the Lifespan Research Foundation and co-author with Dr. Mark Schultz of the book The Good Life. Dr. Waldinger directs a psychotherapy teaching program for Harvard psychiatry residents. And as a Zen master, he also teaches meditation. Joe 42:41-42:48 After the break, we’ll learn how trained mental health professionals can help people who are in crisis. Terry 42:49-43:01 And we should mention here that if you are in crisis or if you know someone else who is, you can call 988 for support. That’s 988 for the crisis line. Joe 43:02-43:06 How do you go beyond a casual, “How are you doing?” Terry 43:07-43:14 As we pay more attention to our relationships, we should be teaching our children how to be a friend. That’s how you have a friend. Joe 43:15-43:25 Dr. Waldinger will give us some ideas on how to turn down the noise from social media and pay attention to real live humans. Terry 43:41-43:44 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 43:53-43:56 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 43:56-44:12 And I’m Terry Graedon. Joe 44:12-44:21 How can you support friends and family who may be having a hard time? The holidays can be especially challenging for a lot of people. Terry 44:22-44:29 When everyone around you seems to be feeling festive and you’re feeling overwhelmed, it can be hard to cope. Joe 44:29-44:57 To learn more about how to support friends and family and the importance of relationships, we’re talking with Dr. Bob Waldinger. He’s a professor of psychiatry at Harvard Medical School, director of the Harvard Study of Adult Development at Mass General Hospital, and co-founder of the Lifespan Research Foundation. His book is “The Good Life: Lessons From the World’s Longest Scientific Study on Happiness.” Terry 44:59-45:35 Dr. Waldinger, you have just described how a trained mental health professional can support and assist a person who is feeling pretty desperate. What about the rest of us who have not had that kind of training? Family members, friends, even acquaintances. How do we approach supporting a person we may know? How do we ask the appropriate question? Joe 45:35-45:47 How do we not freak out? How do we get past how you doing? Yeah, yeah. And then not really want to get an answer that’s honest. Dr. Robert Waldinger 45:47-47:13 Right, right, right. Please just say fine and let’s move on, right? Don’t tell me how you’re really doing. Right, so I think the first thing is to start with what you can see. So sometimes it’s helpful to say, you know, you look kind of down. How are you feeling? Just to notice. And someone is free to say, no, I’m really not feeling down. Okay. But at least you’ve noticed, right? Or you seem kind of sad or you don’t seem to have your usual energy or your usual sense of humor. What’s going on? That, that, it doesn’t pull for the… because “How are you?” pulls for the automatic “fine.” And actually, when someone asks me, how am I, I have to stop. Am I going to answer anything but fine? It’s a disturbance in the field almost. So I don’t ask that question. I will try to ask something else that invites a less automatic answer, including if I can notice something. Because people really appreciate when you notice them, and any of us can do that. The other thing is that it could be very helpful to ask that kind of question. Like, you’re looking down, how are you feeling? Don’t ask it at the dinner table in front of a lot of people. Terry 47:14-47:15 Ah, right. Good point. Dr. Robert Waldinger 47:15-47:44 Right? Ask it. Say, you know, do you want to take a walk, right? After Thanksgiving dinner or after a holiday meal? Do you want to, you know, let’s go out for a chat or let’s just, you know, and then ask. Ask when you’re sort of alone, just the two of you. And if someone wants to admit that they’re feeling bad, they can do that without a whole audience involved. Joe 47:44-48:48 Dr. Waldinger, I think of you as the relationship doctor. The person who really, really emphasizes the importance of relationship. We are in anxious times. I don’t care whether it’s political or whether it’s work or whatever it is. We are, I think, a nation that’s kind of freaking out over all of the social media and all of the news and all of the input just never, never stops. And I wonder if at this time of year you can tell us about why relationships are so important and how we can reestablish relationships, sometimes with perhaps a family member who we’ve been distant from for not just a few weeks or months, but maybe years, how we can reconnect with old friends. Give us that DNA of relationships and why it’s so critical. Dr. Robert Waldinger 48:48-52:19 Hmm. Right. The why. Well, one of the things we know from really good research, and I bet all of your listeners know this, is that relationships help us with the slings and arrows of life. Relationships help us through hard times. Something upsetting happens during the day. If you have somebody you can talk to about it, you can feel yourself calm down. You can feel yourself lighten. And so we know that relationships help us through hard times, including literally like I’ll loan you my truck when you’re stuck and you need to go somewhere. I’ll drive you to the doctor when nobody else can take you. All those things. Relationships matter. But they also bring joy. One of the things that we know is that having a good conversation, an authentic conversation with another person makes us feel more connected. And it gives us more of a sense of kind of belonging and warmth that we matter. And so both on the upside and the downside of life, relationships amplify the upside and they help soften the downside of life. So we know they work. And then you’re asking, well, then how do you work with relationships to allow them to give us this kind of help. And certainly with the relationships we already have, no relationship is without difficulty. If it’s an important relationship, you’re going to have disagreements. You’re going to annoy each other. That’s just the truth of it. But I think what we can do is spend more time reminding ourselves of what we appreciate about the other person. It’s so easy to dwell on what we don’t like. And it’s really hard to remember, oh my gosh, but yeah, I don’t like the way my wife loads the dishwasher, but my God, what if she weren’t in my life? What if I didn’t have her? I mean, when you do that kind of gratitude practice, it becomes really clear why these people matter. And it really makes you feel different about the relationship. So that’s one way to work with it. Another is to spend more time staying connected. A friend just sent me an email today saying, you know, it’s been a while since we got together. Do you want to take a walk this weekend? And I realized, oh my gosh, I haven’t been paying attention to that relationship. He’s absolutely right. So I wrote him right back and said, yeah, let’s take a walk on Sunday. We could do that. It’s small actions that keep us connected to each other. And one more thing I could think of for people we care about, let’s say you’re going to be at holiday gatherings. Maybe you could think in advance, there’s this one niece or there’s this one cousin or there’s this one friend who I don’t get to see. Maybe I could make it a point to spend time at this holiday party with that person and really reconnect. That’s an intention you could set before you even go. Terry 52:20-52:41 I like that idea. And as we started talking about relationships just now, I was thinking, is anyone these days teaching kids that to have a friend, you have to be a friend? I mean, it seems totally obvious, but I don’t know how well we’re modeling that for the young people in our lives. Joe 52:41-52:43 Where’s Mr. Rogers when we need him? Dr. Robert Waldinger 52:44-53:39 Oh, you’re right. You’re right. Where is he when we need him? But yeah, to be a friend, which means, I think, really paying attention to the other person. What’s this person going through? What’s happening in their life? And maybe how could I help? So I will say my wife is the best person at this. She’ll say, so-and-so’s surgery is next Wednesday. So I want to be sure to call and find out how they’re doing. So-and-so, I wonder if they need a meal because they’re recovering from something. She holds other people’s lives in her mind. She holds what’s happening to them in her mind. I think that’s something we can all get better at. I wish I were as good as my wife is at doing that, but I really admire her capacity to do that. I think we can all do it if we try. Joe 53:39-54:03 One of the things that you have told us about in the past is when you give a talk, you sometimes suggest that the audience text a friend that they haven’t been in touch with for a long time and then see by the end of the talk how many folks actually respond. Tell us a little bit about that process. Dr. Robert Waldinger 54:05-55:30 It’s fun. I did it last week. I gave a talk. The process is really to help people see that this idea of tending to our relationships is not as much of a heavy lift as you could imagine. Because when you hear me talk about the importance of relationships, you could think, oh my God, I have so much going on in my life. Now I’m supposed to spend hours each day taking care of my friends and family and those relationships? It can feel overwhelming. And so by doing this, I say to people, think of somebody you miss or you’d like to connect with and just take out your phone and send them a little text saying, hi, I’m just thinking of you and wanted to connect. And it takes all of one to two minutes during my talk. And then during the Q&A, I will ask, did anybody get anything back? And all these hands shoot up. You know, people say, oh, my friend was so glad I reached out and we made a dinner date for next Tuesday. Right. You know, it’s like people get these little hits of joy because they realize, oh, yeah, this person is happy to hear from me. And and actually we’re going to reconnect. So that’s that’s what I do. And it’s a way to demonstrate that this is not difficult. It just requires paying attention to it. Terry 55:32-56:11 One of the things that we tend to pay more attention to these days are the social media feeds, the headlines, the this, the that, which are actually designed to make us feel anxious or scared or something. Well, do you have some suggestions as to how we can turn down the noise and address our lives without that constant buzz of what’s going to happen to everything? Joe 56:11-56:33 Well, I don’t know that our listeners realize that you, in addition to being a psychoanalyst, a professor of psychiatry, you are also a Zen master. So could you give us a little Zen insight into all of the overwhelming messages we get on a not just daily basis, but a minute by minute basis? Dr. Robert Waldinger 56:35-58:40 Okay, I’ll go back to my Zen teacher, John Tarrant, who said something I come back to all the time. He said, attention is the most basic form of love. Let me repeat it. Attention is the most basic form of love. Because, you know, if you think about it, giving another person our undivided attention is probably the greatest gift we’ve got to offer. Now, in this era when social media compete for our attention, right, because it makes them money. If they grab our attention and hold on to it and don’t let us go, they make more money. They sell more ads. We are less able to give our undivided attention to each other in real time. And that’s why you’ll see teenagers sitting around a table at a restaurant, all looking at their phones, sometimes texting each other, but not looking at each other, not really giving each other their full attention. And we as adults do this too, of course. So what I would say is that, first of all, know that when we go down the rabbit hole of clicking on all these clickbaits, right, that we are letting the social media companies train our brains. We’re letting them win for their own profit. And that what we can do instead is be very mindful and curated about it. We can say, okay, I’m going to be on my social media feed for 10 minutes a day or 20 minutes a day, and then I’m turning it off. Or I’m going to take a holiday from the social media feeds and see how I feel. That it requires being really intentional about where we’re deploying our attention, because otherwise our attention is going to get hijacked all day long. Joe 58:43-59:00 Dr. Waldinger, we have just a minute and a half left. And I want to tell you personally how grateful we are for your role in our lives. We only get to talk to you every once in a while, but your message. Dr. Robert Waldinger 59:00-59:03 I love talking to you guys. You guys are the best. Joe 59:03-59:13 Your messaging, your books, your work has just been such an inspiration. In the minute we have left, can you tell us the importance of gratitude in our lives? Dr. Robert Waldinger 59:15-01:00:04 Sure. So gratitude is almost like a corrective for what our brains are wired to do. Our brains are wired to pay attention to what’s wrong because we think we evolved to look for threats on the horizon because it helps us survive, but it doesn’t help us be happy. So we’re more likely to pay attention to those negative headlines than we are to what’s positive in the world. What gratitude practice does is it says, let’s reverse this. Let’s stop and think about the good stuff in our lives, the things we are so glad we have, and that it is literally a corrective for the ways that our brains evolved maybe to help us survive better, but they evolved to make us less happy. Joe 01:00:06-01:00:52 Dr. Waldinger, you have emphasized the importance of relationships and gratitude. We can reach out to friends, family members, acquaintances that we haven’t been close to. How do we practice gratitude? How do we make that a part of our lives when it’s so easy to fall back on anger, disappointment, being upset? Oh, the trains aren’t running on time. The plane is delayed. My friend is not responding in a way I would hope. Help us really get some concrete steps down the path of gratitude. Dr. Robert Waldinger 01:00:53-01:01:56 Sure. So gratitude actually is a feeling. And so in some ways, it’s not a great label for the practice because we can’t make ourselves feel gratitude, but we can set ourselves up to make it likely we’re going to feel gratitude. And so it’s a fine distinction, but the practice is not to fake it till you make it, it’s really not. It’s sometimes called a subtraction practice. So let’s say, okay, the train is late and you can be really annoyed and yeah, I’m going to be late to work or my friend’s going to be waiting for me. All right. But then do the subtraction practice. Think to yourself, what would it be like if there were no trains? What would it be like if I couldn’t, you know, in 20 minutes go all this distance and to be able to see people and to do things that I want to do in my life. So you’re not dwelling then on the late train this morning, you’re dwelling on the very existence of trains. Terry 01:01:56-01:02:05 So it’s, yeah. So it’s a little bit like the angel talking to Bailey in It’s a Wonderful Life. Dr. Robert Waldinger 01:02:05-01:02:46 Exactly. Exactly. Exactly. That is it. It’s a wonderful life. It’s a movie that brings me to tears. And it’s just because that angel gets George Bailey to do the gratitude practice, where he looks at what life would have been like if George Bailey had never lived, right, in this town. And, you know, I think about this, boy, I think about this with my wife all the time when I get annoyed. And, you know, because I get annoyed with my wife and she gets annoyed with me because we lived together for 40 years. But, you know, but boy, when I do that, when I like, what if she was never in my life? Whoa, the gratitude just kind of comes rushing in. Joe 01:02:46-01:03:07 Well, I think about the airplane that’s delayed by half an hour or an hour, you know, oh man, I’m going to be late. Oh, that’s terrible. What’s the matter with this airline? And then all of a sudden, if you stop and think, well, how would I get from Boston to San Francisco if there were no airplanes? Dr. Robert Waldinger 01:03:07-01:03:21 Exactly. Exactly. And how often would you ever be able to do that, right? You know, it would be a major trip. Terry 1:03:17-1:03:18] Oh, exactly. Dr. Robert Waldinger 01:03:19-01:03:21 Yeah. That most people would never make in their lives. Joe 01:03:24-01:04:08 Dr. Waldinger, I think one of the most painful experiences that people can go through in life is estrangement from a family member or a friend. Because here is an important relationship that has somehow fallen on really hard times. And I suspect in many cases, both parties would like to solve the problem, but they just don’t know how to communicate anymore. Do you have any thoughts about estrangement and how people can rebuild relationships that have ended up on the shoals? Dr. Robert Waldinger 01:04:10-01:06:43 Yes, because estrangements, as you say, are really common in families. Some families more than others, because some families, just the tradition is if you have a big disagreement, you just don’t talk to that person again. Well, one of the things that we can ask listeners to tune into is, is there somebody you’re estranged from or you’re just so mad at you’re just not going to deal with anymore? How much space does that take up in your mind? Right? How much energy does it sap from you? So I’ll tell you, I was estranged, actually from one of my former teachers, a very important teacher, and we had a falling out. And this was unusual, fortunately for me, but it was terrible. I was estranged and I kept thinking about it. I couldn’t let it go. And it was a source of pain because we knew people in common. And it was just kind of there, this thing that sat on the sidelines, sapping my energy. And at one point, we both ended up at the same gathering. And we looked at each other. And I walked over. And she said to me, could we start over? And we both just hugged each other. And it was like that metaphor of the weight being lifted off your shoulders. I almost could literally feel weight coming off my shoulders. It was like, and now we’re not the best of friends again, but we’re in regular touch. And we both say, oh my God, it is so great that we’re no longer mad at each other, right? That we’re no longer holding this grudge. And so what I would say is do it for yourself. If you have the courage to reach out to the person you’re having a feud with, do it for yourself. Say, I would love to talk with you. I’d love to find a way for us to make peace, to be okay with each other again. Just offer that. And offer some of how you think you’ve played a role in it. Not assuming, well, you have to apologize to me. But really know that in every feud, there are two sides, multiple sides, if you will. And that when each person acknowledges more of how they have contributed, it really makes a difference toward healing those rifts. Terry 01:06:44-01:06:50 Dr. Bob Waldinger, thank you so much for talking with us on The People’s Pharmacy today. Dr. Robert Waldinger 01:06:51-01:06:53 Oh, this was my pleasure. Terry 01:06:54-01:07:20 You’ve been listening to Dr. Bob Waldinger, Professor of Psychiatry at Harvard Medical School, Director of the Harvard Study of Adult Development at Massachusetts General Hospital. Dr. Waldinger directs a psychotherapy teaching program for Harvard psychiatry residents. His book is “The Good Life: Lessons From the World’s Longest Scientific Study on Happiness.” Joe 01:07:20-01:07:35 We spoke earlier with Dr. Awais Aftab, Clinical Associate Professor of Psychiatry at Case Western Reserve University. He writes a substack newsletter called Psychiatry at the Margins. Terry 01:07:36-01:07:53 Remember, the crisis number, if you need it, is 988 anywhere in the country. Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 01:07:53-01:08:01 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Terry 01:08:01-01:08:19 Today’s show is number 1,456. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You could also reach us through email, radio at peoplespharmacy.com. Joe 01:08:20-01:08:34 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. This week, the podcast has video. How about that, Terry? Terry 01:08:34-01:08:40 Well, not if you’re listening on your podcast platform, but if you go to the website, there will be video. Joe 01:08:40–01:09:03 Video, and it’s also on YouTube. You’ll hear about supportive communities that have formed around certain diagnoses. In addition, we talk about the pain of estrangement from someone near and dear to you. Reestablishing contact can be challenging, but Dr. Waldinger offers some interesting ideas about how to do that. Terry 01:09:04-01:09:32 You can find that at peoplespharmacy.com and you could sign up for our free online newsletter and get the latest news about important health stories. When you subscribe, you also get regular access to information about the weekly podcast. We’d be grateful if you’d consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. If you find our topics interesting, please do share them with friends and family. Joe 01:09:33-01:09:35 In Durham, North Carolina, I’m Joe Graedon. Terry 01:09:35-01:10:08 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 01:10:09-01:10:18 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 01:10:19-01:10:23 All you have to do is go to peoplespharmacy.com/donate. Joe 01:10:24-01:10:37 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.

Transcribed - Published: 19 December 2025

When doctors talk about infections, they are usually referring to acute situations in which the immune system gets overwhelmed by a virus such as influenza or chickenpox. Infections also result from the interaction of bacteria with the immune system, as in the case of pneumonia or sepsis. These can be crises, but they are relatively short-lived, resolving one way or the other within a few weeks or at most months. Could infections trigger chronic diseases? Our guest, evolutionary biologist Dr. Paul Ewald, thinks they do. 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, Dec. 13, 2025, 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 live 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 streaming audio on this post starting on Dec. 15, 2025. It can be found under the photo at the top of the page. How Infections Trigger Chronic Diseases: Investigating the origins of chronic diseases requires a great deal of patience and the ability to examine several different areas that might be relevant. Over the past few decades, the technology for evaluating genetic contributions has improved greatly. What we have learned is that most chronic conditions are associated with a range of genes that each add a small amount of risk. To get further insight, we have to look at the environment. This broad area includes topics as far ranging as sunshine, stress and nutrition. In particular, we need to look at the pathogens present in any given environment, as they could play an important role in our health. Scrutinizing the environment is not enough. To understand the impact on disease, we need to know more about human behavior within that environment. How much sun exposure do the patients get? Are they sleeping? Where do they spend most of their time, and with whom? These all will help us understand the link to pathogens. What We Have Learned About the Microbiome: Over the past several decades, scientists have learned a great deal about the microbiome. The original conception of gut bacteria has been enriched with the understanding that almost every part of the human body has its own microbiome, almost as unique as a fingerprint. These collections of microbes live in harmony–or disequilibrium–with microbes from the environment. Some of these may be beneficial. Others undoubtedly are harmful, and we call them pathogens. How do pathogens trigger chronic diseases? How Does the Body React to Pathogens? When pathogens are detected, the immune system responds. Often, that comes in the form of macrophages, immune cells that circulate in the blood and attack the pathogens. Even a type of microbe that normally cohabits peacefully with the others in its space can cause trouble if it becomes too numerous or goes out of bounds. One example is Porphyromonas gingivalis. It’s usually found in the mouth. If it gets too exuberant there, it can cause gum disease. Worse, though, the macrophages dispatched to deal with P. ginigivalis anywhere in the body can end up collecting in atherosclerotic plaque in arteries (Signal Transduction and Targeted Therapy, May 23, 2025). Another example of pathogens causing unexpected trouble is Clostridium (or Clostridioides) difficile (C. diff). These bacteria can live among other gut microbes and you might not even know they were there. But if the microbiota become disturbed, from a course of antibiotic treatment, for example, C. diff can proliferate and cause terrible diarrhea that may be very difficult to treat. Studies indicate that C. diff has evolved so that the strains in hospitals are now more likely to be resistant to antibiotic medications. Alzheimer disease seems like a chronic condition rather than a complication of infection. Certainly, researchers have been examining genetic predispositions for the accumulation of beta-amyloid plaque in the brain. Yet Alzheimer disease is associated with microbes such as Chlamydia pneumoniae and P. gingivalis. Could flossing your teeth to reduce your chance of periodontal disease also help lower your risk of Alzheimer disease? Recent research has shown that older people receiving the shingles vaccine are less likely to be diagnosed with dementia. Perhaps amyloid plaques in the brain are part of an immune response to infection. Has Long COVID Shifted Our Perspective on Chronic Disease? Several decades ago, The People’s Pharmacy interviewed Dr. Paul Cheney, then of Incline Village, Nevada, about his patients with chronic fatigue syndrome. He believed at the time that epidemiological patterns of this mysterious illness pointed to an infectious origin. Years have passed, and no pathogen has been identified to satisfy the criteria as THE cause of myalgic encephalomyelitis (ME/CFS). Recently, though, millions of Americans have been struggling with a condition that seems rather similar. The only difference is that we know their symptoms began with a COVID-19 infection. Long COVID is difficult to treat. Patients suffering with this condition appear to be afflicted with a serious chronic disease. Researchers have not always found evidence of persistent infection with the SARS-CoV-2 virus. Nonetheless, in most cases a COVID infection was clearly the origin. How has that changed our attitude toward the possibility that infections trigger chronic diseases? Other Mystery Conditions: As we contemplate the possibility that infections trigger chronic diseases, we should not overlook chronic Lyme disease. Most infectious disease experts insist it isn’t an infection. Some even resist the idea that people are suffering. Dr. Ewald suggests that perhaps the inability to identify pathogens in the wake of Lyme disease is due to using old techniques. The pathogens don’t show up on these tests, but that could be because they are hiding. Will newer techniques reveal them? What about the possibility that diseases like arthritis or schizophrenia are caused by pathogens in some cases? The evidence is tantalizing. Dr. Ewald urges us to look at the chronic phases of infection as well as the acute phases. This Week’s Guest: Paul Ewald, PhD, is an evolutionary biologist, specializing in the evolutionary ecology of parasitism, evolutionary medicine, agonistic behavior, and pollination biology. He is currently a Professor of Biology at the University of Louisville. Professor Ewald is a pioneer in evolutionary medicine and infectious disease research. He has challenged conventional wisdom on the causes and prevention of many chronic diseases with his idea that many diseases of unknown origin are the result of chronic low-level infections, which has ultimately been shown to be correct for a wide range of diseases to date. He is the author of Evolution of Infectious Disease and Plague Time: The New Germ Theory of Disease. 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). Paul Ewald, PhD, describes how microbes evolve Listen to the Podcast: The podcast of this program will be available Monday, Dec. 15, 2025, after broadcast on Dec. 13. You can stream the show from this site (the arrow inside the green circle under the photo at the top of the page) and download the podcast for free. In this week’s extra episode, Joe asks Dr. Ewald how to get specialists to consider the possibility that infections may be at the root of many chronic conditions. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1455: 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. Heart disease, diabetes, asthma, Alzheimer’s disease, and arthritis are challenging diseases. Could pathogens be responsible? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:43 Our guest today, Dr. Paul Ewald, is an evolutionary biologist who’s been studying how pathogens could spark some of our most vexing chronic diseases. Joe 00:44-00:53 Whether it’s Alzheimer’s disease, rheumatoid arthritis, heart disease, or chronic fatigue syndrome, the cause might be an unsuspected infectious process. Terry 00:54-01:05 If infections are responsible for a wide range of chronic conditions, treating symptoms might not be effective. How can we treat the cause of many of our most serious and challenging disorders? Joe 01:06-01:10 Coming up on The People’s Pharmacy, how infections trigger chronic diseases. Terry 01:14-02:40 In The People’s Pharmacy Health Headlines: Health insurance companies are struggling with their budgets. The enormous popularity of the GLP-1 drugs, such as semaglutide and tirzepatide, is a big part of the reason. These weight loss medications sold under the brand names Wegovy and Zepbound, respectively, are pricey. So the large numbers of people taking them has increased expenses more than expected. According to stats, some insurers have already spent more in nine months of 2025 than they did in all of 2024. Perhaps as a consequence, some employers are considering leaving these meds off the formulary. Certain states have also dropped them from their Medicaid programs. Although most states still cover semaglutide for diabetes, North Carolina, California, New Hampshire, and South Carolina are dropping coverage for obesity treatment. In Michigan, Medicaid will cover GLP-1 obesity drugs only for patients who are classified as morbidly obese. Health plans for state workers are also reassessing coverage of these medicines. Some physicians are concerned because people who had lost significant weight are now starting to regain it without their medication. Along with excess weight come additional health risks. Joe 02:41-03:52 Tattooing dates back thousands of years. Historically, body art served a variety of purposes from religious to healing ceremonies or rites of passage or as an indicator of group identity. In recent years, social media and celebrity influencers have popularized tattoos for millions. But are they safe? A new study in the Proceedings of the National Academy of Sciences links tattoo ink to inflammation in lymph nodes. The investigator studied the biological reaction to tattoo ink in humans and mice. The dyes that are used accumulate in the lymph nodes and appear to trigger long-term inflammation. The pigments can also be found in the spleen, liver, and kidneys. This study looked at the impact of tattoo dyes on the immune system. The researchers found that following tattooing, the macrophages were less capable of responding to a number of viruses. The COVID-19 vaccine appears to be less effective for tattooed individuals. The authors call for long-term research into the health effects of tattoos, including the risk of cancer. Terry 03:52-04:46 There are new data on the benefits of a shingles vaccination against dementia. Shingles is a painful outbreak on the skin of people who had chickenpox earlier in life, often many decades before. The shingles vaccine reduces the likelihood that older people will experience such an outbreak. Previous studies took advantage of natural experiments in Wales and Australia to determine that the original shingles vaccine, Zostavax, could lower a person’s chance of a dementia diagnosis. Further analysis of these data showed that this vaccination also slows the progression of cognitive impairment in people already living with dementia. People with dementia who received the shingles vaccine were almost 30% less likely to die from their disease over a nine-year period. People with more advanced dementia appeared to benefit the most. Joe 04:47-05:23 The flu is back, and it could be an especially challenging season. That’s because the flu virus mutated this year after manufacturers locked in the formula for the vaccine. Canada has seen a dramatic 61 percent increase in flu cases in November. Now, states such as Colorado, Michigan, and Massachusetts are reporting increased cases and hospitalizations for influenza-like illnesses. If the U.S. follows in the footsteps of countries in the southern hemisphere, such as Australia, New Zealand, and South Africa, we’re likely to see an early and severe flu season. Terry 05:24-06:17 Intermittent fasting has long been a popular weight loss strategy. Chinese researchers report it also shifts connections between the gut and the brain. They recruited 25 obese individuals for a two-month study with every other day fasting. Volunteers also provided stool samples at the beginning and end of the study. This regimen resulted in weight loss and also changes in brain activities seen on fMRI. This was correlated to alterations in the gut microbes. The researchers conclude that intermittent fasting altered the gut microbiome, and that in turn provoked changes in brain regions associated with appetite and addiction. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:33 And I’m Joe Graedon. If you ask a cardiologist what causes heart disease, chances are good you’ll hear about LDL cholesterol. Likewise, if you ask a neurologist about Alzheimer’s disease, you’re likely to hear that the culprit is beta-amyloid plaque. Terry 06:33-06:41 But what if these and many chronic diseases result in part from infections? Would that change the practice of medicine? Joe 06:42-07:06 To help us answer such questions, we turn to Dr. Paul Ewald, professor of biology at the University of Louisville. He is a pioneer in evolutionary medicine and infectious disease research. Dr. Ewald is the author of “Evolution of Infectious Disease” and “Plague Time: The New Germ Theory of Disease.” Terry was working remotely when we recorded this interview. Terry 07:08-07:11 Welcome back to The People’s Pharmacy, Dr. Paul Ewald. Dr. Paul Ewald 07:12-07:14 It’s great to be back to join you again. Joe 07:15-08:05 Dr. Ewald, I looked back in our calendar and it shows you joining the People’s Pharmacy in April of 1999, show number 263, talking about the evolution of infectious diseases. And then we had you back again in March of 2001, show number 350, “Plague Time: The New Germ Theory of Disease,” which was your second book. We called that show How Germs Shape Your Destiny. I guess it must be astonishing to you to look back over 25 years and how things have changed. But before you tell us that, please share what is an evolutionary biologist. Dr. Paul Ewald 08:07-08:34 Well, an evolutionary biologist is someone who just looks at the biological changes of organisms over time. And you can look at it in terms of how they’re adapted to particular environments, or you can do that descriptively, just describing which organisms evolved from what other ones and what characteristics evolved. My focus tends to be more on the former. I’m interested in how it is that organisms adapt to particular environmental conditions. Joe 08:35-09:03 So looking back over the last two or three decades, especially with COVID in the mirror, it seems like the kinds of problems that you predicted decades ago have kind of come to pass. Tell us about your view of the world and how pathogens have impacted us since your two books. Dr. Paul Ewald 09:04-10:21 Well, I would say over the last two decades, the information that’s become available has reinforced the idea that pathogens are pretty much important in almost every aspect of our lives. I was working largely on understanding the causes of chronic diseases. And over the last two decades, a lot of information has come out that has very gradually indicated that infections are much more important in chronic diseases than we thought. But the way in which they’re important involves interactions between infectious organisms and mutualistic organisms, and also between the genetics of people in the case of human diseases, the genetics of the organisms, and also the non-infectious environmental factors. So all of these three categories come together, the microbes, the non-microbial environments, things like, you know, do we exercise or do we not? What’s our diet like? And then the genetics, which determines what kinds of things we’re vulnerable to, what kinds of negative things we’re vulnerable to, and what kinds of characteristics we have in place to stay healthy. Terry 10:22-11:14 Well, it all sounds rather complicated if we have to look at genetics and behavior and environment and pathogens, these infectious organisms. And one of the things that Joe and I have noted is that the infectious disease specialists, the doctors who specialize in treating infectious diseases, they know a lot about antiviral drugs and antibiotics, but they don’t seem that interested in your idea that some of these infectious agents, these pathogens, might be behind chronic diseases like cardiovascular disease or Alzheimer disease. How come? Dr. Paul Ewald 11:14-12:29 Well, I think that physicians are trained to diagnose and treat. And so we can’t expect that they’re necessarily going to have a focus on this bigger picture of what actually causes disease. They have particular protocols for treating disease once they diagnose them. And, you know, there’s some pressure on them to do that. If they deviate from the standard protocols, they could be liable for malpractice. And so I think what basically we have to realize is that physicians are trained to do one thing in a clinical setting, diagnose and treat. And what an evolutionary biologist is interested in doing is trying to understand how all of this fits together. In other words, trying to understand how evolutionary forces shaping humans influence disease, how evolutionary forces shaping microbes influence disease, and how all of that depends on the environments we’re in. And often that involves noticing that there are mismatches between our current environments and the environments in we evolved and those are the environments in which we generated the adaptations to deal with health and disease. Joe 12:29-13:50 Dr. Ewald, when we spoke to you two decades ago, I don’t think we had heard of the term microbiome. I mean, everybody knew that there are bacteria and fungi and such organisms in our digestive tract, but microbiome was not a term that was used very much. Now it seems like everybody’s talking about the microbiome, and it’s not just of the digestive tract. There’s a microbiome of the lungs. There’s a microbiome of the skin. There’s a microbiome of the brain. And the idea that there are pathogens that are living in our bodies, it seems alien to most people, but we’re beginning to gradually recognize, yes, we’re living in quote-unquote harmony or disharmony with a lot of different bugs. So I’m curious as to how this concept of the microbiome throughout our body is affecting your work in evolutionary biology and the idea that there are a lot of germs, viruses, and bacteria that have set up housekeeping in us and may sometimes cause problems. Dr. Paul Ewald 13:51-15:47 Well, I think we overlook the microbiome because the members of the microbiome are very small. We don’t see them, okay? So once we recognize that they’re there, then our task is to figure out which of these microorganisms are beneficial to us, actually helping us, and which ones are harmful. And this problem has been a little bit clouded by some of the terminology. So once microbiome was recognized as being important potentially for our health, then people who are studying this tended to use this term commensal for any organism that wasn’t overtly negative or positive. But in an evolutionary context and in biological context, a commensal is something that neither harms nor helps the host. And so basically, if we really could measure the net effect of all these different organisms, we would classify them all as either parasitic or mutualistic, neither unbalance their net harming us or unbalance their net helping us. And that seems like sort of an academic distinction, but it’s a really important one because if we’re thinking about supplementing our microbiome, then we want to be supplementing it with mutualists. We don’t want to supplement it with an organism that is slightly pathogenic, especially because sometimes we supplement the microbiome for people who are in particularly vulnerable situations. And so we’ve learned sort of the hard way that some of the things that look like they’d be good to supplement our microbiome with ended up not being so great, but others ended up being fantastic. And so I think that there’s a bit of a problem in the way in which this has been addressed. But the basic idea is really good, that we’re recognizing that we are not just individuals walking around in an environment. We have our own ecology of organisms in and on us. And we need to understand that if we want to be able to improve health and avoid disease. Terry 15:49-16:33 Dr. Ewald, I wonder if you could give us an example of one of those microorganisms that we’ve discovered is actually unexpectedly helpful. Sometimes a microorganism that we think is just kind of neutral turns out to be maybe just fine as long as the rest of the microbiome is in balance. But if the microbiome gets out of balance, that neutral guy sitting in there can get out of control. And I’m thinking of Clostridioides difficile, I think. Dr. Paul Ewald 16:34-17:38 Yes. Well, that is a really great point that we need to be thinking about the effects of the organisms in the context of all the other organisms that are there. And sometimes an organism that is going to be helpful in one context will actually be harmful if the microbiome has changed. Clostridium difficile is a very interesting example because interest started on this organism about 30 years ago when it was recognized it was causing some problems in hospital settings. And so people found that a lot of individuals are carrying Clostridium difficile without any problem, but they were causing problems in hospital settings. And so they jumped to the conclusion this organism was a commensal or a very mild pathogen, maybe even a mutualist, without enough data. When you look at Clostridium difficile in a general population, it really doesn’t cause noticeable harm, but that doesn’t mean it doesn’t cause some harm. Joe 17:38-17:48 Dr. Ewald, we are going to take a break. But when we come back, what we want to do is find out when it causes problems and how to get rid of it. Terry 17:49-18:05 You are listening to Dr. Paul Ewald. He’s an evolutionary biologist and professor of biology at the University of Louisville. Dr. Ewald is the author of “Evolution of Infectious Disease” and “Plague Time: The New Germ Theory of Disease.” Joe 18:05-18:09 After the break, we’ll learn how C. diff infections can start to overwhelm hospitals. Terry 18:10-18:17 Cardiologists pay a lot of attention to cholesterol levels. Should they also keep an eye out for pathogens in the arteries or even the mouth? Joe 18:18-18:25 We also worry about Alzheimer’s disease. Are there germs that might contribute to its development? 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 19:12-19:27 Modern medicine has a tremendous number of specialties and subspecialties. There are not just cardiologists, but interventional cardiologists who perform angioplasty and place stents in coronary arteries. Terry 19:28-19:37 Neuroimmunologists study multiple sclerosis and neuromyelitis. Such subspecialties may focus very narrowly on a small range of symptoms. Joe 19:38-19:50 When specialists are stuck in silos, they may not consider the bigger picture. The idea that infections might trigger a number of hard-to-treat chronic diseases is somewhat foreign to them. Terry 19:50-20:18 We’re speaking with Professor Paul Ewald. He is an evolutionary biologist specializing in evolutionary medicine and pollination biology. He is professor of biology at the University of Louisville. Professor Ewald is a pioneer in evolutionary medicine and infectious disease research. His books include “Evolution of Infectious Disease” and “Plague Time: The New Germ Theory of Disease.” Joe 20:20-20:29 Dr. Ewald, you were just talking about C. diff infections, and it’s my understanding that they can be really hard to get rid of once they take hold. Dr. Paul Ewald 20:30-22:03 Yes, and the C. difficile infections are very problematic in hospitals. It used to be thought that they were just causing problems because a person’s microbiome was upset or a person was vulnerable in one way or another because they’re in the hospital. But when you look at the strains that are in hospitals and the strains in the outside community, you find the strains in hospitals are actually more severe. And this was not recognized for a while. Over the last 10 years, it’s gradually become recognized. And so what looks like it’s happening is this Clostridium difficile organism is actually evolving increased virulence in hospitals where it can get from one patient to another, even if the patient’s sick. It gets transmitted between patients on the hands of attendants. So it is resistant to antibiotics. Antibiotics are not as effective as we would like them to be. But there are a lot of ways in which we can deal with C. difficile. And one of the best ways is improving hygiene so that you actually don’t get attendants transmitting the organism from an infected individual to a susceptible individual. And if you do prevent that kind of transmission, you’ll do two things. One, you’ll actually protect individuals who become infected, but also you should actually turn down that evolutionary pressure in the hospital environment favoring the harmful strains. And so you’ll get a gradual leakage of the milder strains into these hospital environments, and they can protect against the harmful strains through cross-protection immunologically. Joe 22:04-23:01 Dr. Ewald, I’d like to change gears a little bit now and go back to some of the what were really radical ideas that you were expressing 25 years ago. And let’s just start with heart disease because it is the number one killer in America, if not in the world. And if you were to talk to most cardiologists, they would say, well, the number one killer is caused by cholesterol, in particular, bad LDL cholesterol. And statins are the savior. And along comes Dr. Ewald and he says, yes, but there are some bacteria that might be responsible and possibly even other pathogens. And I think that’s a hard sell for most specialists in the field of cardiology. So how is it possible that pathogens could be causing heart disease? Dr. Paul Ewald 23:02-27:38 Well, pathogens invade our blood system, and they can be transported in cells, macrophages, and they can get into the insides of these blood vessels. And when I talked last time, or not last time, but 20 years ago when I was talking with you, I was mentioning some pathogens that had been identified in these lesions, these cardiovascular lesions. One of them is Chlamydia pneumoniae. And there are pathogens from the oral cavity that cause gingivitis and periodontitis that are found there. And at that point, there were a few studies indicating that there were these associations. People did more studies and some of the studies didn’t agree. And so people sort of lost interest. People tried to treat with antibiotics and the antibiotics weren’t effective in remedying cardiovascular disease. But the microbiologists say, of course, they weren’t. These microorganisms by that time are living sort of encrusted in all of this decayed tissue. And so the antibiotics aren’t going to get to them. So the flash forward 20 years, what [has] now been recognized is that with many different studies that are done, mostly outside the United States, because the United States sort of stopped funding this work about 20 years ago. Now, if you look at all those studies together, there’s a very robust trend for chlamydia pneumonia, this respiratory tract pathogen that gets into the vessels of the arteries, the arterial vessels, to be strongly associated with cardiovascular disease. So people that dismiss that, my response is just look at the literature. The literature has changed so much. It’s become so developed over the last 20 years that now there should be no argument about whether those organisms are there. The only argument is the extent to which they’re actually causing the disease. But there are more data indicating that there’s an answer to that question as well. And one of the best batches of data has come out of Taiwan, which has this health system where they’re keeping track of everybody’s health records. And what people did in Taiwan was to look to see whether people who came in with Chlamydia pneumoniae pneumonia, that is pneumonia caused by this organism, were, if they were treated, were they less likely to come down, in this case, with Alzheimer’s disease? Because the argument about chlamydia pneumonia applies to Alzheimer’s disease as well as cardiovascular disease. And so what they found is those individuals that came in with pneumonia caused by Chlamydia pneumoniae, they were treated, did not have an association with Alzheimer’s later on, whereas the ones who came in with chlamydia pneumonia that were not treated did. Okay, so you’ve got this, what’s getting close to an experiment. You couldn’t run an experiment on people for ethical reasons, but this is pretty darn close. So you’ve got the evidence now for cardiovascular disease and also for Alzheimer’s really being quite overwhelming that this organism’s associated with these diseases. Now, a similar situation has occurred with the oral pathogens, things like Porphyromonas gingivalis, which is also not only causing periodontal disease, but is associated probably causally with Alzheimer’s disease and with cardiovascular disease. So going back to the original point about cholesterol and statins, the evidence on cholesterol indicates that, yes, that’s contributing as well. But the actual degree to which cholesterol is contributing looks like it’s modest, but it’s something that’s easy to measure. And so I think what happened historically is that people measure what they could measure. They can take a blood test. They can easily measure cholesterol and they could find that association. And so they sort of hung a lot of their advice on that association. But just because something’s easy to identify doesn’t mean it’s the main player. And so when you look at some of these organisms, you find that they actually do better when people have higher fat and cholesterol in their blood. And some of them, like chlamydia and pneumonia, actually increase the amount of cholesterol. So when you find that cholesterol is associated, you have to say, okay, so what’s causing the increase in cholesterol? And you have to reopen the idea that it could be a very complicated set of factors, including microorganisms that are, they are sort of upsetting the system. Terry 27:38-28:01 Well, Dr. Ewald, you did mention Alzheimer’s disease with reference to Taiwan, where they do have excellent healthcare records. And I think you suggested that people with Chlamydia pneumoniae infections were more prone later to develop Alzheimer disease. Did I get that right? Dr. Paul Ewald 28:02-28:02 Yeah. Terry 28:04-28:37 So what I want to ask you about is what we’ve been hearing from the Alzheimer’s disease researchers, not necessarily the ones we’ve been talking to most, but the most prevalent ones, the most prominent ones, is Alzheimer’s disease is caused by buildup of amyloid plaque in the brain. Some of the researchers we’ve been talking to say, yes, but amyloid plaque is actually a response to infection. What’s your take on that? Dr. Paul Ewald 28:37-29:50 Well, we now know that beta amyloid is a protein that actually is antimicrobial. So if you’ve got infections in the brain, you’re going to have amyloid beta being produced, and that is going to be associated with the degree of threat. So the real problem is thinking about the correlation between the amyloid plaques and the damage to the brain in Alzheimer’s and trying to figure out how much of that is a response to something else and how much of that is actually creating the problem of Alzheimer’s. And the bottom line, it’s a little bit of both. It looks like the amyloid proteins do have some negative effects, but it is clear that they’re also antimicrobial and they’re elevated. And the particular subsets of amyloid beta are elevated in response to infection and they actually control the infection. So that’s been pretty well looked at for one of these organisms of the oral cavity, periodontal pathogens, in particular, Porphyromonas gingivalis. So it’s been looked at in animal models. Joe 29:50-30:39 Dr. Ewald, the idea that Alzheimer’s disease or dementia might somehow be precipitated by infection is still pretty radical. And there have been papers about herpes simplex virus as one possible contributor. You’ve now suggested Chlamydia pneumoniae as another possible [contributor]. There may be a whole bunch of infectious agents that are contributing to Alzheimer’s disease. And I’m just wondering, well, patients want to know, well, what can I do about it? You know, how can I prevent Alzheimer’s disease? How can I prevent heart disease? How can I get rid of those infectious agents that might be contributing to these very serious chronic conditions? Dr. Paul Ewald 30:41-31:15 Yes, I think you’re exactly right. The emerging trend is that there are a lot of organisms that are involved, including herpes simplex and Porphyromonas gingivalis and Chlamydia pneumoniae. So there are a number of ways in which we can actually prevent this damage. One way that has been very slow to be assessed, but now it looks like it’s actually having a big effect, is taking better care of your oral cavity. Flossing, for example, looks like it has been associated with a much lower rate of Alzheimer’s. And so… Joe 31:15-31:26 Whoa, whoa, whoa, wait a minute. Are you telling me that flossing your teeth on a regular basis might reduce your risk of Alzheimer’s disease? Dr. Paul Ewald 31:26-34:16 That’s what you wanted, Joe. We wanted some practical applications. So let me tell you the mechanism that is almost certainly the right mechanism. When you floss, you take care of your oral health. This could also involve use of antibiotics to control periodontal disease. You’re controlling organisms that are found in the brain and are associated with Alzheimer’s. And you’re also controlling organisms that are found in the artery walls that are associated with atherosclerosis. And you’re also controlling one of the big bad guys I mentioned before, Porphyromonas gingivalis, which contributes to diabetes. And it looks like that’s a two-way street. Diabetes contributes to porphyromonas growth. Porphyromonas growth contributes to diabetes. And the whole thing is related to these other diseases because diabetes, when it’s bad, is related to bad cardiovascular disease. It’s also related to Alzheimer’s. And almost certainly the mechanism is that when you’ve got high blood sugar, then organisms that are normally sort of kept in check by the immune system are not so easily kept in check. So these organisms that are contributing to cardiovascular disease and to Alzheimer’s, at least in theory, and probably in practice in reality, they’re not controlled as well by the immune system when you’ve got high blood sugar. And so diabetes then exacerbates these other diseases. Now, if you ask people, you know, sort of that are not thinking about this in a broad, integrative way, so why is it that people with diabetes have more heart attacks and have more Alzheimer’s and have more periodontal disease? They’ll often say, well, it just messes everything up. Well, this is a very different view. It says that when we understand what the actual causal mechanisms are, we see connections. And that explains why diabetes is so associated with so many of these other chronic illnesses. They’re actually exacerbating the situation by favoring microorganisms that look like they’re involved in the pathology of these chronic diseases. And so I would just come back to your original point, Joe, and I would just say when people are skeptical, my response is dig deeply into the literature. Look at this information and you’ll see these connections. People are just working in such isolated ways that they’re not seeing these connections. And Terry, as you said, it is complicated. It takes work. And I am sympathetic to physicians, for example, who may not have the time to look at it. But if you don’t have the time to look at this vast literature that’s emerging, then I would think a little circumspection is in order to say, well, you know, I haven’t looked at the literature. It’s an idea worth considering. Let’s look at the evidence. Joe 34:16-34:16 Terry? Terry 34:17-34:52 One thing we do see in the literature in terms of how can we reduce our risk for coming down with Alzheimer’s disease is related to viruses. It turns out that people who are vaccinated against shingles, which is of course caused by the chickenpox virus, are at a significantly reduced risk, not perfectly protected, but significantly reduced risk of developing Alzheimer’s disease or other dementias. You want to comment on that? You know, viruses, they’re pretty important too. Dr. Paul Ewald 34:53-35:18 Yeah, that was my next point. You beat me to it. I was just going to talk about the varicella zoster virus and how evidence now is really clear, based on a lot of studies, that vaccination against the varicella zoster virus, a shingles vaccination is associated with a quite dramatic decline in the probability of developing Alzheimer’s. Joe 35:18-35:54 So, Dr. Ewald, it seems like a lot of the specialists, I don’t care whether they’re cardiologists or gastroenterologists, psychiatrists, rheumatologists, they just don’t think about pathogens. They think about blood sugar or they think about cholesterol, but you’re sort of suggesting that they’ve got it backwards, that we need to start looking at the pathogens as the causative agents and everything else is secondary. And you have about 30 seconds to respond before the break. Dr. Paul Ewald 35:54-36:15 Okay. Well, I think you hit it, the nail on the head. They’re specialists and specialists aren’t thinking about how all these things are connected. But when you look at it, you see that there are these connections, very strong connections, that are generating explanations that really are robust as opposed to explanations that are just dealing with one little part of the problem. Terry 36:16-36:38 You’re listening to Dr. Paul Ewald. He is a professor of biology at the University of Louisville. Professor Ewald is a pioneer in evolutionary medicine and infectious disease research. He’s the author of Evolution of Infectious Disease and Plague Time, the New Germ Theory of Disease. Joe 36:39-36:58 After the break, we’ll be talking about some ancient history. When chronic fatigue syndrome first showed up, it seemed to be connected to an infection. Scientists have never identified a single pathogen that’s responsible for this devastating condition. How do they think about it now? Terry 36:59-37:06 Long COVID has some similarities to chronic fatigue. Is that changing how we understand these problems? Joe 37:07-37:17 Lyme disease can also cause trouble for a long time, even though tests don’t always show pathogens. Could they be in hiding? Terry 37:18-37:24 One surprising link is between infection and schizophrenia. What should you know? Joe 37:24-37:31 Another potential connection is between arthritis and infection. Might it change how we treat joint pain? Terry 37:39-37:43 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 37:55-38:12 And I’m Terry Graedon. The People’s Pharmacy is brought to you in part by Spatial Sleep, a non-drug approach to help you fall asleep and stay asleep without medications. More information at SpatialSleep, S-P-A-T-I-A-L, sleep.com. Joe 38:13-38:23 When Dr. Paul Chaney described the first outbreak of chronic fatigue syndrome, he suggested an infectious origin. His colleagues were skeptical. Terry 38:24-38:42 Our guest today, Dr. Paul Ewald, proposes that many chronic conditions could be rooted in infections. He is professor of biology at the University of Louisville and author of Evolution of Infectious Disease and Plague Time, the New Germ Theory of Disease. Joe 38:44-39:57 Dr. Ewald, many decades ago, even before we spoke with you, we talked with Dr. Paul Cheney, who was, I think, an internist in Nevada. And he saw a bunch of people who had come down with a rather odd condition where they had terrible fatigue and couldn’t think very clearly after they came down with an infection of some sort. And he basically was the first clinician, as far as I can tell, who identified what we now call chronic fatigue syndrome or ME/CFS, as some people refer to it. And that idea that you could have this rather nasty upper respiratory tract infection, kind of like the flu, but it never completely goes away. And you’re kind of left with, you know, exhaustion on exercise and brain fog and a whole bunch of other symptoms. And that seems a little reminiscent of long COVID. How has COVID changed the way we think about these kinds of problems? Dr. Paul Ewald 39:57-44:07 Well, I would first say that the idea of looking for infectious causes of chronic fatigue syndrome makes a tremendous amount of sense because we know that when infections occur, one of the things the brain does is makes us feel fatigued. And so if you have a persistent infection, you’re likely to feel fatigued for a longer period of time, depending on how persistent it is. Now, if we flash forward to SARS-CoV-2, and what has become apparent is that the acute phase is part of it, and then there’s a long chronic phase, and people disagree about whether the organism’s still there. I suspect it still is, in refugia–it’s hard to find out whether it’s there or not, if it’s there in very low densities. I would, in answer [to] your question, what has COVID told us about or informed us about, I would say it’s informed us about a lot, but not enough. Okay. I think there are a lot more lessons. And one of the lessons is that we need to be thinking about infectious diseases much more in the context of both acute and chronic phases, because the acute phase is just part of the story. As soon as you start looking at a chronic phase, people will start saying, oh, well, we don’t see the organism. Well, the organism’s not as abundant in the chronic phase if it’s there. Also [it] may be causing problems much more indirectly. And so we have the same kind of problem with Lyme disease, where people are arguing that a lot of these chronic correlates of Lyme disease are not because the organism’s still there because their tests don’t show it. Well, again and again, over the last few decades, we’ve found that people are dismissive of infectious causes because they’re using the old techniques that are not sensitive enough, when you start using new techniques and you start thinking more broadly about the ways in which disease organisms can be causing chronic disease, then things appear that you didn’t think were there. So I would argue that for COVID, we need to really be focusing on thinking about detecting pathogens, the virus that could be there in the long run, and then thinking about how we would combat that. The other lesson from COVID is one that I think we may have talked about the last time I was talking with you, which is that evolutionary thinking informs us that organisms like the coronavirus that causes COVID, those viruses are dependent on hosts being not healthy, but not terribly sick for transmission because they’re moderately durable in the external environment. And the evolutionary theory, which is really supported by a comprehensive evaluation of all human diseases, indicate that if a pathogen is really durable, it’s likely to evolve to be very harmful. If it’s very non-durable in the external environment, it’s likely to be mild. And if it’s in between, it’ll evolve to be in between. And so one of the points I was making back in 2020 was that we can expect that SARS-CoV-2 is going to be evolving towards a level of virulence that is very much like influenza because that’s how durable is the external environment. And unlike what a lot of people, most people would argue that, oh, it could just become virulent again with a new mutation, I would argue that it will not become more virulent with new mutations over the broad population because those variants will be too harmful for the mode of transmission of this virus. And so that’s a test we can look at. I made that prediction 2020. So far, it’s held up. The organism over about a year evolved to be more mild and it has not evolved to be more severe like the earlier strains were. And so it’s a prediction from evolutionary thinking that we will be able to evaluate as time goes on. And hopefully people will look back and see that the evolutionary perspective generated these predictions. And if the predictions don’t hold up, then we can say the evolutionary perspective is not great. But if they do hold up, then it lends credibility to this evolutionary perspective. Joe 44:07-44:10 Well, we certainly hope you’re right. Terry, you have another question? Terry 44:10-44:35 I do. I’m wondering, Dr. Ewald, you say that we’re using old techniques, old technology, presumably, to look for these pathogens that have caused an infection, and we assume the person is now recovered, and yet they still are feeling bad. The tests that we use don’t show that the pathogen is there. Could a pathogen be hiding? Dr. Paul Ewald 44:35-48:40 Yes. Well, I think that’s exactly why they’re hard to detect. They’re essentially hiding. They’re in places where the immune system can’t get to them, and so it’s harder for us to identify them because it’s harder for us to get to those places. [They] may not be as abundant in the body and they also might be much more hidden. So if the immune system can’t get to them, that’s why they’re persisting. We may not have an antibody response that’s very high. And so people say, well, there’s a slight antibody response, but it doesn’t really look like an active infection, but it’s very well likely to be a moderate antibody response. This is associated with, like you say, a hiding infection. And this is really quite important because what it means is we have to be able to generate tools that will identify pathogens that are there in much lower density and in tissues where they’re not so obvious. And this is very apparent in cancer, for example, because it used to be thought that if a pathogen was causing a cancer, you would see it in essentially all cells in the tumor, right? And it makes sense. And the first cancers that were accepted as caused by infection did have pathogens that were present in virtually all cells. And so people then presume that that would be the model for all viral-induced cancers. But now we know that some cancers are caused by viruses that are only present with about 1% of the cells in the tumor. So Hodgkin’s lymphoma is an example of that. And so what that means is we have to be looking much more carefully at all of those cells. And there are techniques now: you can do techniques that involve looking at single cells and then putting all of those cells together, let’s say in a tumor, to see what the overall structure is. And then you can assess whether just a few of those cells are actually cancer cells. And other cells might be infiltrating cells. There might be cells that have lost a virus and therefore are not infected anymore. So I think that this is a really important issue. People have rejected the idea that infections are causing cancers because they’re found in, let’s say, only 1% of the cells. But now we know that cancers can be caused by viruses that are only affecting 1% of the cells. In the case of Hodgkin’s lymphoma, where this has been accepted, it was a little more obvious because those cancer cells look different. Okay. And so people [say], what are those cells doing? They found out that those cells were the ones who were infected with the Epstein-Barr virus. Other cells in the tumor were not, and those were the cells that are cancerous. Okay. So you have a clue, it’s kind of conspicuousness of infectious causation. And what we have to remember is we’ll identify and accept infectious causation for diseases in which the infectious causation is more conspicuous than it is in other diseases that are caused by infection, right? Because we will, if it’s conspicuously caused by infection, then everybody can agree on it faster. If it’s inconspicuously caused by infection, then people are going to argue about it. And so that actually has been the history of the germ theory for the last 130 years, is that we’ve identified the infectious agents that are conspicuously causing infection. And then we’ve argued about the ones that are less conspicuously caused, and then we solve those. And then we argue about the other ones because they’re even less conspicuously caused. And so now we’re arguing about things like cancer in which you have only a few cells that may be infected in a tumor, a few cancerous cells in the tumor. And we’re dealing with cancers like breast cancer, for which there are six different viruses that have been rigorously associated with breast cancer. This is with multiple analyses and looking at the various studies and using meta-analyses to see what the overall trend is. And so if you’re looking to see whether one virus is associated with breast cancer, it might not be in that population, but another virus might. You have to be thinking about all five, I’m saying all six viruses that have been significantly associated with breast cancer and probably more that haven’t yet been associated. Joe 48:40-48:42 Dr. Ewald, we are running out of time. Dr. Paul Ewald 48:42-48:42 Okay. Joe 48:43-49:47 And I’d like to ask you about schizophrenia. Dr. Paul Ewald 48:47-48:47 Yes. Joe 48:47-49:41 Because when you mentioned that a couple of decades ago, I think it came as a real shock to our listeners. How could mental illness, something severe like schizophrenia, be caused by a pathogen? And just in the last several months, there’s a story in the popular media of a woman who was diagnosed with schizophrenia for many, many years. And then she came down with something that required an antibiotic. And after a course of treatment for whatever infection she had, all of a sudden, her schizophrenia disappeared for good. And it was like, how could that possibly happen? And so can you give us, in a short period of time, your overview of schizophrenia in particular and how there might be an infectious cause? Dr. Paul Ewald 49:43-51:43 Okay. So schizophrenia is a great example of a disease entity that’s an umbrella category. And that category used to be embedded in an even bigger category, which included syphilitic insanity. And your question was, how could a pathogen cause such severe mental illness? Well, syphilis, the syphilis organism does it. It was recognized. And as soon as they recognized it, they separated it off from what we now call schizophrenia. And so for the last hundred years, we’ve been dealing with this term schizophrenia. And I think we’re poised on the edge of making some more divisions, taking away what we’re calling schizophrenia and putting it in another category. So one big advance was to recognize that a lot of schizophrenia really has mood associations. And so in the last 10 years, there’s been a tendency to talk about schizoaffective disorder. And when we look at pathogens, one thing we find is now with many studies, there’s a highly significant association between Toxoplasma gondii, this cat-rat pathogen, and schizophrenia. But in particular, it seems to be associated with schizoaffective disorder. So I think what we’re poised on doing now is looking at schizophrenia and saying, we want to take off certain parts, carve out certain parts of what we’re calling schizophrenia, and we’ll put it into, make a new category, and then we’ll be left with a smaller category. And this has been happening, as I said, for over 100 years for psychoses. And so what we can imagine is a new category that we can call ‘toxoplasmal schizoaffective disorder,’ which will be maybe as much as a third of what we’ve called schizophrenia out and put it into this new category. Then we’ll be left with two thirds of something we don’t understand very well. And we have to look carefully at it and figure out whether there are other subsets that we can carve out in a more realistic category that represents an understanding of the causation of those problems. Joe 51:45-52:00 Dr. Ewald, we only have two minutes left, could you quickly squeeze in something about arthritis, especially rheumatoid arthritis, and then sum up what people should learn from your books and from your research? Dr. Paul Ewald 52:02-54:50 Well, arthritis is, again, a big umbrella category. We’ve recognized that some arthritis is caused by infection. And when we recognize it, we carve off that aspect of arthritis and give it a new name. So we’ve given some arthritis a new name, reactive arthritis, which indicates that it is associated with and caused by infection with, in this case, bacteria. And particularly infection with Chlamydia trachomatis, a sexually transmitted pathogen also associated with Neisseria gonorrhoeae. And so that’s an example of what has happened in this process in which we take these umbrella categories and subdivide off. I think we’ll see more of that kind of subdivision. In the case of rheumatoid arthritis, we know that this is an antibody-mediated disease. The antibody is causing a lot of problems. So what is causing the antibodies to misbehave? Okay. We don’t expect the immune system just to misbehave on its own. Something’s got to be pushing it. And so there are pathogens that look like they’re associated with rheumatoid arthritis, and we need to really look at them. So Epstein-Barr virus, one that is associated with Hodgkin’s lymphoma, looks like it’s associated with rheumatoid arthritis. Also, the one I mentioned before, the periodontal pathogen, Porphyromonas gingivalis, looks like it’s associated. And the details really look like those associations are causal. So I think it comes back to what can you do to reduce the chance of having these infections? And the Porphyromonas [gingivalis] comes back to flossing, weirdly. How would you ever expect that flossing would be related to protecting yourself against rheumatoid arthritis? But it also raises a general question, which is really important now in this atmosphere of our politics, our governments, and our social setting. And that is that there’s this tendency among some people to think that vaccines aren’t extraordinary tools that have helped the medical sciences to combat diseases. And I think, again, looking at the evidence, you have to realize it’s one of the great categories of advancement. And it’s likely to be even greater in the future as we recognize a lot of these pathogens we don’t have vaccines for are causing chronic diseases. And some of the pathogens that we have vaccines for are causing more problems than we thought they were causing. So I think that a shout out to the idea that we really have to be thinking clearly about the value of vaccines. Vaccines do have some side effects, but the side effects are so rare compared to the benefits that I think we really should be hesitant to act against the administration of vaccines and also the support for vaccine research. Joe 54:52-56:06 Dr. Ewald, you have described a whole bunch of chronic conditions that could be triggered by pathogens, by bacteria, viruses, perhaps some other organisms, whether it’s cancer or whether it’s schizophrenia or whether it’s heart disease. And it feels like we’ve just scratched the surface. If you could pull together all of the specialists, the cardiologists, the pulmonologists, the psychiatrists, the gastroenterologists, and put them in a room and say, hey, guys, hey, women, all of you professionals, you need to start looking at the causes of the conditions that you’ve been diagnosing and treating for decades. And some of those causes, many of those causes, may be pathogens. And until you start killing off or preventing those pathogens from causing the diseases that you’re treating, you’re fighting a losing battle. How could you ever accomplish that huge feat? Dr. Paul Ewald 56:10-58:11 I have been trying to work towards that end by sort of continuing to write on these issues, continuing to show how certain explanations are missing certain things and how those missing parts are filled in. And you look at interconnections between genes, environment, and infection. And so I would just say that this is nothing. This slowness is nothing new. It’s been happening for over 100 years. And we just have to have patience. And I don’t think that getting everybody in the room is going to do it. I think we’ve got to actually have papers written, books written, that actually people can take time to read and ponder. And then people who tend to be leaders in these areas will say, hey, wait a minute, I think we have been a little bit wrong. And then the people that tend to be followers will say, well, this leader said that we’ve been wrong in neglecting this interface between genetics and infection and environment. And so maybe it makes sense. And so then the default, as people shift, is to then give some credibility to these arguments. But, you know, progress happens. It’s just very slow. It’s like slow motion germ theory of disease. You know, the germ theory started millennia ago, actually, but certainly centuries ago. So and then the progress has been very slow. And the slow progress has been because the things that are to be discovered in the future are less obviously caused by infection. We just have to get people to realize that. And I think, I’m thinking the best way is by writing books and papers that people can read, take their time with and ponder rather than trying to get people in a room and sort of make arguments based on evidence that then goes by so fast. And the meeting would go by so fast that people then leave and they’re not changed by it. That’s my sense. And also, I think it’s good to have shows like your show where we can actually get these ideas out. Terry 58:12-58:18 Dr. Paul Ewald, thank you so much for talking with us on The People’s Pharmacy today. Dr. Paul Ewald 58:19-58:20 Thank you for having me. It’s been a pleasure. Joe 58:22-58:48 You’ve been listening to Dr. Paul Ewald, professor of biology at the University of Louisville. He’s a pioneer in evolutionary medicine and infectious disease research. Professor Ewald has challenged conventional wisdom on the causes and prevention of many chronic diseases. He’s the author of “Evolution of Infectious Disease,” and “Plague Time: The New Germ Theory of Disease.” Terry 58:49-58:57 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 58:58-59:05 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Terry 59:06-59:22 Today’s show is number 1,455. 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 59:23-59:39 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. The podcast this week has additional information on how to consider the possibility that many chronic diseases are caused by pathogens. Terry 59:40-01:00:10 At peoplespharmacy.com, you could sign up for our free online newsletter. And that way, you can get the latest news about important health stories. When you subscribe, you also get regular access to information about the weekly podcast. We’d be grateful if you’d consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. If you find our topics interesting, please share them with friends and family. Joe 01:00:11-01:00:14 In Durham, North Carolina, I’m Joe Graedon. Terry 01:00:14-01:00:49 And I’m Terry Graedon. Thank you for listening. Please do 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. 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Transcribed - Published: 11 December 2025

Do you worry about things you can’t see, smell or taste? Most of us don’t. Yet particles we can’t detect with our five senses are often present in the air we breathe. They have the power to make us sick. How can we achieve cleaner indoor air so that we have less chance of coming down with a serious infection? 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, Dec. 6, 2025, 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 Dec. 8, 2025. The Importance of Cleaner Indoor Air: When we talk about air pollution, the image that may arise is factories belching dark plumes of smoke. While the particles generated by industrial processes can be dangerous for our health, sometimes the greatest danger is from particles we can’t see. The COVID-19 pandemic brought this into sharp focus, as we realized that people who had not yet begun to experience symptoms could be spreading infectious viruses. But the need for cleaner indoor air is not limited to COVID, or even to an epidemic like measles or the flu. Many infections spread primarily on viral particles wafting through the air. We are reminded of this every winter, as cases of influenza start to rise. But respiratory syncytial virus, human metapneumovirus and dozens of rhinoviruses and coronaviruses that cause colds also travel on the air. So do measles viruses. Our guest, Dr. Linsey Marr, is one of the country’s leading environmental engineers. She got interested in airborne transmission of infection even before SARS-CoV-2 appeared. Then, with COVID, it became clear that the advice to the public about maintaining 6 feet of distance was inadequate to protect people from coming down with the infection. It was developed based on an outdated understanding of how infectious particles travel. Can You Tell If Indoor Air Is Contaminated? Given the extremely small size of viral particles, we might have to use our imagination to understand how they could be present. We can’t smell viruses. But if you imagine someone smoking a cigar in the room, you know that the smell will linger for quite a while after the smoker has left. Viral particles can float around like the smell of cigar smoke, which is why they can still be present even after an infected person has left the space. This viral behavior means that the riskiest places are those where many people congregate, especially during a season when infections are spreading. Think of grocery stores, hospitals, or athletic event venues. Wearing a tightly fitted N95 or KN95 mask could provide some protection (especially if others also wore masks). It is not a magic bullet, though. Japanese people accept mask protocol during flu season, and they have still experienced the spread of influenza. In the US, it is very unlikely that most people will accept wearing masks, even if it could help reduce their risk of infection. While we can’t measure viral particles in the air without complicated equipment, we can use a simple relatively inexpensive piece of equipment to check the ventilation in a space with multiple people. It is called a carbon dioxide (CO2) monitor. Because people exhale CO2, high levels of this harmless gas indicate lots of people breathing in the space without much ventilation. Fresh outdoor air runs about 400 ppm CO2. Once indoor air reaches 1,000 ppm or higher, you may want to take action. Moving Toward Cleaner Indoor Air: Ventilation: Improving ventilation would be very advantageous. Most public places should strive to achieve at least 4 to 6 air exchanges per hour. More sensitive spaces such as health care facilities might benefit from a higher level of ventilation. Filtration: The other way to deal with airborne viruses is through filtration. Home air handling systems could be equipped with a high-efficiency particulate arresting (HEPA) filter. This is ideal, but it may not be practical in every space. Ordinary air filters carry a MERV number such as 8, 11 or 13. Higher numbers indicated better filtration capacity. In general, you’d want to use the highest MERV number your HVAC system will tolerate. Too high a number can create too much pressure and cause problems. What if you don’t have access to the filters for your air? That is the case for many apartment dwellers who have to share their air with everyone else in the building. One affordable option is to build and use a Corsi-Rosenthal box. It can be assembled at home for $50 to $70 and it works quite well to provide cleaner indoor air in the space where it is operating. Dr. Marr describes how to build one. Here is a link to our interview with Dr. Corsi, including instructions on building a Corsi-Rosenthal box. Elimination: Another step toward cleaner indoor air might be to utilize ultraviolet (UV) light as a disinfectant. A unit that uses germicidal UV at a wavelength of 250 nanometers needs to be tucked into air ducts. That wavelength can damage eyes and skin. New technology is being developed using a slightly different wavelength of 222 nanometers. While still germicidal, it is supposed to be safe for human eyes. This Week’s Guest: Linsey Marr, PhD, is a professor of civil and environmental engineering at Virginia Tech, where she leads the Applied Interdisciplinary Research in Air (AIR2) laboratory. Her research group focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Marr teaches courses in environmental engineering and air quality, including topics in the context of global climate change, as well as health and ecosystem effects. She has been thinking and writing about how to avoid airborne viral transmission since the pandemic began, as in this article published in Environment International (Sep. 2020). Photo by Peter Means, courtesy of Virginia Tech. Dr. Linsey Marr of Virginia Tech. Photo by Peter Means, courtesy of Virginia Tech Dr. Marr mentioned her publication, with many colleagues, advocating for cleaner indoor air in public buildings. Here is a link. Joe Graedon conducted this interview, as Terry was unavailable. Listen to the Podcast: The podcast of this program will be available Monday, Dec. 8, 2025, after broadcast on Dec. 6. You can stream the show from this site and download the podcast for free. This week’s episode contains some additional discussion of outside air, including the dangers of smoke from wildfires, along with particulates from car tires or microplastics. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1454: 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. How do you catch the flu, COVID, or cold? Such respiratory infections are transmitted through airborne viruses. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:46 Dr. Linsey Marr is one of the country’s leading experts on air quality. She was among the first scientists to identify airborne transmission as a problem during the COVID pandemic. Joe 00:46-00:51 Dr. Marr will tell us how we can improve the quality of the air we breathe. Terry 00:51-00:58 Do you know how well the air in your home is filtered? What about the air quality at school, at work, or in your doctor’s office? Joe 00:59-01:07 Coming up on The People’s Pharmacy, how cleaner indoor air reduces your risk of infection. Terry 01:14-02:16 In the People’s Pharmacy Health Headlines: viruses are on the move, through the air and on surfaces. Subclade K type A H3N2 influenza is spreading. People catch it primarily by inhaling invisible viral particles. Public health authorities are worried that current influenza vaccines may not protect well against this new variant. The other virus that’s causing a lot of misery is norovirus, also known as stomach flu, the cruise ship virus, or the winter vomiting bug. It’s one of the most easily transmitted infections because just a few particles can make you very sick. Wastewater scan shows a significant uptick in the last couple of weeks. If anyone in your household starts throwing up or having diarrhea, you’re at risk of catching this virus. That’s because it can be transmitted through the air. There is no vaccine or effective treatment against norovirus. Joe 02:17-03:31 Nutrition experts have been arguing about fat for decades. Starting in the 1980s, Americans were encouraged to follow a low-fat diet. Instead of using butter, people were told to use vegetable oil. Saturated fat was the enemy because it was thought to clog coronary arteries. Hydrogenated vegetable oils were promoted because they had no cholesterol. And seed oils, such as peanut, corn, and safflower oils, became popular because they, too, were low in saturated fat. In recent years, though, researchers became concerned that hydrogenated vegetable oils contributed to atherosclerosis. And now, researchers at the University of California, Riverside, report on an experiment with soybean oil. Mice fed on soybean oil developed obesity more easily than those fed coconut oil. The investigators identified a liver protein that determines how the body handles linoleic acid, a major component of soybean oil and some other vegetable oils. They point out that many processed foods contain soybean oil, which could be contributing to the obesity epidemic. Terry 03:32-04:51 Diet can play an important role in controlling blood sugar for people with type 2 diabetes. A study published in the American Journal of Clinical Nutrition demonstrates that slowly digestible starch can be very helpful. Because this slowly digestible starch is metabolized over a long time, it does not lead to spikes in blood glucose or insulin. Investigators recruited 51 people with type 2 diabetes and randomly assigned them to diets either high or low in slowly digestible starch. For three months, the volunteers kept track of their blood sugar with continuous glucose monitors. They also met with dietitians for nutritional and culinary counseling. Those whose diets were high in slowly digestible starches such as peas and beans, nuts and seeds, and whole grains had less dramatic changes in blood sugar. Both groups lowered their levels of HbA1c, a medium-term measure of blood sugar. Those on the diets rich in slowly digestible starches actually got their A1c below 7%, which was the target. The researchers believe this offers an effective and accessible strategy to help people with type 2 diabetes gain control. Joe 04:52-05:44 Australia’s equivalent to the Food and Drug Administration is called the Therapeutic Goods Administration, or TGA. Like the FDA, it monitors drug safety. Recently, the TGA issued a new safety warning to people using GLP-1 drugs such as semaglutide, tirzepatide, liraglutide, and dulaglutide. These drugs have become household names such as Ozempic, Wegovy, Mounjaro, and Zepbound. The TGA is concerned about reports of suicidal thoughts and behaviors associated with these medications. The regulatory agency is urging doctors to monitor patients for the emergence or worsening of depression, suicidal thoughts, or behaviors, and or any unusual changes in mood or behavior. Terry 05:45-06:17 Residents of several states are being warned to stay indoors because of poor air quality. High levels of ozone or fine particulates too small to see are making breathing dangerous in many places. You can check your local air quality index at the website airnow.gov. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:27 And I’m Joe Graedon. We’re entering cold and flu season, except there are lots of other pathogens circulating in the air we breathe. Terry 06:27-06:41 We can’t see them because they’re much too little. Infectious agents such as respiratory syncytial virus, human metapneumovirus, pertussis, and mycoplasma pneumoniae can cause a lot of misery. Joe 06:42-06:57 And let’s not forget that SARS-CoV-2 has not disappeared. This year, a new variant of influenza A, subclade K, is making people sick, and the flu shot may not protect us as well as we’d hoped. Terry 06:58-07:26 To find out why air quality matters, especially when pathogens are circulating, Joe talked to Dr. Linsey Marr. She’s a professor of civil and environmental engineering at Virginia Tech, where she leads the Applied Interdisciplinary Research in Air Laboratory. Her research group focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Joe 07:28-07:32 Welcome to the People’s Pharmacy. It’s so nice to have you back, Dr. Linsey Marr. Dr. Linsey Marr 07:33-07:37 I am thrilled to be here, to be back on the People’s Pharmacy. Thanks so much for having me again. Joe 07:37-08:21 Well, you know, unfortunately, Terry can’t be with us today, but I am so pleased to find that you have received so many awards and recognition for the work that you have put in over the last five years, especially with regard to COVID. I mean, you are an environmental engineer, you’ve been involved in bioengineering for a long time. And it seemed like COVID was just waiting for somebody with your expertise to come along. Can you tell our listeners what is an environmental engineer and how did you get interested in aerosol viruses? Cause you were into this field before there was COVID-19. Dr. Linsey Marr 08:23-09:22 Right. Environmental engineers dedicate their careers to ensuring that we have a clean and healthy environment, whether it’s in the natural environment and also in the built environment. The built environment [is] buildings and roads and other infrastructure. And so, for example, some environmental engineers focus on clean water. You know, we take it for granted that you can turn on your tap and get clean water that is safe to drink. But that wasn’t always true. And that development was thanks to the work of environmental engineers. Another example is that of clean air. Air in the U.S. used to be much dirtier in the 1970s. It was heavily polluted by dirty cars and the steel industry and other sources. And environmental engineers are the ones who kind of recognize this and helped lead, I guess, research and actions to help clean it up. Joe 09:22-09:36 Now, I’m saying that COVID changed your world, but you were already in this field. You were already interested. Tell us how COVID did make a difference in your life. Dr. Linsey Marr 09:37-10:51 Yeah, I had been studying viruses in the air since about 2008 or 2009. And I got into it mainly, well, for a couple reasons. One, I had been studying traditional particulate pollution in the air. As I mentioned, environmental engineers study air pollution. And then a second reason is that I had a child in the end of 2007, and he had started daycare and was getting sick all the time. So I really became both fascinated and frustrated by the rapid spread of disease in daycare centers. And so I started reading up on this and found out that we really didn’t know as much as it seemed. And what I did read about how the flu spreads between people, some of it just didn’t really make sense with my understanding of how particles move through the air. And so my research group started out by going into daycare centers, a health center on campus, and airplanes. We collected air samples, really particles in the air, and analyzed those and found the flu virus present in like half of them. And it was in small enough particles that they would stay in the air for a long period of time, float around, and people could breathe them in. And after several hours, they could breathe in enough to become infected. Joe 10:51-11:15 So you were already beginning to suspect that viruses could float on the air. And then along comes COVID. And the CDC and the World Health Organization, all these public health experts were saying six feet. As long as you’re, you know, eight feet away from somebody who’s infected, you’re home free, no worries. And you are going, whoa, whoa, wait a minute. Dr. Linsey Marr 11:16-13:01 Yeah. All of a sudden, all the research I had been doing for the previous 10 years really was here. And I had been studying this because I was worried about a new flu pandemic. It wasn’t flu, but it turned out to be a coronavirus. And then there was this constant messaging about, oh, stay six feet away from people and that’ll protect you. And I knew from what I had been studying that that was likely not true. And it was based on some older, let’s say, kind of dogma or kind of, yeah, just dogma about how respiratory viruses transmitted, that it was mainly in these large droplets that people cough or sneeze into your face big enough to see. And they’re large enough and heavy enough to fall to the ground within six feet of anyone who coughed them out. So that, if that were true, then if you stayed at least six feet away, then there would be no way that you could come in contact with these, the viruses being emitted by other people. But it turns out that, you know, based on research I had done earlier and putting together a lot of studies that other people had done, even going back to the 1940s, I knew that people, whether they’re infected with a respiratory virus or not, but that they emit respiratory particles of all sizes, both those large wet ones when you cough, but also smaller stuff when you talk. And even some people when they breathe. And based on older studies, I knew that the virus could be present in those across the whole size range and could also survive in those. And so the idea of the six-foot distancing, to me, it just didn’t sound like enough. I think it was due to a misunderstanding about how this type of virus would transmit. Joe 13:02-13:43 What surprises me in retrospect is that the six-foot rule kind of lasted a long time. It made no sense. And I kept wondering, well, where did it even come from? But I think your research and your colleagues’ work demonstrated pretty effectively that these viral particles could float through the air not for a few minutes and not for six feet, but for a long time and a greater distance, a much greater distance. So when did we finally begin to recognize that, Yeah, six feet wasn’t going to be the answer. Dr. Linsey Marr 13:44-16:17 I think it was a gradual series of kind of research studies and also observations of super spreading and other types of events that helped us realize that six feet wasn’t enough. And I should say that six feet is helpful because it does keep you kind of farther away from the most concentrated plume. If you imagine somebody’s talking, there’s a kind of a plume of air coming out as if they’re smoking a cigarette and you want to stay away from that. So six feet is good for staying away from that, but it’s not going to absolutely protect you from breathing in those smoke or other respiratory particles. But there were a number of things that happened. So one was that there was that the outbreak in the Skagit Valley Chorale in early March of 2020, I believe, where there was a choir that went through a rehearsal and maybe one or two people were were infected. They didn’t feel quite well. The group, you know, knew that there was this new virus around. And so they avoided shaking hands, touching each other. And yet still something like over 80% of the members of the choir became infected after that practice. So that to me was one sign of, oh, this thing is probably in the air because it’s really hard to infect that many people just by touching the same doorknob. Even if everybody did touch the same doorknob, you know, after the first few people touch it, you know, any virus that was on there will probably be gone, have been removed. So that was one thing. And then there was a study that came out of China in a hospital where they did aerosol particle sampling with the types of instruments, the same types of instruments that my group uses, and they found virus in the very small particles. Now, it was the viral RNA, like its genetic signature, it wasn’t infectious virus. And so some people said, oh, well, it’s not infectious. That doesn’t prove anything. But, you know, we know that it’s hard to, it’s really hard to maintain infectious virus when you’re sampling from air. So that was another hint that it could be there. And then there were, there were additional studies. Finally, I think later that summer, there was a group that sampled air in a hospital where there were patients, and it was more than six feet away from their beds. And they used a newer sampling device that is gentler and help better keep the virus infectious. And they discovered a lot of infectious virus in the air in those samples. Joe 16:18-16:59 So there was enough evidence that accumulated over those first year or two that people began to recognize. But they didn’t really want to believe it. And in a sense, there was like, well, we don’t want a mask because that’s a pain in the neck. And we aren’t going to change our heating and air conditioning systems. And so nobody really knew what to do about it, including, I think, a lot of the public health people. We just have about a minute left before we take a break. But have we learned from COVID? Have we made changes that are significant so that it won’t happen again? Dr. Linsey Marr 16:59-17:33 I think we have learned there’s a totally new discussion about transmission of viruses through the air that used to be completely absent or was reserved for really special cases. But I think now it’s understood to be widely applicable to colds and flus. And then, for example, I think the CDC, Centers for Disease Control, had a new website where they recommended a certain amount of ventilation, minimum ventilation in rooms. And so that’s progress. That’s something that did not exist before. Joe 17:34-17:45 Well, when we come back after this break, let’s talk about progress and what we need to do in the future to prevent another pandemic. Terry 17:45-18:02 You’re listening to Dr. Linsey Marr, Professor of Civil and Environmental Engineering at Virginia Tech. She leads the AIR2 Laboratory, which focuses on the dynamics of biological aerosols, like viruses, bacteria, and fungi, in indoor and outdoor air. Joe 18:02-18:07 After the break, we’ll learn about other pathogens in the air besides viruses. Terry 18:07-18:13 Researchers pay attention to the size of the particles that are wafted around indoors. How do they affect our health? Joe 18:13-18:19 If you have to spend time where there might be a lot of pathogens in the air, are there ways to protect yourself? Terry 18:19-18:25 Which places are especially dangerous? Are some public places we should be extra cautious? Joe 18:25-18:29 Air filters might help. How could we improve ventilation and filtration? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:40-20:43 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:43-21:01 And I’m Terry Graedon. Joe 21:01-21:20 Air quality is important for health, but public health experts have not required landlords to install high-efficiency filters or UV lights to eradicate pathogens. Is there anything we can do to monitor air quality and protect ourselves from airborne pathogens? Terry 21:21-21:47 I was on assignment out of town and could not participate in this interview with Dr. Linsey Marr. She is one of the country’s leading experts on indoor air quality. She’s focused her research on the dynamics of biological aerosols such as viruses, bacteria, and fungi. Dr. Marr is professor of civil and environmental engineering at Virginia Tech and leads the AIR2 Laboratory. Joe 21:48-22:24 Dr. Linsey Marr, we’ve been talking about COVID, a virus, but there are all kinds of pathogens that float in the air besides viruses like influenza and COVID, SARS-CoV-2. Tell us about the size of the particles, whether it’s a bacteria or whether we’re talking fungi or some other pathogen, and how all of the stuff that’s in our environment, whether it’s inside or outside, may affect our health. Dr. Linsey Marr 22:26-23:54 Yeah, there’s a whole… world of microscopic organisms in the air around us. And bacteria are around one micron in size. And to put that in perspective, a strand of your hair is probably 50 to 100 microns in diameter. So imagine something that’s one-fiftieth to one-hundredth that size. Fungi might be that size or a little bigger. Viruses are maybe smaller than that bacterium. Maybe like the coronavirus and flu viruses are around 0.1 microns. So one-tenth the size of the bacterium. But those things do not float around naked. They’re released from a respiratory tract or with bacteria. It might be splashed out of water somewhere, blown out of soil. And so it’s carrying, there’s a particle that is carrying the virus or bacterium or fungi, but often it also, usually it carries other things from that fluid. So like our respiratory fluid, your saliva, sure, it’s liquidy, but if all that water evaporates, you’re left behind with a lot of salts and proteins and other organic material. And in fact, that amount of material, you would have almost like 100,000 times as much of that other material, mucousy, salty stuff, than you would the amount of virus in it. And so these things are all around us. They’re very tiny. We can’t see them, but they’re there. Joe 23:55-25:53 Well, you know, you’ve used the metaphor of smoke. And I think it’s really, you know, it’s a great example. If you enter a room where somebody has been smoking a cigar, you will know it instantly because it smells. You probably won’t see the smoke, especially if they were in the room maybe 30 minutes before you walked in and they had left. But the idea that there are still those smoke particles floating through the air and you can smell them, that kind of is a wake-up call that whenever we walk into any room, almost anywhere, there are going to be particles, especially if there are a lot of people in that room. And I think of concerts. I think of sporting events, basketball season, and thousands of people all screaming their lungs out, some of them sneezing. And I’ve seen your video that you’ve shown with people sneezing, and it’s really scary. And so there are a lot of venues where you’re going to be breathing in a lot of different pathogens. And the question is, why are some people more likely to get sick than others? We got a lot of email from people who said, oh, I don’t worry about that stuff because my immune system is so good. I take lots of vitamins and nutrients and I can ward off anything. And then I’m thinking, yeah, but what about norovirus? If you walk into a bathroom where somebody threw up or had diarrhea, there are going to be norovirus particles floating through that public restroom. Or what about influenza? Or just, you know, there are so many kinds of pathogens out there. So I guess the question becomes one of, we can’t see this stuff, but it’s there, how do we protect ourselves? Dr. Linsey Marr 25:54-27:53 We covered a lot in that question. So let me, that’s a great question. Let me go back to the cigar. So what we are smelling is often the gases that are in there, not the actual particles. Although if the gases are present, there may still be a few smoke particles around. And then in terms of kind of particles in the air all around us, there’s even in a room that appears clean, a typical amount of particles in the air, and this is not just like microbial stuff, but just total particles of all kinds, is you would have like a thousand particles per cubic centimeter. And a cubic centimeter is roughly the size of a sugar cube. So you take a big deep breath in and you’re breathing in like a million particles. And a lot of those come back out, but some of them do deposit. And some of them are salts and other organic material and lots of different materials. Only a small fraction of them are actually microbes. And an even smaller fraction of those are actually pathogens. And so how do we protect ourselves in these types of places where they’re all around us? Well, the fact that the pathogen is in the air and you breathe it in is only one part of the equation of whether you’re going to get infected and sick or not. Because indeed, your immune system plays a big role here in trying to fight off these pathogens. And that response is going to vary hugely from individual to individual. And that’s outside my area of expertise. But, you know, I work with people who know a lot more about that. And that certainly plays a big role. And then, you know, how do you protect yourself if you are, let’s say, immunocompromised or you’re on a big, important trip and you don’t want to get sick? Well, you know, for things in the air, you would want to wear a high quality mask, a respirator, something like an N95 that, you know, fits well, especially when you’re in around other people and in crowded, poorly ventilated areas. Joe 27:55-29:02 And then, let me interrupt… let me interrupt you right there, Dr. Marr, because Americans hate masks. That’s pretty clear. People in other countries, South Korea, for example, China, they’re more than happy to wear masks. But here it’s like, no way. It’s an invasion of my personal freedom. And, you know, when you get on an airplane, you have to walk through that passageway where I suspect there’s very little in the way of ventilation. And if there are a lot of people getting on the plane, you’re going to be standing in line and you’re breathing everybody’s air. And even on the airplane, it may not be as well filtered as a lot of people would like it to be. So the culture of masking seems not going to work here in the United States. As soon as people could stop wearing a mask, they did. And people who do wear masks, people sometimes look at them like, “What’s the matter with you?” So how do we change that culture, or is it impossible? Dr. Linsey Marr 29:03-29:55 Yeah, clearly, you know, American culture is not into wearing masks. That’s for sure. There’s other things we, you know, I don’t know if we how to change that culture, you know, that maybe if we get celebrities wearing them and it becomes cool, that would help get some, you know, advertisers on this to shift the view. But in the meantime, there are a lot of other things that we can do regarding cleaning the air. As you mentioned, you know, when you’re in the jetway, I’ve, you know, I’ve carried around a little sensor to kind of get a sense for where, where’s the air best ventilated or not. And actually on the jetway, I think because one end is pretty open to the air, you do get decent airflow through there. On the airplane, of course, it’s recirculated, but it’s also very well filtered at the same time. Joe 29:56-30:19 What are the most dangerous places? Since I assume you’ve been using a CO2, a carbon dioxide monitor, what have you discovered in supermarkets, in doctor’s offices, in pharmacies, wherever you may go and test? Where do we need to be especially cautious? Dr. Linsey Marr 30:19-31:06 Yeah, I’ve seen the highest numbers in things like restaurants, certain types of restaurants, poorly ventilated ones and crowded ones. Supermarkets, not so much, although I tend to go to the big stores that have really high ceilings and they’re not totally packed with people. Buses, I would say, I see higher levels. Some classrooms, I’ll see higher levels. So the higher level is an indicator of poor ventilation because carbon dioxide is in our exhaled breath. You do see higher levels on airplanes, but you have to remember that that air is running through filters every two or three minutes. And those filters will remove particles. Joe 31:07-31:47 Well, speaking of filters, because obviously there are a lot of places where we go where you really can’t test the way you have with your portable CO2 monitor. When you walk into a restaurant, what would you like to see if you had the power to influence public health authorities to actually improve filtration? And then maybe we can talk about how we can start using ultraviolet to kill some of these viruses and bacteria that are floating in the air. Dr. Linsey Marr 31:48-32:16 I would like to see, and maybe you wouldn’t be able to see it because it would be hidden in the docks and also in the walls, but good filtration systems with the air being circulated a lot of times through that filtration system, and open windows if the weather’s conducive to it so that the air in that restaurant feels as fresh as it does outdoors. Joe 32:18-32:27 It sounds like Florence Nightingale, you’re sort of adopting her recommendations from more than 100 years ago. Dr. Linsey Marr 32:28-32:36 She was onto it. She knew what she was talking about. I mean, she observed people getting sick in hospitals and knew how to reduce that. Joe 32:36-33:05 The only trouble is that most of our public buildings these days are sealed very tight to be energy efficient. And so it’s not always possible to open those windows. Should public health authorities be testing, investigating, making recommendations, and then perhaps requiring public establishments to actually improve filtration and ventilation? Dr. Linsey Marr 33:06-34:23 Yeah, this is something that a group of scientists and other organizations are working on. I mentioned earlier that the CDC now recommends a minimum ventilation rate of four to six air changes per hour in public spaces. And there was a, I attended an event at the United Nations General Assembly a couple of weeks ago that was intended to raise the profile and spur more action for cleaner indoor air. And so that, you know, some places will do this voluntarily, but really the way that we get it more broadly installed is through standards and regulations like we do for fire safety. And so we have, you know, a group of scientists has talked about and written a paper that appears in Science about the need for air quality, indoor air quality guidelines and regulations that are widely implemented. You know, it’s not going to change overnight, but I’m hoping that this starts the discussion and that maybe, you know, 10, 20, 30 years from now, our building stock takes a long time to turn over, but we’ll start designing buildings that are designed not just for energy savings and thermal comfort, but also for good indoor air quality. Joe 34:23-34:46 Well, at the present time, we can’t always tell. And so what about one of those portable carbon dioxide monitors? Should people be carrying them around with them when they go, for example, into a restaurant or into their local pharmacy? And if the numbers are too high, and what would that be? Maybe turn around and change their mind about going in. Dr. Linsey Marr 34:48-35:34 Yeah, if you’re someone who’s really concerned about getting sick from respiratory viruses, you could carry one of those around and keep an eye on it for numbers over roughly 1,000 parts per billion. That would be an indicator that the place is not well ventilated. They could, though, have good filtration, which would remove pathogens from the air. So maybe you see that high number, you turn around and go out, or maybe you carry a mask with you and you put on your mask. So I did hear that I think stores in Japan were required to display their CO2 levels in the window. Something like that would be really helpful for people to be able to see from the outside, oh, what’s it like in there? And then they can decide whether to go in or not. Joe 35:35-35:56 Oh, that’s a cool idea. I love that idea. You know, having a little electronic sign that says, OK, your CO2 levels here are under 600. It’s like breathing outside air. And then everybody feels, okay, I can go in. And if they’re over 1,000 or 1,500, you say, uh-uh, I’m not coming in today. Don’t thank you. Dr. Linsey Marr 35:56-36:01 Yeah, I should correct myself also. I think I meant 1,000 parts per million PPM. Joe 36:01-36:19 That sounds right. Now, one of your colleagues, Dr. Corsi, has come up with a filtration system that’s inexpensive. Not something you can carry around with you, mind you, but something that people could have in their homes or in their offices. Tell us a little bit about that. Dr. Linsey Marr 36:19-38:01 Yeah, it’s called the Corsi-Rosenthal box, and it acts as a very effective portable air cleaner or filtration unit. Some people call them air purifiers. But it basically mimics what a $200 piece of equipment does for, I don’t know, $60 or so to buy what you need. So one item is a box fan. And then you would also need, let’s see, that’s one, four filters, like kind of those rectangular HVAC filters that you might put into your air conditioning system, you might replace them. And then you tape them together, and you set it on the floor. So you have this box, this cube, that’s where it’s like the box fan is sitting on top. And it’s pulling air through those filters and then ejecting it out of the top. And what you’re getting out of the top is pretty clean air. And what’s interesting is that those filters do not have to be HEPA level. So HEPA is high efficiency particulate air filters. Those remove 99.9% or more of particles in the air. They can be slightly less efficient because this thing moves so much air. So even if I have, let’s say I do have a HEPA filter, If I’m barely moving any air through it or trickling a little bit of air through it, it’s not actually cleaning that much air. But with the Corsi-Rosenthal box, also called the CR box, it’s moving a ton of air through there. So even if it’s only filtering out like 95% of particles, that air is going to go back through the filter and it’ll remove another 95% of the particles. So you get this, you get a benefit of having a high airflow rate through those. And again, it’s inexpensive and you can make it yourself. Terry 38:01-38:42 You’re listening to Dr. Linsey Marr, Professor of Civil and Environmental Engineering at Virginia Tech. She leads the Applied Interdisciplinary Research in Air, the AIR2 Laboratory. It focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Dr. Marr teaches courses in environmental engineering and air quality, including topics in the context of global climate change, as well as health and ecosystem effects. She’s been thinking and writing about how to avoid airborne viral transmission since before the pandemic began. Joe 38:43-38:54 After the break, we’ll find out about the air filters in your home. Do you have a HEPA filter? We’ll also find out about how to interpret MERV numbers. Terry 38:54-38:59 How well do HEPA filters work? And how often do we need to change them? Joe 38:59-39:05 Could you kill airborne viruses with UV radiation or ozone? Is that a practical and safe way to go? Terry 39:05-39:10 Are there any UV systems commercially available for places like hospitals? What about homes? Joe 39:11-39:18 Dr. Marr will share her list of worrisome airborne pathogens. Flu and measles are obvious. What about norovirus or TB? Terry 39:28-39:31 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 39:40-39:43 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 39:43-40:01 And I’m Terry Graedon. Joe 40:01-40:18 Air quality is always important for good health, but because we can’t see pollution or pathogens, we tend to ignore the air we breathe. How would you know about the quality of the air you breathe in your local supermarket, bank, or pharmacy? Terry 40:18-40:40 Ventilation and filtration are the cornerstones for maintaining air quality indoors. Do you know what kind of filter your air handling system uses? What about at your doctor’s office? When asked why he robbed banks, Willie Sutton said that’s where the money is. When you go to an urgent care clinic or a doctor’s office, that’s where the germs are. Joe 40:41-40:56 Most people have stopped wearing face masks, and they’re optional at many health facilities. But COVID is still with us, along with influenza, RSV, metapneumovirus, and many other airborne pathogens. Terry 40:57-41:43 To learn how to improve air quality indoors, Joe spoke with Dr. Linsey Marr. She’s a professor of civil and environmental engineering at Virginia Tech, where she leads the Applied Interdisciplinary Research in Air, AIR2 Laboratory. Her research group focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Dr. Marr teaches courses in environmental engineering and air quality, including topics in the context of global climate change, as well as health and ecosystem effects. She’s been thinking and writing about how to avoid airborne viral transmission since before the pandemic began. Joe 41:44-42:25 Dr. Marr, you were talking a little bit about the Corsi… is it Rosenthal box? And how you can do it yourself for a relatively modest amount of money, but you could also put a better filter in your heating and air conditioning system, whether it’s an office building where there are lots of people or whether it’s your home. What are the best filters? You’ve mentioned the HEPA filter, H-E-P-A, but there are also MERV filters. And I’ve never quite got the numbers right. So if you could explain filtration a little more, we’d be grateful. Dr. Linsey Marr 42:25-44:23 Yeah. MERV stands for Minimum Efficiency Reporting [Value]. I can’t remember exactly what it is. Everyone just calls it MERV. And if you go to a big box store like Home Depot or Lowe’s, they’re going to have filters with their own numbering system on them in terms of how good the filters are. But they should also, you should be able to correlate that with the MERV scale. And the MERV scale is kind of standardized and a higher number is better. And so it goes all the way up to, I think, 17, which is like HEPA equivalent, um, it starts at one. So I would say, you know, kind of your, and the higher number indicates that it’s going to remove more particles. It has higher filtration efficiency. So the highest ones are going to remove over 99% of particles. And then the lower MERV numbers are really just there to protect your HVAC system from leaves and other big, you know, maybe hairballs from your cat and prevent those from going in. And so, you know, home systems might have something like a MERV 4 or 8 filter. If you’re getting into commercial buildings, they might have had 8 or 11. But since the pandemic, I think we’ve realized that, oh, having a higher filtration efficiency or better quality filter is, you know, going to give us healthier air for people. And so I think buildings that can are moving more towards MERV 13 or MERV 14 filters. Now, one caveat here is that the higher efficient, the higher MERV filters that are better removing particles also create a bigger pressure drop. It’s a little harder to push air through those, pull air through those. And so your air handling system needs to be able to handle whatever that filter you put in. So you need to kind of check and make sure your air handling unit is okay. So for example, we tried this in my house. We tried to put in a higher MERV number filter, but then the system stopped running. It gave me a fault. And so I realized, okay, we’re creating too much pressure drop. We’re asking our fan to do too much work. And so we had to go back down. Joe 44:25-45:04 So as people begin reinstalling new HVAC systems, whether it’s in an office building, in a supermarket, in a big box store, or at home, they should in the future, hopefully with public health encouragement, design systems that can handle those higher efficiency MERV filters so that we’re up around MERV 13 or above. And how well do they work? Do they really capture enough, let’s say, viruses and bacteria to make a difference? And then how often do they need to be changed? Dr. Linsey Marr 45:06-46:16 Yeah, once you get up into MERV 13, 14, you’re removing over 80 percent, 90% of particles in the air. And so that’s helpful. But that’s kind of in the mixed air that’s throughout the whole room and throughout the whole building. Now, we think it’s not clear, but it’s some of the research we’re doing with humans and animals. We think that in a lot of cases, transmission occurs in these closer face-to-face interactions. And in that case, the filter doesn’t help as much because that’s like the whole room air. It’s got to go through the HVAC system and come back before the, and it doesn’t have the chance to do that when you’re talking face-to-face with someone. So in that case, you need other strategies. But as far as the filters, yes, absolutely. If you’re upgrading your HVAC system, you should be thinking about getting one that can handle the higher efficiency, higher MERV number filters. And then depending on the system. They may recommend filter changes every quarterly, every three months, or maybe semi-annually, so every six months, but it depends on the system. Yeah. Joe 46:16-46:41 Let’s move beyond filtration and ventilation because that goes along with the filtration. You want to have fresh air being introduced into your system, but let’s talk about killing those bacteria and viruses. What about ultraviolet light? Are there safer systems? What about ozone? Give us an update on how we can purify the air. Dr. Linsey Marr 46:43-49:11 Right. You had mentioned UV before. And so UV works by killing the viruses or bacteria. It actually messes up their genetic material, DNA or RNA. And so this has been used for decades, a certain type of UV light called germicidal UV, which is at a certain wavelength, 254 nanometers for those who are interested. The issue with that type of UV light is that it is dangerous for us to look at and it’s bad for our skin to be exposed to it. So those types of systems can only be installed inside air ducts where people are not going to be seeing it and their skin won’t be exposed to it. Or they’ll install it in kind of these upper air systems at the ceiling if they have a high enough ceiling and it’s pointing upward so nobody gets directly exposed to the light. Now, there’s a newer technology called FAR-UV, and that’s at a different wavelength, 222 nanometers instead of 254. And that is really intriguing because it still kills off viruses and bacteria. And it’s also considered to be eye safe and skin safe. Like it can’t penetrate through the very outer layer of cells in our eyes and skin. And you mentioned ozone. So UV of any kind can generate ozone also because UV, you’re adding UV light and that generate that kind of can can photolyze or cause chemical reactions with the oxygen and other compounds in the air. Ozone is bad for us. We have health standards for ozone. And so there’s there’s kind of a trade off here of, well, you have the benefit of killing off pathogens, but you may be generating a small amount of ozone. And, you know, it’s still in the research phases of whether there’s a net benefit and what any long-term effects might be of exposure to far UV. But it does show a lot of promise. Certainly in laboratory studies, it really effectively kills off pathogens. And, you know, I think of it like we use UV in our drinking water for drinking water treatment in some places instead of chlorination to kill off pathogens. And so this is something, oh, well, we do that in our water. We could do that in our air to kill off pathogens in the air so that we don’t have to breathe them in. Joe 49:12-49:27 Are there systems now available for, let’s just say, hospitals, for example, or for people’s homes if they wanted to install a UV system? And how would they know if they’re safe? That is to say, not putting out too much ozone. Dr. Linsey Marr 49:28-50:25 Yeah, I’ve seen there are vendors out there selling far UV lights that you can put in your home. They do recommend that you put them in certain locations in the room. And they have been testing them for ozone. There’s ways you can estimate through there. I know one has a kind of a model where you could put in the dimensions of your room and how many lights you want to put in and what the resulting increase in ozone would be. So again, we still don’t know what that trade-off is between, okay, you’re removing pathogens from the air, but you’re increasing ozone a little bit. And it’s not just ozone, but the ozone can react and other things that the UV light generates can react with things in the air and produce byproducts that maybe are potentially more harmful and can also produce particles in the air, interestingly. Joe 50:26-51:10 So it sounds like we don’t yet have a magic wand to be able to purify our air and make everybody safe so they don’t have to think about transmission of pathogens. And while we’re talking about pathogens, if you could just run down the list of things that concern you, because we’ve heard a lot about measles over the last couple of years and how there’s been quite a spread of measles. I do worry about norovirus. I know a lot of people go, oh, that’s just a cruise ship thing, and you can’t possibly get it by breathing. It’s just by touching handrails, for example. But if you could run through some of the pathogens that concern you, please. Dr. Linsey Marr 51:11-52:59 Certainly. Norovirus is, oh, it’s memorable. I think we don’t know if norovirus transmits through the air. There have been some interesting studies where there was one in Australia in a performing arts locale where the students were going and someone threw up on the carpet. And the next day, a group of students went there and they walked past this spot on the carpet, which had been dried, but I guess not fully cleaned up. And then several students got sick the next day from that stomach bug. So yeah, we don’t know. I wouldn’t be surprised if [norovirus] can transmit through the air. I’m guessing because it’s a gastrointestinal thing, it’s more from touching, but again, we don’t really know. Other things that are, you know, things that cause the common cold are rhinovirus and adenovirus. Those almost certainly go through the air, although adenovirus can also cause gastrointestinal issues. There’s other coronaviruses. There’s four seasonal types of coronaviruses in addition to SARS-CoV-2, which caused COVID-19. Those can cause colds. We’ve also recently discovered that something called human metapneumovirus is more prevalent than we thought. And that’s just another one of these respiratory viruses that causes colds. Flu, we should definitely not ignore because that still leads to an average of over 30,000 deaths per year. I think last year was bad. There were 100 or 200 maybe kids who died from it. So we should not forget about flu. Measles, unfortunately, is making a resurgence due to under-vaccination. And that, everyone knows, travels through the air and is very, very contagious. Joe 53:00-53:21 And I worry about something that seems out of the ancient past, and that’s tuberculosis. I remember talking to an infectious disease expert who said, yeah, TB is not gone. And if somebody is infected, they can spread it pretty fast. Thoughts about tuberculosis? Dr. Linsey Marr 53:22-54:45 Yeah, I think, you know, I have heard of some cases in the U.S. It’s often in those living in less sanitary conditions and who don’t have regular access to health care because there are treatments, but it requires vigilance, I would say, for the treatments. And so tuberculosis is caused by a bacteria, bacterium that travels through the air. For sure, we know that this is one of the kind of very well-known, well-accepted airborne diseases because the way it infects is that it has to get down to deep in the lungs because that’s the only place where there’s the right types of cells with the right types of receptors for the tuberculosis, for the bacterium to infect. Now, another one that we, you haven’t mentioned is Legionella, which I think cases are increasing that’s partly due to greater awareness of it. But this is something that transmits from, not from person to person, but more from water and you inhale it. And so that can be through, you know, it was named after an event in a meeting of the Legionnaires, I think in Philadelphia in the 1970s, but that can be through water that’s contaminated. There’s outbreaks that have been noted in New York City that are linked to cooling towers on top of buildings where the bacteria grows and then it gets aerosolized in the cooling tower and then can spread throughout the neighborhood. Joe 54:45-55:02 Dr. Marr, we’re just about out of time. We have about two minutes left. What are you doing for your family and for your students? And what are you recommending to your colleagues when it comes to reducing the likelihood of catching some of these pathogens that we’ve been talking about today? Dr. Linsey Marr 55:04-55:45 As we mentioned, the carbon dioxide sensor is a good tool. I recently had a colleague who asked me about high levels he was seeing in his office. And we did a little bit of investigation, were able to figure out that air was coming from the hallway and classrooms into his office. And so, you know, they consulted with the facilities department to try to look into that. They talked about potentially installing an exhaust fan. So, you know, if someone in my family is sick, we will often try to run the exhaust fans, we bring out our portable air cleaner, the HEPA filter unit and kind of it follows that sick person around the house, wherever they happen to be, to try to clean the air and reduce the chances of other people getting sick. Joe 55:47-56:00 And recommending our listeners should be masking when they’re going into places where there’s the likelihood of people having influenza and colds and other kind of respiratory infections? Dr. Linsey Marr 56:01-56:27 Certainly during the respiratory season, if you want in the wintertime, if you’re really concerned about getting flus or colds, you’ve got an important event coming up. Masking is going to be probably one of your best defenses, whether that’s traveling on an airplane or you’re in a really crowded area, dense with people. And it seems like the it’s small, the space is small and it’s poorly ventilated, that that will definitely help reduce your risk. Joe 56:29-57:06 Dr. Marr, we’ve been talking about inside air. Let’s talk about outside air. There’s been a lot of smoke in the air because of forest fires. There has been a lot of other kinds of contaminations. You have looked at a lot of kinds of contaminants in a lot of other places, whether it’s ozone or particulates, even [fluorocarbons or] hydrocarbons. Tell us about outside air and why we should be concerned about it. Dr. Linsey Marr 57:07-58:13 Outside air is, you know, obviously when we’re outside, we’re breathing that. And a lot of our indoor air actually comes from outdoors. And so, you know, highly polluted outdoor air can come indoors and then we’re breathing it indoors. So outdoors, there’s things like ozone in the summertime is generated from industrial emissions and also things from motor vehicles and even vegetation contributes to that. We have particles, which are probably the biggest cause of health, have the biggest health impacts in the U.S. and many parts of the world. And those can be generated by combustion and other processes. Interestingly, a lot of them are generated also by reactions involving gases that form particles. And let’s see, you mentioned fluorocarbons. Those are not directly, they don’t directly impact our health, but they can get high into the atmosphere and react with ozone that’s protective, that’s good up there. And so reduce our protective layer of the ozone. Joe 58:14-58:50 I’ve got one that just struck me a couple of weeks ago: Tires. I mean, you know, there are millions of automobiles and trucks on the road, and we always have to replace our tires after 30, 40, 50,000 miles. And I got to thinking, well, what happens to all of those chemicals and all of that material that is in our automobile tires? Where do they end up? Do they end up in the air? Do they end up in the earth? And how far are they? Dr. Linsey Marr 58:50-59:34 That’s a great question. In fact, one of my colleagues here at Virginia Tech is looking at that exact question. And he told me a startling statistic about the number of pounds that your tires reduce because of all the tire wear particles when it’s running on the road. And so a lot of that, if it’s big, chunky, that’s just going to stay on the ground and then it gets washed into our soils or into our bodies of water. Some of it does get into the air. We know that. And so it contains organic compounds and metals and other things. It’s not going to stay in the air forever. Everything in the air eventually has to come back to Earth. But yeah, people are breathing that stuff in, especially, I think, near roadways. But it’s and I think we don’t it’s something we’re still learning more about. Joe 59:35-01:00:01 And last, microplastic or nanoparticles of plastic or those itsy bitsy little tiny pieces of plastic are everywhere, and they’re in us. Your thoughts about plastic as part of the air, we don’t think of it as something that we breathe because we think, oh, they’re too big, but it seems like plastic is just pervasive. Dr. Linsey Marr 01:00:02-01:00:37 Yeah, the microplastics are definitely there. They’re going to be worn down into pieces smaller than we can see. They’ve been detected. I had a student who was doing a project in a school and collected dust samples and found lots of microplastics in them. I think I’m concerned about those, especially because of some of the health studies I’ve seen where you find plastics in the brain and it might be associated with dementia. This is, yeah, it’s an emerging pollutant that I think deserves a lot more attention because it’s something new that we didn’t have nearly as much 50 years ago and really none of 100 years ago. Joe 01:00:38-01:00:43 Dr. Linsey Marr, thank you so much for talking with us on The People’s Pharmacy today. Dr. Linsey Marr 01:00:44-01:00:46 Thanks so much for having me. It’s been a real pleasure. Joe 01:00:47-01:01:27 You’ve been listening to Dr. Linsey Marr, Professor of Civil and Environmental Engineering at Virginia Tech. She leads the Applied Interdisciplinary Research in Air, AIR2 Laboratory, which focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Dr. Marr teaches courses in environmental engineering and air quality, including topics in the context of global climate change as well as health and ecosystem effects. She’s been thinking and writing about how to avoid airborne viral transmission since the pandemic began. Terry 01:01:28-01:01:37 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 01:01:37-01:01:45 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Terry 01:01:45-01:02:03 Today’s show is number 1,454. 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 01:02:04-01:02:24 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. The podcast this week has some extra information about outdoor air, especially when it comes to smoke or forest fires. You’ll also hear about particulates from car tires and microplastics. Terry 01:02:25-01:02:47 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 get regular access to information about our weekly podcast. We’d be grateful if you’d consider writing a review of the People’s Pharmacy and putting it on the podcast platform you prefer. Joe 01:02:47-01:02:50 In Durham, North Carolina, I’m Joe Graedon. Terry 01:02:50-01:03:26 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. 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Transcribed - Published: 4 December 2025

Diabetes is a serious metabolic disorder that affects close to 40 million Americans. Most of them have type 2 diabetes, which means their bodies produce insulin, but their cells are not very responsive to it. As a result, blood sugar builds up and people run the risk of cardiovascular complications like heart attacks or strokes, along with kidney disease or vision problems. Nerve damage and even dementia appear to be more common among people with diabetes. Should we be rethinking the way we treat diabetes? 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, Nov. 22, 2025, 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 November 24, 2025. Rethinking How We Treat Diabetes: Our guest, Dr. John Buse, is known for his decades of diabetes research. We began our conversation by asking about his most recent study, called CATALYST. It considered the effects of a medicine that is not usually thought of as a method to treat diabetes: mifepristone. This research highlighted the impact of high cortisol levels (Diabetes Care, Dec. 1, 2025). This placebo-controlled trial compared the effects of mifepristone, which moderates the effects of this stress hormone, to those of placebo. Although many people found that mifepristone (Korlym) was difficult to take because of side effects, those who stuck with it lowered their HbA1c significantly. That is a measure of blood glucose over weeks rather than an instantaneous read-out. They also lost weight and waist circumference, on average about two belt notches. That made it a bit easier for their bodies to control their blood sugar. Consequently, some needed lower doses or fewer diabetes medicines. One advantage of this study is that it may help explain why some people have hard-to-control diabetes. Until now, neither patients nor doctors knew why, even though they were trying hard, some patients couldn’t make any progress. Dr. Buse admits that physicians used to blame patients, assuming they were not following their diet or taking their medicines. Now, seeing the dramatic effects of mitigating cortisol, they are starting to re-evaluate those assumptions. This could change how we treat diabetes. What Are the Side Effects of Mifepristone? Despite the benefits, nearly half of the study participants assigned to mifepristone missed out on them. They found the fatigue, nausea, vomiting, headaches joint pain and swelling intolerable. These are the consequences of interfering with cortisol. Some people experience dizziness or increased blood pressure. One particularly dangerous side effect is a drop in potassium, which could affect heart rhythm. People who are having trouble controlling their blood sugar despite their best efforts might ask their physician to check their cortisol levels. Where Does Lizard Spit Come In? Several years ago, Dr. Buse talked about lizard spit in one of our interviews. Why in the world would he mention lizard spit? It turns out that one of the components in the saliva of the Gila monster led to the first GLP-1 agonist. Rather than a monster, this is actually a very large venomous lizard native to the Sonora desert. It is illegal to capture or kill a Gila monster in Arizona. Researchers investigating the chemistry of its saliva developed the drug exenatide (Byetta). Subsequently, drug company researchers came up with a wide range of medications that work through GLP-1. You have probably heard of the best-known, which are semaglutide (Ozempic, Rybelsus, Wegovy) and tirzepatide (Mounjaro, Zepbound). These drugs are already changing the way we treat diabetes. Can You Reverse Prediabetes? The lifetime risk for prediabetes is one in three worldwide. Here is a short video clip of our guest, Dr. John Buse, describing the diabetes pandemic: But if we could identify and intervene before people actually develop diabetes, we might be able to prevent it. Doctors have been testing lifestyle changes and medications that might be able to keep people with prediabetes from progressing any further down that path. Physical activity can make a big difference, as it changes how the muscles utilize glucose. Changes in diet are also promising, although certainly far from easy for most of us. Doctors can also prescribe drugs like metformin as an early intervention. It is almost as effective as exercise. Other drugs that are changing the way we treat diabetes include the glitazones (pioglitazone and rosiglitazone). Another category of diabetes drug, those similar to empagliflozin (Jardiance), is already making a difference. Of course, like all medicines, these also can cause adverse effects as well as benefits. One exciting treatment for the future will be gene-modifying technology to treat diabetes. Proof of concept studies have already been conducted. How should the American diet change to reduce our risk of diabetes? Here is a short video clip of our guest, Dr. John Buse, describing the three changes he recommends. You will want to listen to the whole interview either live on Saturday morning or when it becomes available on this website Monday morning (11/24/2020). You can stream the audio by clicking on the white arrow inside the green circle under the photo of Armour Thyroid. You can also download the mp3 file by scrolling to the bottom of this article. Why not sign up for all our podcasts at this link so you will never miss another People’s Pharmacy episode again? This Week’s Guest: John Buse, MD, PhD, is the Verne S. Caviness Distinguished Professor of Medicine at the University of North Carolina at Chapel Hill, School of Medicine. He has received international recognition for innovative clinical care and efforts at prevention of type 1 diabetes, type 2 diabetes and their complications. Dr. John Buse, UNC School of Medicine, Chapel Hill, NC Listen to the Podcast: The podcast of this program will be available Monday, Nov. 24, 2025, after broadcast on Nov. 8. You can stream the show from this site and download the podcast for free. This week’s episode contains some additional discussion of the GLP-1 agonists, as well as the phenomenon of coffee to prevent diabetes. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1453: 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. Diabetes remains one of our most prevalent and challenging health problems. What does the latest research show? This is the People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:46 Our guest today is one of the country’s leading diabetes researchers. He’ll share some exciting news about a study called Catalyst. It used an old drug for a new use against type 2 diabetes. Joe 00:47-00:56 What about the GLP-1 agonist medications like Ozempic and Mounjaro? How are they changing the treatment of diabetes? Terry 00:56-01:01 We’ll also discuss the importance of lifestyle in controlling blood sugar. Joe 01:01-01:08 Coming up on The People’s Pharmacy, new research points to advances in treating diabetes. Terry 01:14-02:26 In The People’s Pharmacy Health Headlines: The CDC originally told Americans that this would be a mild flu season, but after more than six weeks of a government shutdown, the agency is detecting an upward trend in cases of H3N2 influenza. The southern hemisphere is six months ahead of us when it comes to winter respiratory infections. Australia, South Africa, Chile, and New Zealand all reported a severe flu season. Now, public health authorities in Japan, South Korea, Great Britain, and Canada are also reporting an early and severe start to the season. There’s growing concern that the H3N2 strain that’s circulating has mutated. That could mean that the flu shots will be less effective than previously hoped. Dr. William Schaffner at Vanderbilt University Medical Center is a renowned expert on influenza. He notes that even if there is not a close match, use of the vaccine continues to prevent hospitalizations, intensive care unit admissions, and continues to help keep people out of the cemetery. Joe 02:27-03:01 For decades, cardiologists, nutrition scientists, and public health authorities have been warning Americans to avoid saturated fat. Now, though, the head of Health and Human Services, Robert F. Kennedy Jr., is planning to release new dietary guidelines that will end the war on saturated fats. Instead, HHS will promote full-fat dairy, including butter, milk, yogurt, and cheese. It will also recommend red meat. These guidelines will shape school lunches for 30 million children. Terry 03:03-03:48 Increasingly, health experts are acknowledging that food is medicine. Figuring out how to operationalize that insight is tough, though. A state-level incentive program in Rhode Island called “Eat Well, Be Well” offered SNAP recipients 50 cents of credit for every dollar spent on fruits and vegetables. Two statewide grocery chains participated. Investigators hoped that this incentive would increase the consumption of fruits and vegetables among low-income plan participants. It worked, but only for those who already were consuming more produce. Those who weren’t eating many vegetables or fruits at the start of the program didn’t increase their consumption very much. Joe 03:49-04:58 There’s growing interest in lifestyle interventions to reduce the risk of dementia. A new study published in JAMA Network Open used data from the ongoing large-scale Framingham Heart Study. Investigators collected data on physical activity from people as young adults, middle-aged individuals, or late-life participants. These volunteers were followed for many years. The researchers report that higher levels of physical activity in middle age and later life were associated with significantly lower risk for developing dementia. They hypothesize that physical activity may slow amyloid beta production or reduce tau phosphorylation. They think that physical activity might also improve brain structure and function along with blood flow. In addition, physical activity has anti-inflammatory effects. And fourth, physical activity improves glucose metabolism and may reduce stress. Terry 05:00-06:17 GLP-1 receptor agonists like Ozempic and Wegovy have been getting a lot of attention for their ability to control blood sugar and help people lose weight. Now, a new study points to a different advantage. A study of 6,871 colon cancer patients found that those taking one of these drugs were half as likely to die as those not on a GLP-1 agonist. The five-year mortality rate for people taking such drugs was 15.5%. Those not taking a GLP-1 drug had a five-year mortality rate of 37.1%. This advantage was seen almost exclusively in people who were obese when they were diagnosed with colon cancer, as it was restricted to those with a BMI of 35 or greater. Not only were people taking a GLP-1 drug less likely to die of colon cancer, they were also less likely to have fatal heart attacks. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:45 And I’m Joe Graedon. According to the CDC, nearly 40 million Americans have diabetes. The overwhelming majority have type 2, which means they produce insulin, but it just doesn’t control their blood sugar adequately. Insulin resistance occurs when the cells cannot utilize glucose effectively. This condition can result in prediabetes, which may precede a diagnosis of diabetes. Terry 06:45-07:11 When blood glucose is not well controlled over a long period of time, people are at risk for many serious health consequences. Those can include cardiovascular disease, vision problems, nerve damage, and kidney disease. People may also be at a higher risk for dementia. But we now have many new strategies for controlling type 2 diabetes. What does the new research reveal? Joe 07:12-07:26 One of the country’s leading diabetes researchers is Dr. John Buse. He’s the Verne S. Caviness Distinguished Professor of Medicine at the University of North Carolina at Chapel Hill School of Medicine. Terry 07:27-07:31 Welcome back to the People’s Pharmacy. Dr. John Buse. Dr. John Buse 07:31-07:33 It’s a pleasure to be with you again. Joe 07:34-07:40 Dr. Buse, you have been involved in diabetes research for, dare I say, decades? Dr. John Buse 07:41-07:52 Yeah. You know, it depends on when you make the starting line. But my first job in a lab was when I was 14 years old, and I just had my 67th birthday. Joe 07:52-08:05 Wow. So it’s been a while. A long time. And the most recent study that you’ve been involved with is called Catalyst. And it is amazing. Tell us how it got started and what you’re learning. Dr. John Buse 08:06-08:31 Yeah. So it’s been known for a long time that high levels of steroids in the blood, and particularly what we call glucocorticoids, the medications would be medicines like prednisone, that that causes, you know, can cause diabetes to manifest itself. Or in people who have diabetes, it can make their diabetes care much more complicated. Joe 08:31-08:53 Well, let me share a quick story with you: my mom, in her 80s, was diagnosed with polymyalgia rheumatica. And for the first time in her life, they put her on a corticosteroid prednisone. And not long after, I’d say within about a year or less, she had type 2 diabetes. Dr. John Buse 08:54-08:54 Exactly. Joe 08:55-09:01 And it was a shock to her. And we were like, oh, but there’s no diabetes in the family. But it was the prednisone. Dr. John Buse 09:02-09:55 Right. So, you know, it’s not that everybody who takes prednisone gets diabetes. But the idea behind the Catalyst study was to specifically examine how common was high cortisol an issue for people with, quote, poorly controlled or difficult to control type 2 diabetes. That was the entire premise of the study. It was divided into two parts. The first part was to find out the prevalence or the frequency of hypercortisolism in difficult to control type 2 diabetes. And the second part was a study to see if mifepristone, a cortisol receptor antagonist, it doesn’t block the cortisol receptor, but it makes it harder for cortisol to work. Would that improve blood sugar control and other things in people with, quote, difficult to control type 2 diabetes? Terry 09:57-10:10 Well, I do want to ask about difficult to control type 2 diabetes. But first, I want to know the answer. How common is this problem, and how well did the mifepristone work? Dr. John Buse 10:10-10:51 Right. So the problem is quite common. It was nearly 25% of the people with difficult to control, type 2 diabetes, had an abnormal result on the so-called one milligram overnight dexamethasone suppression test. So that’s the test that was used. And another 25% had a value that was greater than the 95th percentile for the normal range. So technically, the right answer on your board exam is going to be one in four. But there’s some evidence of a problem in half. At least. Terry 10:51-10:54 That’s a lot. That’s really a lot. Dr. John Buse 10:54-11:20 It is far in excess of anything that we expected, the investigators involved in the study. Though, you know, if we’d been a little bit more trusting of some international studies that were smaller, where the definitions they used for hypercortisolism were a bit different, etc., etc., there are other studies that suggest that that number is probably right all around the world. Joe 11:21-11:44 So all of a sudden, there’s a light bulb that goes off and you say, aha, there’s something going on here. Let’s move on to the second phase of the study. Now, let’s be honest, mifepristone, most people, they’ve never heard of it, but it is a highly controversial drug. Tell us about it. Dr. John Buse 11:44-13:19 Well, the controversy is around the fact that it is part of tablet medication to terminate a pregnancy. And this is a completely different use and, frankly, a completely different product. This product that we used, the generic name for the drug is mifepristone. The brand name for the drug is Korlym. And we administered a 300 milligram tablet or a matching placebo. So nobody knew what people were getting. After a few weeks, they could increase the dose to 600 milligrams if tolerated. And then they could increase again to 900 milligrams as tolerated. What we found was from a baseline hemoglobin A1C, an index of overall blood sugar control of 8.5, which is not great. people came down to about 7% on mifepristone, which is the general target for adults, despite the fact that more than half had some reduction of their pre-existing diabetes medications and almost half stopped taking the drug because of side effects. So even though not everybody took the drug, on average, It was a 1.5% reduction in A1C and very small reduction, a 0.15 reduction with placebo. Joe 13:21-13:28 You know, 1.5% doesn’t sound like that big a deal. But the numbers you’re citing are extraordinary. Terry 13:29-13:37 Well, Joe, 1.5% on the HbA1c is actually a big deal. Joe 13:37-13:44 But I’m just saying for the average person, they’re listening and they’re going, oh, 1.5% reduction. Uh, who cares? Dr. John Buse 13:44-13:53 But that’s not like going from $1 to 98.5. This is a scale where 7% is the goal. Joe 13:54-14:00 5% is pretty much the normal, normal, normal. Dr. John Buse 14:01-14:05 And a world record high would be 15% to 18%. Joe 14:05-14:07 An 8.5% is high. Dr. John Buse 14:08-14:27 Yeah, and we would say an 8.5%, if you were going to give somebody an old school A, B, C, D, F grade, an 8.5%, some people would say it’s a C. Some people might say it’s a B minus. But a 7, you know, where we got is definitely at worst an A minus. Some people say it really should be less than 7. Joe 14:29-14:30 But stunning results. Dr. John Buse 14:31-14:47 Stunning results. And people lost on average 5 kilos or 12 pounds in 24 weeks. And the weight was continuing to come down over that period of time. They lost two notches in their belt in their waist size. Terry 14:48-14:53 It was pretty impressive. They weren’t just losing weight. They were losing waist as well. Dr. John Buse 14:54-15:38 Right. And hypercortisolism, I’m glad you mentioned that, hypercortisolism is a disease where we talk about central obesity. But the strange thing here is a lot of people with hypercortisolism, they’re not technically obese, but they’re round. And so the quintessential case, the one that was described by Harvey Cushing’s – Cushing, you know, 70 years ago, when you look at a picture of her, you’d say, oh, she’s really, you know, really round. Her BMI was actually around 23, but she had massive central obesity. And so this was really a waist approach. Joe 15:38-16:05 Now, there are a lot of people who have hard-to-control diabetes. And, you know, they take not one but two or three different diabetes medicines. They’re trying to lose weight. They’re doing everything that their doctor says, and they’re still having trouble. And nobody knows why, why isn’t this working? Your discovery would answer that question for a substantial number of people. Dr. John Buse 16:05-16:46 Right. And it is such a relief to providers and to patients to get this answer, because I think the usual thought process among patients was, you know, I know I’m trying as hard as I can, but my family is disappointed in my results. My doctor is disappointed in my results. They think I’m not really paying attention to my diabetes. Obviously, I could do more with regards to diet and exercise, but I’m doing the best I can. And the doctor has the same kind of feeling. You know, why am I failing Mrs. Jones? You know, I usually can handle this problem, but obviously I haven’t come up with the right solution. And then sometimes the doctor blames Mrs. Jones. Terry 16:47-16:48 Exactly what I was thinking. Dr. John Buse 16:47-17:13 Now, less so now. When I first met with you guys 30 years ago, that was rampant. You know, we called it non-adherence, non-compliance. I think now the understanding is that most people with diabetes actually do the best they can. You know, they’re not perfect. None of us are. And it’s a very challenging disease to manage. But we have great drugs. And now we have this new insight. Terry 17:14-17:26 Well, we do have a lot more drugs now than we did the last time we talked to you. Diabetes research has really produced a lot of potential treatments. Joe 17:27-17:49 We’re going to take a short break. But when we come back, how does mifepristone work? This miracle, that’s A, do you know? And then we’re going to talk about the GLP-1 agonists, you know, Ozempic, Wegovy, Mounjaro. All of these drugs are taken the country by storm. Terry 17:50-17:59 You’re listening to Dr. John Buse, the Verne S. Caviness Distinguished Professor of Medicine at the University of North Carolina at Chapel Hill School of Medicine. Joe 18:00-18:05 After the break, we’ll learn more about the study Dr. Buse conducted, Catalyst. Terry 18:06-18:14 Even though the drug was helpful, a lot of people had to drop out due to side effects. Which side effects were most troublesome? Joe 18:15-18:19 Are diabetes doctors ready to prescribe mifepristone? Terry 18:19-18:24 Should patients be asking for this drug? What would suggest that it might be beneficial? Joe 18:24-18:33 We’ll also learn about semaglutide, known as Ozempic, and Wegovy. Could you take it in a pill to treat diabetes or obesity? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 20:40-20:43 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 20:44-21:00 And I’m Joe Graedon. The People’s Pharmacy is brought to you in part by Sonu, an FDA-approved drug-free treatment for nasal congestion and runny nose, using sound instead of steroids. More at GetSonu.com. That’s GetS-O-N-U dot com. Terry 21:00-21:31 Today, we’re talking about research that may lead to new advances in treating diabetes. Our guest is one of the country’s leading diabetes researchers. Dr. John Buse is the Verne S. Caviness Distinguished Professor of Medicine at the University of North Carolina at Chapel Hill School of Medicine. He has received international recognition for innovative clinical care and efforts at prevention of type 1 diabetes, type 2 diabetes, and their complications. Joe 21:33-21:50 Dr. Buse, you’ve described this amazing clinical trial called Catalyst with a drug called mifepristone. The brand name is Koryn? Dr. John Buse 21:46-21:46 Korlym. Joe 21:46-21:50 Korlym, K-O-R-L-Y-M. Dr. John Buse 21:51-21:51 Exactly. Joe 21:51-21:53 How does it work, this miracle? Dr. John Buse 21:53-22:30 Well, it works to normally cortisol, the hormone, or prednisone, the drug. It works by binding to receptors that bind to DNA in the nucleus of our cells. And that’s why it has such broad effects. The mifepristone interferes with that interaction. It’s a competitive agonist or antagonist. So it binds to the place where the cortisol is supposed to bind, and that way diminishes the effect of cortisol. Joe 22:30-22:33 And has this profound impact on blood sugar. Dr. John Buse 22:34-23:46 Right. And how does that happen? That’s another question. And we don’t know all the how for that. But I will tell you the one thing that we don’t know yet is, you know, we know in the people who have the overnight dexamethasone suppression test with a value greater than 1.8, those people that were treated with mifepristone did very well from a blood sugar lowering and weight lowering perspective. We don’t know for the people that have medium high levels what would happen for them. And frankly, we don’t know what would happen is if we put it – if we gave it to every person with diabetes, it wasn’t doing well. And namely, it’s possible that cortisol is so important for many different mechanisms in diabetes that it would work for everybody. Now, hopefully, we’ll do a study in the near future. There’s a follow-on drug that’s being developed and could be available as early as next year. It’s much better tolerated. And as I mentioned before, that was the fly in the ointment of this study is that a lot of people stopped the drug. Terry 23:46-24:01 Well, that really is my next question. You mentioned that almost half of your people who were taking the drug had to stop it because they couldn’t deal with the side effects. Tell us about those side effects. Dr. John Buse 24:01-25:39 Yeah. So it’s interesting. Whether you have surgery to remove a tumor, usually from the adrenal, that makes excess cortisol, or whether you take any drug that interferes with cortisol action, you have something called glucocorticoid withdrawal syndrome or cortisol withdrawal syndrome. So the body gets used to being exposed to extra cortisol. And when they take the drug that blocks or interferes with the action of cortisol, people start to feel bad. The most common feeling is nausea. Some people just have terrible fatigue. Some people have headaches. They really don’t feel well at all. Usually that goes away after five to 15 days or it gets better. But you do have to sort of tough people through the process. And then the other thing I would mention, in this study, we didn’t know whether people were getting the drug or the placebo. And already a lot of the people were on GLP-1 receptor agonists, you know, these drugs that we’ll talk about nausea for them. And so it was a little bit confusing what we really should tell the patients and what they should expect. So I think my clinical practice is in clinic you can do better with patient counseling and support. You can fool around by having people instead of taking it every day, take it every other day and make the symptoms a little bit less worse. But maybe they last a little bit longer. There was a second side effect, though, that’s a little bit more worrisome, and that’s hypokalemia. Terry 25:40-25:41 So low potassium. Dr. John Buse 25:42-26:06 And that is something that’s very well described with the drug. It’s expected. Normally, in clinic, you would use a drug that would interfere with hypokalemia like spironolactone, quite cheap blood pressure medicine, in advance of using the mifepristone here because we didn’t know were they going to get placebo or drug. We didn’t do that. Joe 26:06-26:26 So here’s a question. This is exciting research. Your colleagues, diabetologists all around the world are going to be shaking their head going, hmm, what about this? Are we ready to start prescribing mifepristone? This is very new and different. Dr. John Buse 26:27-27:34 Yeah. And to be honest, it’s a great question, right? I want my colleagues to think extra hard about that. Today, I would strongly advocate for looking for hypercortisolism, and when you find it, you know that you’re dealing with a different bear. You can’t fight this battle in the same way. There are other treatments that can be used and I didn’t mention that in a quarter of the patients that had hypercortisolism, we did adrenal CT scans in everyone. A quarter of them had a tumor in their adrenal that theoretically could be surgically removed. So that’s a potential surgical cure. And secondly, there are new medicines that are being studied and new medicines that may be approved by the FDA in the next few months that are much better tolerated and easier to use. And so making the diagnosis, I think, is really important to do today. Treating with mifepristone, it’s not the easiest drug to use. Joe 27:34-27:43 So people who are having a hard time controlling their type 2 diabetes should definitely bring up the possibility that they might have a cortisol problem. Joe 27:44-27:45 Let’s change gears, Terry. Terry 27:45-28:28 Well, before we switch away from Catalyst, you mentioned, of course, the drop in blood sugar in HbA1c from 8.5% to 7%, which is excellent. That’s what you were hoping for. you mentioned that some people were losing weight, which, you know, I don’t think mifepristone is thought of as a weight loss agent, but evidently it has that effect. But one of the reasons that we wanted to talk with you about it is that somebody posted a comment on our website saying they found that blood pressure went down. Was this person misunderstanding what she heard? Dr. John Buse 28:29-29:05 Right. So blood pressure did not go down. And we kind of thought that it might, but there’s an effect that when you block the action of cortisol with mifepristone, that the cortisol is metabolized to cortisone, which has a variety of actions, blah, blah, blah, blah, blah. So there is a mechanism by which blood pressure could go up. On average, the blood pressure went up a tiny bit on average. So that’s something that needs to be monitored as well. But blood pressure definitely did not go down on average. Joe 29:05-29:31 So now we can change gears. Yes. GLP-1 agonists, Ozempic, Wegovy, semaglutide. And then, of course, there’s Mounjaro and Zepbound, a little bit different because there are two blockers in there. Has this represented a sea change in your world of diabetes control? Dr. John Buse 29:32-29:40 Absolutely. And I’m pretty sure if you check back in your archives, I came here and talked to you once about lizard spit. Terry 29:40-29:41 Yes. Joe 29:41-29:42 You did. Terry 29:42-29:42 Yes. Dr. John Buse 29:42-29:53 And there was the first drug in this class, exenatide. And the very first study of exenatide in people with diabetes was done here at UNC. Joe 29:54-29:56 Now, why did you say lizard spit? Dr. John Buse 29:56-31:30 Well, it was a peptide, a small protein, a hormone that was discovered from the saliva of the Gila monster, a pretty big, very attractive lizard that lives in the Gila River Valley of Arizona. And this guy, John Eng, discovered the peptide. It was developed into a drug. So literally you were injecting a thing that is in the saliva of the Gila monster. But in any case, that drug showed good effect on lowering blood sugar. And it did so without promoting weight gain, which is not, you know, at least in that day, not the usual thing with diabetes drugs. The more effective drugs that lasted longer seem to have this effect on weight loss. And then semaglutide and tirzepatide, the current hot products, have even more effect on weight loss. So people without diabetes are losing 25%, 20%, 25% weight with the most effective of these agents. People with diabetes are improving their blood sugar control and losing 10% to 15% of body weight, which is a big deal— mostly for diabetes because that is a setting where if you lose 10 to 15 percent of your body weight, basically you can functionally get rid of diabetes. You’re taking a medicine, but the diabetes is gone. Joe 31:30-31:44 Terry, we just saw a study this week that involved oral semaglutide. Do you remember where it was published? Was it New England Journal of Medicine or JAMA? It was someplace pretty prominent. Dr. John Buse 31:44-31:47 I think it was Lancet Diabetes and Endocrinology. I think I’m an author. Terry 31:47-31:49 I think it was the New England Journal. Joe 31:49-31:52 But regardless, what did they find? Terry 31:53-32:24 Well, what they found, they used a dose of 25 milligrams per day oral semaglutide. And when you talk about semaglutide, almost all the time, what we’re talking about is an injection, like a once-a-week injection. So this once-a-day pill is a different way for people to get their semaglutide. And what they found, it was a weight loss, it was a weight loss application for people who did not have diabetes. And it did, it was effective. Joe 32:24-32:37 A lot of people don’t like shots, let’s be honest. And plus, it has to be refrigerated. So it means, you know, if it’s shipped to your home in the summertime, that’s a bit of a problem. But oral medicine, that could be a game changer. Dr. John Buse 32:39-33:06 Absolutely. You know, this medicine is not the easiest oral medicine to take. It has to be taken on an empty stomach with a small swallow of water and eat or drink absolutely nothing for 30 minutes. So it’s not ‘pop this in before the shower and when you get out of the shower, have your cup of coffee.’ No, you cannot eat or drink anything for 30 minutes. So at least in my clinic, you know, most people find taking a shot once a week. Terry 33:06-33:07 Easier. Dr. John Buse 33:08-33:11 Arguably easier. Less complicated, let’s put it that way. Terry 33:11-33:12 Sure. Dr. John Buse 33:12-33:30 But you have to kind of get over that shot thing. Now, sometimes we encourage people to have their spouse give them the shot because it is kind of a weird thing to put a needle into your own flesh. But most spouses like the opportunity of putting a needle into their spouse’s flesh. Terry 33:31-33:32 Well, they know they’re being helpful. Dr. John Buse 33:33-33:33 Right, exactly. Terry 33:34-33:35 Even if it hurts. Dr. John Buse 33:35-33:36 Right, exactly. Terry 33:36-33:36 Okay. Dr. John Buse 33:37-33:38 It’s a win-win situation. Terry 33:39-33:55 And now I’d like to follow up on this idea that you could medicate your way out of diabetes. So we’re talking type 2 diabetes here. So let’s please first explain what are the differences between type 1 and type 2 diabetes. Dr. John Buse 33:56-35:39 So type 1 diabetes proportionally is more common in younger people, but can occur at any age. And the process is one by which the cells that make insulin, specifically just this one cell type called a beta cell, is destroyed usually by an immune process. Rheumatoid arthritis destroys joints. Type 1 diabetes destroys beta cells. So the treatment for type 1 diabetes is basically just insulin. You just have to replace the insulin production of the body with sophisticated and precise administration of insulin. Completely different game than type 2 diabetes, which is the more common disease in older adults, generally associated with overweight or obesity. And in type 2 diabetes, there are multiple defects. But the big two are insulin resistance, meaning insulin doesn’t work quite as well as it does in normal people. And then insulin deficiency. Not absolute insulin deficiency, but relative insulin deficiency. So they need this bigger need for insulin because of the insulin resistance, but they’re not able to produce that. So they make enough insulin for a non-diabetic person to be perfectly fine. They just don’t make enough insulin for themselves. And one thing that’s commonly misunderstood about type 2 diabetes, there are people who are very, very, very heavy, you know, 300, 400, 500 pounds, whose blood sugars are completely normal because they’re able to make enough insulin. So diabetes and obesity or overweight are not tightly linked. They do go commonly together. Joe 35:40-35:55 We’ve heard that type 2 diabetes has become a pandemic. It’s not just in the United States. It’s in India. It’s all over the world. Why? Why has it become such a problem? Dr. John Buse 35:55-37:47 Yeah. You know, it’s another great question. So there are many, many, many, many genes that contribute to type 2 diabetes. It’s likely that every little tribe on earth, every village and hamlet, they tend to be, you know, a little bit interbred. You know, they would marry the people in the neighborhood, that they developed adaptations that allow them to thrive with their food sources and activity levels. And through multiple different genetic mechanisms, this ability to thrive was very productive thousands of years ago. So specifically, people were able to gain weight when food was plentiful and then lose it slowly when there were lean times. That’s maladaptive today. So there are many, many, many genes. There’s about 10 mechanisms that have been well described that contribute to mainstream diabetes, but there’s probably hundreds, if not thousands, of mechanisms. So now we create an environment where there is very little scarcity of food. Frankly, we have food everywhere. We’re having messages pushing us towards eating this food. It’s delicious. It’s easy to eat in bulk. And so people have gotten heavy. And that promotes the insulin resistance. And so these defects in insulin production and other defects sort of come out and express themselves as diabetes. The reason why we say it’s a pandemic, it used to be that the U.S. led the way. Now the Middle East is probably the highest, but all across the globe. And the lifetime risk on this planet of developing diabetes is about one in three. Terry 37:48-38:10 You’re listening to Dr. John Buse, the Verne S. Caviness Distinguished Professor of Medicine at the University of North Carolina at Chapel Hill School of Medicine. Dr. Buse works with teams of investigators in diabetes clinical trials, comparative effectiveness research, and translation of basic science research towards clinical application. Joe 38:11-38:16 After the break, we will talk about pre-diabetes. What is it and what can we do about it? Terry 38:16-38:24 How well do lifestyle interventions and medicines work to reduce the risk of developing diabetes if you have prediabetes? Joe 38:25-38:28 How good is exercise as an intervention? Terry 38:28-38:36 Metformin is currently prescribed to people who already have diabetes. Could metformin help us prevent the development of diabetes? Joe 38:37-38:53 There are other medications that people take to control their type 2 diabetes, like glitazones or gliflozins, not to mention drugs like semaglutide or tirzepatide, what should we know about them? Can they be used for prevention? Terry 38:54-39:05 We’ll also find out if continuous glucose monitors could help people who don’t have diabetes. If they could help you change the way you eat, that might make a difference. Joe 39:06-39:15 The American diet is widely recognized as problematic. If we could change three things about it, what should they be? Terry 39:28-39:31 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 39:40-39:43 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 39:43-40:02 And I’m Terry Graedon. Joe 40:03-40:25 The CDC estimates that nearly 100 million Americans have prediabetes. The overwhelming majority don’t know they have this metabolic disorder. There is growing interest in keeping prediabetes from turning into type 2 diabetes. What kinds of interventions could make a difference? Terry 40:25-40:58 One of the more controversial strategies for detecting prediabetes is for people to wear a continuous glucose monitor, or CGM. The FDA originally approved these devices to help people with diabetes track their response to meals. They were only available by prescription. But now the agency allows the sale of CGMs over-the-counter. Many people with prediabetes are using continuous glucose monitors to track their blood sugar throughout the day. Is that a good idea? Joe 40:58-41:13 We are talking with one of the country’s leading diabetes experts. Dr. John Buse is the Verne S. Caviness Distinguished Professor of Medicine at the University of North Carolina at Chapel Hill School of Medicine. Terry 41:15-41:50 Dr. Buse, we are interested in this idea of prediabetes, that people may have a condition that could be identified before they develop actual type 2 diabetes. We have heard of people being diagnosed, oh, you have prediabetes. So what is prediabetes and what can we do about it? Because if I were diagnosed with prediabetes, I would want to do something so I didn’t get diabetes. Dr. John Buse 41:50-43:09 Exactly. So prediabetes is an attempt to communicate something relatively complicated concisely. The important thing to realize is that prediabetes, like pre-malignant, is not a guarantee. Meaning if you have prediabetes, it means that you’re at increased risk of developing diabetes, but it’s not a guarantee at all. And you can intervene to reduce those risks. So there have been about five studies done with lifestyle intervention that have shown about a 50% reduction in risk over three to five years. And there have been about 10 studies done with drugs that have shown between 20% and 95% reduction in the risk of developing diabetes over similar periods of time. Generally shorter in the drug studies, let’s say one to three years. The risk for developing diabetes when you have prediabetes is determined by the elevation of the test. So for instance, with the A1C test, a 6.5 gets you a diagnosis of diabetes. A 6.4 is not diabetes. It’s pre-diabetes. Terry 43:09-43:12 Pre-diabetes. So that’s not a big difference. Dr. John Buse 43:12-43:39 Right. A 5.7 is also pre-diabetes. But your risk of developing diabetes if your A1C is 5.7 is modest, probably on the order of 10% in 20 years. If your A1C is 6.4, your chances of getting diabetes in the next three years is probably nearly 100%. But you can intervene and make that go away. Terry 43:39-43:59 Let’s talk about those interventions. I know that for a long time, the research has shown that people taking metformin reduce their risk of going from prediabetes to diabetes. What are the other interventions that people have used? Dr. John Buse 43:59-44:02 Well, I think first it’s important to talk about lifestyle intervention. Terry 44:02-44:03 Absolutely. Dr. John Buse 44:03-44:04 Diet and exercise. Terry 44:06-44:11 But just saying diet and exercise, that’s not quite enough. So please do tell us. Dr. John Buse 44:11-44:21 It’s 150 minutes a week of moderately vigorous physical activity. So this is brisk walking. 150 minutes a week is 30 minutes, five days a week. Joe 44:21-44:27 And somebody once said, it’s like you’re late to an appointment or to your flight. You’ve got to really move along. Dr. John Buse 44:28-44:48 Right. I mean, you know, you don’t have to be huffing and puffing, but it’s not a mosey. And then that coupled with calorie restriction to produce at least 5% and 10% is more than twice as good. So if you can lose 10% of your body weight, your chances of developing diabetes is reduced by 60%. Terry 44:49-45:01 Let me just throw in one little caveat here. That’s for most of the people we’re talking about because most of them are heavy. But not everyone with prediabetes is overweight, right? Dr. John Buse 45:02-46:41 Exactly. So that’s a point well taken. Metformin was studied in some of the studies that lifestyle therapy was also studied in. And in general, lifestyle therapy beat metformin. But metformin was just as good at lifestyle therapy in younger patients under the age of 45, in people with higher glucose levels, you know, the higher A1Cs, the higher fasting glucose levels, in women with prior gestational diabetes that are very high risk for developing future diabetes. So there were settings where metformin worked quite well. Other drugs that have been studied are the glitazones, pioglitazone [Actos] and rosiglitazone [Avandia], quite effective on the order of 60, 70 percent. These drugs have more safety concerns. The big one is probably bone health. The scarier one is bladder cancer, which is quite rare. I mean, the risks to an individual taking pioglitazone for bladder cancer is quite rare, quite low. But then the new studies with these highly effective GLP-1 receptor agonists have been spectacular. Now, they’re controversial because the patients didn’t come off the GLP-1 receptor agonist for a long time, just for a short time. So you don’t really know whether you’re masking the diabetes with a diabetes drug or whether you’re actually preventing diabetes. But the top line result was a 95% reduction in risk. The sort of more gorier details, it’s probably not quite that high. Joe 46:41-47:17 What I want to talk about is diet, cause everybody always says, yeah, diet and exercise, but they don’t ever really tell you what to eat or what not to eat. And we’ve had some controversy with you in the past about the American Diabetes Association and the Feinstein Diet and all the other diets. But I want to talk specifically about CGMs, continuous glucose monitors. For decades, they’ve been around and they were prescription only. You had to have a diagnosis of type 2 before you could get a little thing that you could slap on your arm and actually monitor your blood glucose. Dr. John Buse 47:18-47:28 Well, actually, more than that, you had to be on insulin usually or a sulfonylurea drug. You had to have a risk of hypoglycemia, and that was what you were really monitoring for. Terry 47:29-47:36 And that’s what the insurance companies required so that it would be paid for, and otherwise you probably couldn’t afford it. Dr. John Buse 47:37-47:37 Right. Joe 47:37-48:01 Now you can buy them “over the counter” in quotes. I mean, you don’t need a prescription. You do have to pay out of pocket, and most insurance companies aren’t going to pay for them. But I’m guessing around $40 or $50 a month. And I’ve used them, and they’re incredibly revealing. I mean, I discovered, for example, that oatmeal, which is supposed to be this absolutely wonderful, healthy breakfast. Terry 48:02-48:07 And I do use steel-cut oats. We’re not using the quick and dirty oatmeal. Joe 48:08-48:29 But it really pushed my blood sugar up to around 140. And it’s like, what? The oatmeal is supposed to be good. Why is that happening? Whereas if I have eggs, it doesn’t go up hardly at all. So what about the value of CGMs for people who have prediabetes or just concerned about their blood glucose? Dr. John Buse 48:30-50:21 Yeah. You know, this is like the nuclear arms race of the 1970s. So in medicine, in society, there’s sort of a bit of a tendency if you can do a little, you could do more. And if a little is good, then more is better. I would just caution people that I’m not sure that a blood sugar of 140 after oatmeal is a problem. And if you’re changing your life to eating eggs and bacon, I’m not sure that’s a good solution either. So just be aware this is just another piece of information. It’s not been studied in a way that we really can tell you how that revelation might be beneficial to you. I tend to discourage people from going wild with using technology to monitor every aspect of their life. I think we know what a healthful diet is. We have some good ideas. You know, the idea of less processed food, a variety of foods from a variety of different categories, cereals, nuts, fruits, vegetables, meats— you know eating a variety of foods in moderation. And at the end of the day people have appetites and um, if you like oatmeal you should eat oatmeal. You know life is too short to deprive yourself of everything. Um, now if you like eggs and bacon and you want to use this as an excuse to eat eggs and bacon, go for it. Joe 50:20-50:40 Well, that does bring up a very controversial issue. We interviewed Dr. Eric Westman recently. He is renowned as the ketogenic diet guy, and now he’s moving into the carnivore diet approach. And he maintains that the ketogenic diet will get you off your diabetes drugs. Dr. John Buse 50:41-51:17 For people that can persist with that kind of diet, it generally is associated with a reduction in the amount of drugs that they need. But it’s a big sacrifice. And what we don’t know yet is that people that eat a ketogenic diet and specifically a carnivore diet, whether that’s associated with enhanced longevity, is it associated with a higher risk of kidney disease, of bone disease. And there’s a number of unknown issues with these kinds of diets. Terry 51:18-51:43 So more data needed. We’ve talked a little bit about the GLP-1 agonists, which is a fancy way of saying Ozempic and Mounjaro. I would like to ask about another category of diabetes drugs. And that’s the category that Jardiance is in, empagliflozin, all the “flozins,” there’s lots of “flozins.” What should we know about them? Dr. John Buse 51:44-52:54 Yeah, so they’re really miraculous drugs that soon will be generic and in five years they’ll be dirt cheap because there’ll be multiple generics on the market. These drugs work basically to make you pee sugar. So whatever food you eat, some of it is excreted in the urine when you take the flozins, drugs like Jardiance or empagliflozin. So there’s some weight loss. With that loss of glucose, there’s also a bit of loss of sodium. So you have some blood pressure reduction. And then there’s some magical things that happen within the kidney and within the heart. So it is associated with dramatic improvements in kidney outcomes and heart outcomes, particularly in people who have heart failure or kidney disease. But that is really common in overweight and obese people, particularly with diabetes. Now they’re actually approved for the use of people in general, whether they have diabetes or not, who have kidney disease or heart failure. A really remarkable class of drugs, and the best thing about them is they’re going to be cheap. Joe 52:55-53:20 Dr. Buse, we’re hearing rumors about something called ‘micro dosing.’ We’re not talking about psilocybin or LSD or any of those hallucinogens. We’re talking about micro dosing the GLP-1 agonist, the drugs like Ozempic, like Mounjaro. What the heck is micro dosing and why would it be interesting? Dr. John Buse 53:20-54:46 Yeah. So the GLP-1 agonists we’ve known for a while are associated with nausea, vomiting, various kinds of GI side effects. If you start with a really low dose and you go up slowly, you tend to have much less of those side effects is the first thing. The second thing is that for some people, they are very sensitive to the drug. And while they’re going up slowly on the dose, they may lose substantial amounts of weight. And I have patients that are able to get by with a 20th of the normal dose with consistent, though generally relatively slow weight loss. I think that’s a really healthy way of losing weight. It takes people decades to gain weight. We should take years in getting people to lose substantial amounts of weight. So it’s just it’s an alternative technique that works out quite well in some people. It’s easiest to do with Ozempic because that pen has clicks in it. The other drugs are largely administered as so-called single-use pens where you just push a button and it gives you the dose. So there isn’t really a way to do it. If you buy the vials, which are now available, you can also micro dose. It’s a little bit more complicated because you have to use a needle and syringe. Terry 54:46-54:55 Now, you mentioned that you have patients who are doing this, they are losing weight. Are they also gaining better control of their blood sugar at these very low doses? Dr. John Buse 54:56-55:46 Yes. In general, the GLP-1 receptor agonists provide for what we call a dose-response curve. As the dose goes up, you have a bigger effect on blood sugar lowering than you have on weight. And as you get to higher and higher doses, you get less additional benefit for glucose lowering and more benefit for weight on average. Now, what I’m mostly talking about here is people where overweight and obesity are the main problems is where the micro dosing is worked out. Or in people who have tried GLP-1 receptor agonists in the past and had a rough time with regards to nausea, vomiting and stopped. So I think that’s where the biggest opportunity is. Joe 55:47-55:52 Dr. Buse, one last question: coffee and diabetes. Dr. John Buse 55:54-56:55 It’s like my pet peeve. And the reason is there are probably a thousand papers that have been written about coffee. It takes time to review them, time to publish them, time to read them. And it’s not quite a 50-50 split that coffee is good for diabetes, but it’s pretty close to a 50-50 split. I think it’s inherently a problem with this kind of food epidemiology research that, you know, coffee drinkers are just different than people who don’t drink coffee, right? And particularly people who drink six cups of coffee a day are different than people who drink one cup of coffee a day. So it’s just a really hard study to do. So now that said, you know, if a patient says, ‘You know, I love my coffee’ and I said, ‘Well, that’s great. You should have it just because you love it. And maybe it’s even good for your diabetes.’ And if they say, ‘You know, somebody told me I should drink coffee for my diabetes, but I hate it.’ I say, ‘Do not drink coffee for your diabetes.’ Joe 56:57-57:25 Thank you. We are almost out of time. If you could change three things about the American diet, what would it be? And then what does your crystal ball hold for the future of diabetes research and especially for type 1 diabetes? Cause, you know, as you said: insulin, insulin, insulin. We haven’t had any breakthroughs. We don’t have any cures yet. So: diet and crystal ball? Dr. John Buse 57:25-58:06 Yeah, I think the most important thing about the diet in America is we do need to eat less processed foods. That’s a big ask. It’s easy to eat processed foods. But I think that is number one on my list. And then secondly, a wide variety of foods. You know, I went through my list before. I think those are number one and number two. And then if you’re going to lose weight, if you’re aiming to lose weight, make sure not to forget exercise as part of your, quote, diet, close quotes. Because if you don’t exercise and you start, you know, you’re losing weight and you don’t feel energetic, you will lose muscle mass. And that’s not a good thing. Joe 58:06-58:06 Crystal Ball? Dr. John Buse 58:07-59:28 Crystal Ball in type 1 diabetes, we’re working on a lot of adjunctive therapies using the same drugs that we’ve used in type 2 diabetes and then developing novel adjunctive therapies. So in our clinical trials program, we’re studying GLP-1 receptor agonists in type 1 diabetes. There are major programs from at least two pharmaceutical companies. We’re studying a new class of drugs called glucokinase activators in type 1 diabetes. And then the sort of prevention strategies, generally immune-modifying strategies, are super exciting. And lastly, stem cell-derived therapies. So these would be cells that you can make billions of beta cells, the insulin-producing cells, and infuse them back into people with immunosuppression. And then in the last month in the New England Journal, cadaveric donors, you know, organ donors, their pancreases were disassembled, the islets taken out. They were genetically modified to make them non-immune, and they actually did a sort of proof of concept in a single case, do a transplant for type 1 diabetes reversal without any immunosuppression, so without the dangerous drugs that come along with islet transplantation. Terry 59:28-59:48 So they had somebody who had died in an accident or something. They had signed the form that says, yes, I’m donating my organs. The organ they donated was a pancreas, and the part of the pancreas that the researchers took were the islets that contained beta cells. Is that right? Dr. John Buse 59:48-59:50 Right. Right. Terry 59:49-59:55 And so they put them through the wash, as it were, so they didn’t have immune markers on the surface. Dr. John Buse 59:55-01:00:02 No, no. They used CRISPR-Cas9, a gene-modifying technique… Terry 01:00:02-01:00:03 Okay. Dr. John Buse 01:00:03-01:00:07 …to change a couple of genes within these cells. Joe 01:00:07-01:00:08 And the result was? Dr. John Buse 01:00:10-01:00:14 So this wasn’t a clinical stage. But the cells lived. Joe 01:00:15-01:00:20 So it’s entirely possible that we could have a cure for type 1 diabetes in the future. Dr. John Buse 01:00:21-01:00:43 Well, what I would say is I almost didn’t go back to medical school in 1984 when I was finishing my PhD because I was so sure we were going to cure diabetes then. So we have been at the cusp of a cure for a long time. We keep coming up with these great ideas and Mother Nature is really hard to fool. Terry 01:00:44-01:00:49 Dr. John Buse, thank you so much for talking with us on The People’s Pharmacy today. Dr. John Buse 01:00:50-01:00:52 It’s always a pleasure visiting with you guys. Joe 01:00:53-01:01:03 You’ve been listening to Dr. John Buse, the Verne S. Caviness Distinguished Professor of Medicine at the University of North Carolina at Chapel Hill School of Medicine. Terry 01:01:04-01:01:13 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 01:01:14-01:01:20 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Terry 01:01:20-01:01:38 Today’s show is number 1,453. 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 01:01:38-01:02:01 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. The podcast this week has some extra information about people experimenting with micro dosing of GLP-1 drugs like Ozempic or Mounjaro to prevent diabetes. Does this make sense? Also, what’s the story on coffee and diabetes? Terry 01:02:02-01:02:21 Well, epidemiological evidence over the past few decades has suggested that coffee drinkers have a lower risk of developing diabetes compared to non-coffee drinkers. A lot of people with AFib have been told coffee’s off-limits, but new research shows coffee drinkers have a lower likelihood of AFib recurrence. Joe 01:02:22-01:02:44 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 our weekly podcast. We’d be grateful if you would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:02:44-01:03:20 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 01:03:20-01:03:30 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 01:03:30-01:03:35 All you have to do is go to peoplespharmacy.com/donate. Joe 01:03:35-01:03:48 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.

Transcribed - Published: 21 November 2025

When the thyroid gland stops working efficiently, the effects resound throughout the entire body. That’s because this little gland controls metabolism in all our tissues. Before there was a treatment, thyroid disease was sometimes deadly. Doctors started prescribing natural desiccated thyroid derived from animals 130 years ago. This worked well. Synthetic levothyroxine (a thyroid hormone) was developed in 1970 and marketed aggressively. Now levothyroxine is one of the most commonly prescribed medications in the US. The FDA has announced that it plans to ban natural desiccated thyroid. What are the implications? We’ll check in with two experts to find out. 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, Nov. 15, 2025, 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 November 17, 2025. What Should You Know about Natural Desiccated Thyroid? Thyroid extract from pigs contains two important thyroid hormones. Endocrinologists refer to them as T4, also called levothyroxine, and T3, known as liothyronine. The T4 molecule has 4 iodine atoms and is inactive. To activate it, the body uses an enzyme, deiodinase, that kicks off one iodine molecule resulting in activated T3 that does all the work in the tissue. When scientists discovered that T4 could be converted to T3, it opened the door to prescribing T4 alone, synthetic levothyroxine such as Levoxyl or Synthroid, to all hypothyroid patients. That became standard practice not long after Synthroid was introduced. There was a hitch, however. Some patients did not feel well even though they were taking levothyroxine. Until fairly recently, doctors downplayed these problems. Our guest, Dr. Antonio Bianco, helped conduct the research showing that some people have deiodinase enzymes that are less efficient at converting T4 to T3 (Current Opinion in Endocrinology, Diabetes, and Obesity, Oct. 2018). This enzyme activity seems to be under genetic control. As a result, endocrinologists may find it easier to understand why some patients don’t respond to prescribed levothyroxine as expected. They may need liothyronine in addition. This could be provided with a separate prescription. On the other hand, people get both T3 and T4 when they take natural desiccated thyroid. We think that Dr. Bianco is one of the leading thyroid researchers in the world. Here is a very short video clip from our interview with him: You will want to listen to the whole interview either live on Saturday morning or when it becomes available on this website Monday morning (11/17/2020). You can stream the audio by clicking on the white arrow inside the green circle under the photo of Armour Thyroid. You can also download the mp3 file by scrolling to the bottom of this article. Why not sign up for all our podcasts at this link so you will never miss another People’s Pharmacy episode again? What Symptoms Do People Suffer Without Natural Desiccated Thyroid? A majority of hypothyroid patients, perhaps 80 or 85 percent, are able to convert T4 to T3 well enough that they can use levothyroxine alone. The remainder, however, do not feel well on this regimen. They experience brain fog and low energy. They may also complain of other symptoms associated with undertreated hypothyroidism, such as difficulty with weight control, cold sensitivity and menstrual irregularities or fertility problems in women. An estimated 1.5 million Americans take natural desiccated thyroid. What will they do if the FDA bans this product? About half a million people take a combination of synthetic T4 and synthetic T3. That is one option, but some individuals prefer natural hormone. What Will Happen to Patients? We turn to patient advocate and activist Mary Shomon to learn about the patient perspective. She is concerned about the FDA’s announced plan to take natural desiccated thyroid (NDT) off the market in August 2026. (NDT is sometimes referred to as DTE, desiccated thyroid extract. They are the same thing.) It is not clear that the agency has considered what will happen to people forced to take a medicine that most of them have already tried without success, levothyroxine. Rethinking Levothyroxine Treatment: Mary Shomon points to recent research by Dr. Bianco and his colleagues suggesting that levothyroxine alone may not be quite as effective as most endocrinologists believe. In this analysis of medical records, hypothyroid people taking levothyroxine alone were twice as likely to die during the study period and had a 40% higher risk for developing dementia compared to people getting T3 along with T4 (Journal of Clinical Endocrinology, June 20, 2025). These new findings underscore the importance of information from the large number of patients in touch with Mary. As she says, there is enormous individual variation in which treatments help people thrive. She recommends that everyone who relies on natural desiccated thyroid should contact the FDA (as well as their Congresspeople) to let them know how banning these products would affect their lives. This Week’s Guests: Antonio Bianco, MD, PhD, is Senior Vice President of Health Affairs, Chief Research Officer and Dean of the John Sealy School of Medicine at the University of Texas Medical Branch at Galveston. Dr. Bianco is the author of Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do. Antonio Bianco, MD, PhD VP & Vice Provost Research & CRO, Research Services Mary Shomon is a patient advocate and author. Her books include the New York Times bestseller The Thyroid Diet and ten others. Her website is  https://www.mary-shomon.com She is also a Paloma Health Advisor & Patient Advocate. Find her online at https://www.palomahealth.com/authors/mary-shomon Her newsletter, Sticking Out Our Necks Hormonal Health News, is available on Substack. Here’s the link: https://hormones.substack.com/ Patient advocate Mary Shomon 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, Nov. 17, 2025, after broadcast on Nov. 8. You can stream the show from this site and download the podcast for free. This week’s episode contains additional discussion with Dr. Bianco of his research on the consequences of treating with levothyroxine alone. We also consider the FDA’s claim that natural desiccated thyroid suffers from inconsistent quality and dosing. Mary Shomon offers basic information on what the numbers from a thyroid test mean, especially the goals for T3 and T4. We also review the most common symptoms of hypothyroidism. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1452: 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 00:00-00:26 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. The FDA has announced a ban on natural thyroid extracts like Armour that will impact over a million people. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:44 Most people with under-active thyroid glands take synthetic levothyroxine, but many patients feel much better if they take a natural desiccated thyroid instead. Joe 00:45-00:51 How will the FDA’s ban affect them? What could they do if their medicines were pulled off the market? Terry 00:51-00:57 We speak with an endocrinologist and a patient advocate about the possible ways people might deal with this situation. Joe 00:58-01:05 Coming up on The People’s Pharmacy, why is the FDA planning to ban natural desiccated thyroid? Terry 01:14-02:28 In The People’s Pharmacy health headlines: the FDA has just announced a change to prescribing information for hormone replacement therapy. For many years, this treatment for menopausal symptoms like hot flashes and night sweats has carried a black box warning. This warned women and their doctors that estrogen could increase the risk for endometrial cancer and could increase the risk for blood clots and cardiovascular problems. FDA Commissioner [Dr.] Marty Makary has expressed his belief that the boxed warning frightened women away from a treatment that could help them. He thinks that HRT might reduce the risk of bone fractures, dementia, and even heart disease in women who start taking it at menopause. According to Dr. Makary, with the exception of antibiotics and vaccines, there may be no medication in the modern world that can improve the health outcomes of older women on a population level more than hormone therapy. Some critics are concerned that this action, which was not vetted by an official FDA advisory panel, may undermine the agency’s credibility. Apparently, the warning about the risk for endometrial cancer will remain for products that contain estrogen alone. Joe 02:29-03:39 For years, cardiologists have warned patients with atrial fibrillation to avoid coffee. That’s because they worried that caffeine would aggravate heart arrhythmias. A new study titled DECAF, which stands for Does Eliminating Coffee Avoid Fibrillation, has produced surprising results. The study published in JAMA recruited 200 coffee drinkers with AFib. Half were assigned to drink at least one cup of caffeinated coffee daily. The other half were required to abstain from coffee or any other caffeinated beverages. The study lasted six months. The results were unexpected. Coffee drinkers had a significantly lower likelihood of recurrent atrial fibrillation. One possible explanation is that coffee has anti-inflammatory properties. Because some research suggests that chronic inflammation contributes to AFib, lowering inflammation might be beneficial. The authors conclude that one cup of coffee daily was associated with a lower risk of atrial fibrillation and atrial flutter recurrence. Terry 03:40-04:47 Cardiologists have long known that low levels of circulating vitamin D may increase the risk for a heart attack. A study presented at the American Heart Association’s scientific sessions showed that people taking vitamin D supplements to raise their blood levels to at least 40 nanograms per milliliter significantly reduced their chance of a second heart attack. The study included 630 people who had suffered a heart attack less than a month before entering the trial. Such individuals are at risk for a second heart attack. Investigators assigned them to a control group that received no vitamin D management or an intervention group that had regular measurement of vitamin D and adjustment of their supplements to reach the target blood level. When the study began, 85% of the volunteers were below target. Many required supplements of 5,000 international units of vitamin D3 daily to reach 40 nanograms per milliliter. Those taking supplements were half as likely to experience a second heart attack compared to those not receiving supplements. Joe 04:48-05:20 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. Risk factors for metabolic syndrome include high blood pressure, abdominal adiposity, elevated blood sugar, and high triglycerides. A new 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. Terry 05:21-05:53 Following a DASH diet rich in vegetables and fruits and low in processed foods can help lower blood pressure. But what about people who live in food deserts where fresh produce is not readily available? A study compared home-delivered DASH-type groceries and dietary advice to monetary stipends for groceries. Three months of DASH grocery delivery lowered blood pressure and LDL cholesterol levels more than the $500 monthly stipends. And that’s the health news from the People’s Pharmacy this week. Joe 06:14-06:17 Welcome to the People’s Pharmacy. I’m Joe Graedon. Terry 06:17-06:47 And I’m Terry Graedon. Hypothyroidism is surprisingly common, affecting over 20 million Americans. In this condition, the thyroid gland does not produce an appropriate amount of thyroid hormone. This leads to a wide range of uncomfortable symptoms and some serious health consequences. Treatment is thought to be simple, but not everyone responds to the standard therapy. What can people do if they still feel bad while taking their prescribed medication? Joe 06:48-07:21 To help us understand the complexity of treating hypothyroidism, we turn to one of the country’s leading experts. Dr. Antonio Bianco is professor of medicine and a member of the Committee on Molecular Metabolism and Nutrition at the University of Chicago, where he runs a laboratory funded by the National Institutes of Health to study thyroid hormones. Dr. Bianco is a former president of the American Thyroid Association and author of “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Terry 07:23-07:26 Welcome back to The People’s Pharmacy, Dr. Antonio Bianco. Dr. Antonio Bianco 07:27-07:29 Thank you. I’m glad to be here. Joe 07:29-07:45 Dr. Bianco, a lot of your colleagues, endocrinologists, family practice physicians, internists, they think that thyroid disorders are easy to treat. Why is that a mistake? Dr. Antonio Bianco 07:46-08:29 Well, the most common disease of the thyroid gland is hypothyroidism. And it is true that for the last 50 years, we have been treating patients with hypothyroidism with the daily tablet of what’s called levothyroxine. And the dose is easily adjusted. And usually we tell patients, come back in six months, come back in a year. And this is sort of very straightforward to the point that it doesn’t have to be even treated by an endocrinologist. They can be treated by a primary care physician, a gynecologist, a geriatrician. I mean, most internists can treat hypothyroidism. Joe 08:31-08:34 But you suggest it’s not as easy as that. Dr. Antonio Bianco 08:36-09:54 That’s right. And that has been a mistake that we did in the last 50 years, again. We assumed that once we achieved the dose of this magical drug called levothyroxine, patients will feel without symptoms, would be relieved of their symptoms. And in fact, it is true for most patients. We estimate that about 80%, maybe 85% of the patients are treated with this approach and they feel fine. However, we do have a substantial number of patients that it seemed small, 15%, but hypothyroidism is so prevalent. We have about 20 million people living in the U.S. with hypothyroidism. So if you estimate about 10%, 20%, we’re talking about 3 to 4 million people. And for those individuals, treatment is not as straightforward. Even though the doctor thinks that the treatment is okay, it’s as it should be, they remain symptomatic. They still have symptoms. Terry 09:55-10:48 Dr. Bianco, we have been hearing from people with hypothyroidism for decades ourselves. They write into The People’s Pharmacy or they call and they say, ‘I am taking Synthroid or Levoxyl, one of those T4 drugs, levothyroxine, and I still feel awful. I still feel tired, I still feel cold.’ Women still say, ‘I still am having problems with my menstrual cycles.’ Many people say, ‘I still can’t lose weight, in fact, I keep gaining weight even though I’m trying hard to lose it.’ They have many symptoms and they don’t feel good and they say, ‘My doctor doesn’t seem interested.’ Joe 10:49-11:03 Well, not only that, they say, ‘My doctor says I’m doing great. My TSH level, this monitor for my thyroid, is perfect. No problems, be happy, don’t worry.’ Dr. Antonio Bianco 11:04-11:40 In a nutshell, you capture exactly what the problem is. That’s exactly right. And so what we think is the problem is that these Synthroid or Levoxyl, they contain this molecule called levothyroxine, which is the thyroid hormone. And levothyroxine is not active, meaning when a patient takes a tablet of levothyroxine, levothyroxine by itself cannot relieve symptoms of hypothyroid. It just doesn’t do anything. Terry 11:41-11:46 I think that’s a really important point. That isn’t adequately appreciated. Say it again, please. Dr. Antonio Bianco 11:45-12:53 That’s correct. Yes. The substance contained in those tablets, either Levoxyl or Synthroid or any generic form of levothyroxine, it’s not active. It’s a dead molecule. And we rely on our body to take that molecule and activate, to process it, to transform it into a molecule that is biologically active, meaning can relieve symptoms of hypothyroidism. And some of us do their job very well. Unfortunately, some of us don’t do that. And those individuals that remain symptomatic. We believe they have a sort of a problem in activating the molecule, the T4, to this other molecule called T3. And so they live in a state of chronic T3 insufficiency. And it so happens T3 is the molecule that relieves symptoms of hypothyroidism. Joe 12:54-13:13 Perhaps we could take just a moment to review the physiology of the thyroid gland. Why is the thyroid, and in particular, that active form, T3, so crucial to every cell in our body? Dr. Antonio Bianco 13:14-15:17 The thyroid mostly makes T4, which again is this molecule that is not active. But T4 remains in the circulation, in the blood. A little bit of T4 goes into the cells. Most T4, it’s in the circulation. Now, once T4 gets into the cells and tissues and organs, T4 is rapidly activated in T3. So that inside that organ, T3 can act and relieve symptoms of hypothyroidism. Now, when doctors look at the TSH, and you mentioned TSH, TSH is this hormone that controls the thyroid gland. TSH likes to see T3 in the circulation within the normal range, so that if you have a healthy thyroid, the TSH controls the thyroid gland to the point that T3 in the circulation is normal. Now, when a patient has hypothyroidism and we give the patient T4, only T4, and rely on the TSH to estimate how much T4 we should give, then the system gets confused because TSH regulates the T3 levels in the circulation, and yet we’re giving a lot of T4 to the patient. Yes, we can regulate TSH with T4, but it’s not the same as having an intact thyroid. And that has been the mistake we’ve done over the last 50 years. We relied on TSH and treated patients with only one hormone. And all along, we needed two hormones to treat these patients. I mean, we believe that this T3 insufficiency should be fixed by adding a second hormone to the treatment. Terry 15:19-16:10 Now, Dr. Bianco, a little bit of personal information here: I am one of those people with hypothyroidism. I have had it since 1974. I am part of your 80% of people who actually feel pretty good on T4 alone. So I’ve been taking Synthroid all these years. When I go to my physician for a checkup and she orders a blood test to see how my thyroid is doing, the only thing she’s looking at is TSH. Is that a problem? When Joe gets his blood tested for his hyperthyroidism condition, his doctor is looking at T4, T3, all kinds of different thyroid hormone levels, not just TSH. Dr. Antonio Bianco 16:11-16:49 That is a problem. And that is part of that, I think that’s a big part of the problem. We got used to just looking at TSH to adjust the dose of levothyroxine. And we were missing the big picture, which is a relative T3 deficiency that these patients experience. And you’re right, some patients or most patients can cope with that. You know, they just don’t feel bothered by that. But there’s a small minority that those symptoms are really important. Joe 16:46-16:48 Whoa whoa, Dr. Bianco- Terry 16:49-16:51 15% is not a small minority. Dr. Antonio Bianco 16:49-16:52 Oh, yeah. No, that’s right. Joe 16:51-16:56 I mean, you’ve already, you’ve already said over a million, maybe as many as two or three million. Dr. Antonio Bianco 16:55-16:56 No, that’s correct. Joe 16:56-16:58 This is not a minority. Dr. Antonio Bianco 16:57-17:06 Oh yes, absolutely. Percentage-wise, yes. Percentage-wise, yes, but it is a vocal and it’s a very important minority. Joe 17:07-17:13 What else should doctors be testing for besides TSH? Dr. Antonio Bianco 17:15-17:39 Uh, T4 and T3. They have to control… the purpose of the treatment of hypothyroidism has been to normalize TSH. And I advocate that we have to look at T3 levels because T3 is the hormone that relieves symptoms. T3 is the hormone that actually [does] things. And we should be looking at normalizing those levels. Terry 17:41-18:07 You’re listening to Dr. Antonio Bianco, professor of medicine at the University of Chicago. He’s a member of the Committee on Molecular Metabolism and Nutrition there, and he runs a laboratory that studies thyroid hormones. Dr. Bianco is a former president of the American Thyroid Association and author of “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Joe 18:07-18:14 After the break, we’ll learn about the symptoms troubling some patients even though they’re being treated for hypothyroidism. Terry 18:14-18:21 Low energy and brain fog are not very specific. What should make us suspect they could be due to thyroid problems? Joe 18:21-18:28 Dr. Bianco is challenging the usual approach to hypothyroidism. How are his colleagues reacting? 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 18:54-19:14 And I’m Terry Graedon. Today we’re analyzing the FDA’s plan to withdraw permission for natural thyroid extract, also referred to as desiccated thyroid. What will happen to patients who rely on products like Armour Thyroid if they can no longer access the medications their doctors have prescribed? Joe 19:15-19:36 We’re talking with Dr. Antonio Bianco. He is Senior Vice President of Health Affairs, Chief Research Officer, and Dean of the John Sealy School of Medicine at the University of Texas Medical Branch at Galveston. His book is “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Terry 19:38-20:38 Dr. Bianco, we really appreciate the overview and the history that we have gotten now. The reason we’re talking with you is that the FDA has announced that it is going to withdraw its permission from suppliers of desiccated thyroid extract. I’m not quite sure what the timeline is. I think they suggested perhaps about a year from last August. But thyroid patients who are relying on desiccated thyroid extract to treat their hypothyroid condition are worried that they are going to be left out in the cold. And because they are hypothyroid, they are really going to feel that cold. Can you fill us in on what the FDA has in mind, if you have any insight into that, and what people might be able to do? Dr. Antonio Bianco 20:39-22:19 Yeah, well, that is a problem. I agree with you. We have 1.5 million patients taking this drug. And the FDA just announced that in 12 months, starting in August, that drug is not going to be available. And what the FDA is asking physicians is to switch those patients that are taking desiccated thyroid extract to take levothyroxine, which is the recognized standard of care. But the problem is these patients are on desiccated thyroid extract most likely because they tried levothyroxine before and the levothyroxine was not sufficient to resolve all their symptoms. That’s why they were switched to desiccated thyroid extract. That’s the recommendation that the clinical professional societies are providing. You start treatment with levothyroxine, and if that doesn’t resolve all the symptoms, you can try combination therapy for these patients, either with desiccated thyroid extract or synthetic combination of levothyroxine and liothyronine. So these patients have tried levothyroxine, and levothyroxine failed them. And that’s why they’re happy on desiccated thyroid extract. So the idea that we should all move our patients to taking levothyroxine now, it’s a little bit concerning because it is my experience that these patients rely on that drug. Their lives are many times miserable without the desiccated thyroid extract or the synthetic combination. Joe 22:19-22:49 Let me interrupt you right there. Again, Dr. Bianco, what do you think will happen if a million to a million and a half people are switched from desiccated or natural thyroid to levothyroxine, people who have failed in the past on levothyroxine? What are some of the symptoms that they may encounter when they’re switched back to the pure synthetic levothyroxine? Dr. Antonio Bianco 22:50-23:40 Yeah, the main symptoms include brain fog, the inability to function normally. And I had many patients that complained of brain fog, patients that lost their jobs because they couldn’t focus. I have high school teachers that were functioning well. They were diagnosed with hypothyroidism, they were treated with levothyroxine, and by all accounts, they were okay, biochemically okay. The lab tests were okay, but they did not feel well. They had brain fog, they couldn’t focus, they lost their jobs. I have countless, countless stories, and my colleagues do too. So I think that if they are forced to go back to levothyroxine, it will be a problem for their lives. Joe 23:40-23:47 What are some of the other symptoms? Because we’ve heard of people who say, I just couldn’t lose weight on levothyroxine. Dr. Antonio Bianco 23:47-23:48 That’s right. Yes. Joe 23:48-23:49 And I feel cold. Dr. Antonio Bianco 23:50-23:50 Yes. Joe 23:50-23:52 And I’m constipated. Dr. Antonio Bianco 23:53-24:22 Yes. All the symptoms. The symptoms are very similar to the symptoms of hypothyroidism in lesser intensity. So the second most common is low energy: patients feel very tired, no motivation to do things. And that is very helpful. The third one is difficulty managing body weight, that’s also a major problem. So this is going to be very inconvenient for those patients. Terry 24:23-24:41 And that, I think, is why patients are really, I might say, alarmed at the prospect. Is there any possibility that a desiccated thyroid extract might actually be approved by the FDA? Dr. Antonio Bianco 24:41-25:29 Well, yes, that would be terrific. So we have, I’m aware of about two or three pharmaceutical companies that are currently running clinical trials in communication with the FDA. They are in constant communication with the FDA. The FDA knows about their results and they have these clinical trials that are ongoing and they are in the process of getting this drug approved. So it’s not that they’re doing it without the knowledge of the FDA. No, they know very well what they’re doing. But of course, it takes time because it involves hundreds, sometimes thousands of patients that have to be studied on trial. So it takes time. It’s a long process. Joe 25:30-26:41 Well, you know, I find it rather paradoxical that the overarching company that makes Synthroid, which is the best-selling brand name Levothyroxine, is AbbVie. And the same company, AbbVie, owns the company that creates the best-selling desiccated thyroid, Armour Thyroid. So you have AbbVie with its tentacles, so to speak, in both the brand name synthetic levothyroxine and the natural combination of desiccated thyroid. And so presumably they have enough money, resources, and expertise to be able to run the clinical trials that you’ve described. But the question is, will they be able to meet the timetable of the Food and Drug Administration? And what will patients do if for some reason, for example, they cannot access Armour or any other desiccated thyroid? Dr. Antonio Bianco 26:41-27:41 Right. No, that’s quite interesting. You pointed to a very interesting thing by, you know, it was fate that levothyroxine was going to be manufactured and sold by the same company that makes desiccated thyroid extract. That’s quite interesting. Now, they are running, they are one of the companies that are running clinical trials. They already have actually presented the results of their trial in the meeting of the American Thyroid Association two or three years ago in Montreal. And the results were quite satisfactory, meaning that following the guidance from the FDA, they were able to show scientifically that patients can effectively and safely be treated with desiccated thyroid extract. The results were presented in the American Thyroid Association meeting. Obviously, that’s the first step. Now they’re working with the FDA into the second step of the study, which involves a much larger number of patients. Joe 27:43-27:57 Dr. Bianco, perhaps you can give us an update on your latest research. We have been following you for a very long time, and we’d like to know what you have in the pipeline or what you have recently published. Dr. Antonio Bianco 27:58-28:36 Yes, thank you. So this is, we got very interesting results. So recently I moved to the University of Texas in Galveston. And here we have access to something unique, which is a computer network of electronic medical records. It’s called TriNetX. And once I moved here, I gained access to this network, which involves about 140 hospitals throughout the world, mostly in the United States. And we have access to more than 100 million patients’ electronic medical records. Joe 28:36-28:37 Wow. Dr. Antonio Bianco 28:37-31:02 So obviously, yeah, that’s amazing. My first question is that let’s look at patients with hypothyroidism. And so we were able to identify 1.2 million patients with hypothyroidism that were being treated. So we compared these patients with healthy patients that had a healthy thyroid. So we properly matched them for age, sex. We used about 20 variables to make sure we have two equivalent populations. And much to my surprise, we saw that patients, even though they are being properly treated, They have a higher incidence of dementia, and they have a higher mortality. Mortality is almost double in patients that have hypothyroidism, even though they are being appropriately treated. So that was very concerning to us. Now, the second question is, well, what if the patients were treated with combination therapy as opposed to levothyroxine? So out of these 1.2 million patients, we separated about 90,000 patients that were being treated with combination therapy. Half of them were taking desiccated thyroid extract, and the other half were taking synthetic combination, 90,000. And then we matched those 90,000 patients with 90,000 patients only taking levothyroxine. And we looked at [them] retrospectively for 20 years, how did these patients do? So first, we were expecting, with all honesty, that patients taking the combination therapy, the therapy that contains T3, were perhaps not doing so well as the ones taking levothyroxine. After all, there’s some concern that combination therapy could not be a safe route. Even in the letter of the FDA, they say that desiccated thyroid extract is not safe. So by looking at this population, seeing a very appropriate way of comparing combination therapy, desiccated thyroid extract or synthetic with levothyroxine. Much to our surprise, those individuals taking combination therapy, they had a reduction in mortality of about 30%. Joe 31:02-31:02 Wow! Dr. Antonio Bianco 31:02-31:48 They had a, yes, a reduction in the diagnosis of dementia over these 20 years. So not only the combination therapy were safe, but actually it showed to be slightly safer than levothyroxine alone. And again, this is not one site study. This is not a study that was done here in Texas. No, this was done in more than 100 hospitals across the country. So this is really a multi-center study. It’s a retrospective study. It’s not a prospective study. You can’t just follow 90,000 patients prospectively for 20 years. But even considering that is retrospective, the data is amazing. Terry 31:49-32:21 Dr. Bianco, this brings up a question to my mind, a very personal question. I have been taking levothyroxine in the form of Synthroid since about 1974 or 1975. I don’t remember if it was the end of 74 or the beginning of 75 when I started on it. But all this time, and I’ve counted myself as among that 80% of patients who do fine on synthetic levothyroxine. Dr. Antonio Bianco 32:22-32:22 Right. Terry 32:23-32:32 But what you’re suggesting is perhaps I could do even better if I also had a little bit of T3 in my treatment mix. Dr. Antonio Bianco 32:32-33:43 That’s correct, absolutely. And I think that my research in the laboratory now shows that there’s some clues to why this is. I think that when we treat patients with levothyroxine alone, we do not restore thyroid hormone action in all tissues. And it looks like the liver is one of the tissues that might remain slightly hypothyroid, even though the TSH levels are normal. Remember, the TSH is that hormone that doctors use to control the amount of the dose of levothyroxine that we give to patients. So the goal is to normalize TSH. So it turns out that even though TSH is normal, the liver may remain slightly hypothyroid. And why do I say this? Because patients with hypothyroidism that take levothyroxine, they have slightly elevated levels of cholesterol. Even though the TSH is normal, cholesterol remains slightly elevated. And you know what doctors do? They give statin. Terry 33:43-33:45 Yes, I do know that. Dr. Antonio Bianco 33:45-34:34 Exactly. So it turns out the number one co-prescription medication of levothyroxine is statin. Because, you know, you’re a doctor, you’re treating your patient, you’re giving levothyroxine, you normalize TSH, cholesterol remains elevated. Okay, I’m going to prescribe statin now. So it seems that we are creating patients that have a liver that’s slightly hypothyroid. Statin helps, but statin does not resolve all the problems. And therefore, that creates a risk factor for cardio-metabolic diseases. So these patients are dying of cardio-metabolic diseases. And I’m not surprised that when you use combination therapy, you actually improve a little bit. Joe 34:34-34:37 Dr. Bianco, have you published this new research? Dr. Antonio Bianco 34:38-34:44 Yes, it is published in the Journal of Clinical Endocrinology and Metabolism about two months ago. Joe 34:44-35:12 Well, it seems to me that if you were to present this data to the Food and Drug Administration, that is to say that people actually are doing better on desiccated thyroid, natural thyroid, in the long run with regard to key factors that people really care about. You know, they don’t care about lab values. What they care about is how they feel… Dr. Antonio Bianco 35:12-35:13 That’s exactly right. Joe 35:12-35:16 …and whether they’re living longer and healthier. Dr. Antonio Bianco 34:16-34:16 Yep. Joe 35:16-35:37 It seems like if you were to present this data to the Food and Drug Administration, they might say, ‘Oops, we just made a colossal mistake, we should be allowing natural desiccated thyroid on the market and maybe questioning the value of synthetic T4 levothyroxine.’ Dr. Antonio Bianco 35:38-36:29 Yeah, I agree 100% with you. Including in the letter, the FDA says, we are unaware of any studies demonstrating the safety and effectiveness of desiccated thyroid extract, which is, I mean, absolutely incorrect. There are several studies that have been published and are available on PubMed. There are two clinical trials that were done at the Walter Reed Medical Center, you know, in Washington. And, and uh, proving that this desiccated thyroid extract is effective and is safe. And you don’t even need to look at this study that we just published. The study that we published is powerful because it involves 90,000 patients for over 20 years. So that is very important, I think. Joe 36:29-37:00 I’m curious about your colleagues. I mean, you are one of the world’s foremost researchers in the field of thyroid physiology. Are other endocrinologists concerned about the FDA’s, shall we say, well, it’s just Joe speaking now, short-sighted decision to withdraw approval of desiccated thyroid? Are you hearing from any of your colleagues who are a little bit worried? Dr. Antonio Bianco 37:01-38:02 Yes. I think that I just recently went to the meeting of the American Thyroid Association in Arizona, and that was the conversation that we had with multiple individuals, colleagues of mine, very concerned. In fact, [AACE], the American [Association of] Clinical Endocrinology, put out a statement saying that they are supportive of the patients and they are stressing the FDA to reconsider and make sure that desiccated thyroid extract will remain available until the drugs are approved by the FDA. Because the companies are on track to get this drug approved by the FDA. Also, the American Thyroid Association put out a statement saying that they support the availability of desiccated thyroid extract at the same time that they support the companies going through the approval process. So I think that professional societies and my colleagues are very concerned with this move by the FDA. Joe 38:02-38:56 I do have one other question, and that has to do with quality. One of the concerns that the FDA has suggested is that, well, this natural thyroid stuff, this desiccated thyroid, it might be variable from one batch to another or from one company to another. And therefore, it might be unreliable. And what has me concerned about that perspective from the FDA is that we have received an awful lot of complaints from people who say, you know, generic levothyroxine that may be made in China or India or Thailand or Brazil. We have some problems with that generic thyroid. Terry 38:57-39:21 Well, the problem is that from one month to the next, when you get your prescription filled, you don’t know that the pharmacy is going to be using the same generic company to fill your prescription. And we have heard from people who said it was fine for, you know, three or four months, and then I got switched, and it really was not the same. Joe 39:22-39:42 So it seems a little, you know, I won’t say disingenuous of the FDA to be so worried about quality of the desiccated thyroid, but seemingly says, oh, all the generic levothyroxine is the same. Don’t worry. Everything’s fine and dandy when patients are saying it’s not. Dr. Antonio Bianco 39:44-43:27 Yeah. So you touched on two important problems. One is the variable potency of desiccated thyroid. The other one is the consistency of exchanging levothyroxine formulations. So the first one, it is true that desiccated thyroid extract was, there was this problem of inconsistency, but that was resolved in 1985. And if you look at the FDA letter, all the references that they quoted to support the idea that desiccated thyroid extract is inconsistent. They dated before 1985. I’m looking at the letter and it starts by 1978. So what happened in 1985? The United States pharmacopoeia changed the recommendation for how this desiccated thyroid extract is standardized. And they moved from measuring just iodine in those tablets by measuring T3 and T4 by HPLC. So now, since 1985, everyone, the pharmaceutical companies use HPLC to do this. And by doing that, the standardization became so much better, right? So the potency issue has basically been resolved. Of course, there are recalls. Yes, levothyroxine is also recalled all the time. If you go to the FDA website, drugs are recalled. Lots of drugs are recalled, you know, different lots. Because, and actually I’m happy when I see a recall, because it means someone is looking at it, someone is actually measuring it, and making sure that whatever remains available for the public is within the recommendations. So, recalls are normal. And I think that it means we are looking at, but if it’s not recalled, it’s consistent. It’s within the recommendations that we give by, that are given by the [USP], the United States Pharmacopeia. Now, generic versus brand and multiple generic formats for levothyroxine. Yes, this is an issue that has been in discussion for a number of years. And I have to tell you that most publications, or at least two major publications that I know that have been published in JAMA, show that it is totally possible for patients to switch from one brand to the other, from one generic to the other, because they are all equivalent. I know there are anecdotal reports by patients saying that they don’t feel well once they change, that might be because of the filler or the excipient that contain, [that] different formulations have. But as far as the hormones in the blood, the TSH, and as far, if you look at those, those drugs are interchangeable. So, and I, you know, this is, you cannot control that. That’s beyond our control. We did recently a study in which we saw that about 40% of the prescriptions are switched at the pharmacy level within the first year that patients started taking levothyroxine. If you go to the next second year, the number is even higher. So the exchange happens no matter what because pharmacists are allowed to do that. Joe 43:29-43:55 Now, for somebody who panics and they say, well, what will I do? They could ask their family physician or their endocrinologist to prescribe the synthetic versions. How different is it likely to be clinically if someone were to receive both levothyroxine and liothyronine? Dr. Antonio Bianco 43:56-43:56 Right. Joe 43:56-44:05 Two synthetic [hormones], the brand name, by the way, is Cytomel for that liothyronine T3. Just give us a clinical overview. Dr. Antonio Bianco 44:06-45:42 Yeah. I mean, I think that from a clinical point of view, that would essentially be the best alternative available. The physician will, obviously, it’s not going to be a primary care physician because they will have to refer these patients to the endocrinologist. I don’t think primary care physicians or family physicians will feel comfortable prescribing a combination of levothyroxine and liothyronine. So endocrinologists will be swamped with 1.5 million patients in this country that will be switching to synthetic combination of T4 and T3. Now, this is totally feasible, and I think it’s going to resolve most of the problems if that’s the route. However, two drugs requires two copayments in most cases, and it requires taking two tablets. And some patients, they say that they don’t do well with synthetic levothyroxine. So they just prefer the natural thing. They will tell you, my body does not accept the synthetic levothyroxine. Although I don’t see a scientific reason for that to be the case, the patients are adamant and they really feel the difference. So I’ve been wrong in the past, and I’d rather listen to what the patients are telling me and how they feel about it. And I would rather maintain them on the desiccated thyroid extract if that is the case. Terry 45:43-46:18 Well, we know that there are a lot of patients who would prefer that route as well. I don’t know if this has any relevance for how people might feel, but I know that some versions of levothyroxine– Synthroid, for example– does contain lactose as a filler. And if people were extremely lactose sensitive, it’s a small amount, so they’d have to be very extra lactose sensitive, that might be a problem for them. Dr. Antonio Bianco, thank you so much for talking with us on The People’s Pharmacy today. Dr. Antonio Bianco 46:18-46:21 That was my pleasure. Thank you very much for having me back. Terry 46:22-46:43 You’ve been listening to Dr. Antonio Bianco, Senior Vice President of Health Affairs, Chief Research Officer, and Dean of the John Sealy School of Medicine at the University of Texas Medical Branch at Galveston. His book is “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Joe 46:44-47:05 We turn now to patient advocate Mary Shoman to get some perspective from people who rely on natural desiccated thyroid for their treatment. She’s the author of The Thyroid Diet and 10 other books and a Paloma Health Advisor. You can find her newsletter Sticking Out Our Necks: Hormonal Health News, on Substack. Terry 47:06-47:09 Welcome back to the People’s Pharmacy, Mary Shoman. Mary Shomon 47:10-47:12 Thank you so much. I’m so excited to be here. Joe 47:13-48:02 Mary, we’ve just had an opportunity to talk with Dr. Antonio Bianco, and he shares with us that many of his colleagues who he has talked to, endocrinologists, are concerned about the Food and Drug Administration’s decision to, in a sense, eliminate the DTE, the desiccated thyroid extract, which is kind of shocking, I think, to a lot of us. So both the endocrinology community and, I suspect, patients are kind of worried. What are you hearing from your colleagues, your patients, the people who have been following you for many years? Mary Shomon 48:03-50:04 I am hearing a lot of confusion. As Dr. Bianco has said, there just is not enough information and that there is no real clarity coming out of the FDA and the Department of Health and Human Services. So it feels a little bit like a roller coaster for patients and for their providers, because we are in a situation where we have probably at least a million or more thyroid patients who rely on natural desiccated thyroid or DTE in order to treat their hypothyroidism. Yet the FDA, which we thought was giving us till the end of the decade to get this NDT, DTE situation sorted out, has now narrowed the timeframe, declared this drug to be a biologic after a hundred and some years on the market and has basically left us wondering, are they going to pull it off the market with no approved alternatives for us, which would force patients either to go without medication or to take medication that for many of us, we have taken in the past and it has failed us. It has not worked for us to serve as a thyroid hormone replacement. So it’s confusion on the part of the patients, the doctors and practitioners that prescribed for these patients are confused because they don’t know what to do to protect their patients’ continuity of treatment. And then we get mixed messages coming out of the FDA. You’ve got some of them saying, oh, we’re getting rid of it. We hate it. Dr. Tidwell apparently just can’t stand this, and he has made it very clear. Then we’ve got Dr. Makary, and we have Robert F. Kennedy, the secretary, saying, ‘Oh, no, we’re going to save it. We’re going to keep it. We’re going to make sure it’s available.’ What’s the actual plan? Right now, we think it’s going off the market in about a year, and that’s what we know. And that is a frightening concept for most thyroid patients who rely on it. Terry 50:05-50:21 Mary, I would like to just have you clarify for people who are listening and might not be aware of the abbreviations that we’ve been using, NDT and DTE, they’re really the same thing. Would you explain what those abbreviations mean? Mary Shomon 50:21-51:18 Sure. NDT is the abbreviation for natural desiccated thyroid, and DTE is desiccated thyroid extract. They’re basically synonymous or equivalent, and they are referring to a form of thyroid hormone replacement that comes currently from porcine or pig thyroid glands that have been prepared and dried and created into a thyroid hormone replacement that contains both T4 and T3, the two primary thyroid hormones that are needed to replace missing thyroid hormone in the body. They are different from the prevailing or most popular thyroid drug, which is levothyroxine, which is a synthetic form of only the T4 hormone, whereas the NDT or DTE contains both T4 and T3, but it’s coming from natural sources rather than synthesized. Joe 51:19-51:33 And it’s my understanding, Mary, that if the FDA follows through on its plan, the natural or desiccated thyroid extract will disappear from the market August of 2026. Is that right? Mary Shomon 51:34-52:38 Well, this is at least what the official statements have said. But we have posts on X, formerly Twitter, that suggest otherwise, that, oh, we’re going to ensure that patients still have access to their medication. But that has not been formalized with any releases or official guidance or official policy decisions that have come out from the FDA. So that’s all basically just a promise on social media, but nothing more. Currently, I’m operating as if the policies that are issued by the FDA are the ones that are going to be honored, in which case we’re looking at NDT going off the market sometime next year, probably late summer, as you said. Unless someone miraculously is able to get through the very onerous and expensive and time-consuming process of a biologic license approval to get the NDT approved as a biologic drug, which is what they are requiring for this drug to be able to be sold on the market and prescribed by doctors in the United States. Terry 52:40-52:47 You’re listening to Mary Shoman, patient advocate and author of numerous books about thyroid disease. You can find her newsletter on Substack. Joe 52:47-52:54 After the break, we’ll learn more about Mary Shoman’s 30 years as a patient advocate and her experience with Hashimoto’s disease. Terry 52:54-53:01 Dr. Bianco said that people on levothyroxine alone don’t do as well as those on DTE in controlling their cholesterol. Joe 53:02-53:07 Why hasn’t the endocrinology community taken that discrepancy more seriously? Terry 53:07-53:12 We’ll find out what steps Mary Shoman is taking to advocate for all thyroid patients. Joe 53:12-53:16 What about importing DTE from Canada? Is that feasible? Terry 53:26-53:29 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 53:38-53:41 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 53:41-53:58 And I’m Terry Graedon. Joe 53:59-54:13 Many people who have done well on natural desiccated thyroid extract are worried that the FDA is planning to eliminate these products. Most have already tried synthetic levothyroxine with limited success. Terry 54:14-54:17 What will they do if the FDA’s ban goes into effect? Joe 54:18-54:34 Our guest is Mary Shoman. She’s a patient advocate and the author of “The Thyroid Diet” and 10 other books. Mary is a Paloma Health Advisor. You can find her newsletter, Sticking Out Our Necks: Hormonal Health News, on Substack. Terry 54:35-55:08 Mary Shomon, you are widely recognized as an advocate for people with thyroid problems, especially hypothyroidism. Part of that is because you yourself have had a long-term personal experience with Hashimoto’s disease, which leads, can lead to hypothyroidism. Would you recap for us briefly, please, some of the milestones of your 30-year journey with Hashimoto’s? Mary Shomon 55:09-58:04 Absolutely. When I was first diagnosed with hypothyroidism and Hashimoto’s, it was really not very well known to me. I was in the process of getting married. I was engaged. I kept going for dress fittings. And every time I went for a fitting, instead of taking the dress in, as they often do, because brides are always eager to lose weight, they had to keep letting my dress out, which was unusual because I had always had a normal metabolism. I was fairly slender, I felt great, and all of a sudden, my dress is getting let out and I’m tired and I’m feeling kind of blue and depressed, which is not the norm for a bride to be. So I went to my doctor and I told her what was going on. And luckily, I had a very good integrative physician who immediately decided to go ahead and check my thyroid. And it came back that I was slightly hypothyroid and had slightly elevated thyroid antibodies. And so she said, we’ll put you on some medication. And I thought, OK, great. This is going to solve the problem because I really didn’t know anything about thyroid disease. She put me on the meds and things didn’t get better. I kept gaining weight, I was more depressed, my hair started falling out, I was tired and brain fogged and all of the symptoms that are characteristically associated with hypothyroidism. And I eventually went back to her. We worked on this multiple times and really got to a place where we were able to start changing around, switching over. I started out by taking a T4, T3 combination drug that is not on the market at present called Thyrolar. That was a synthetic combo of the two hormones. Then we switched over to natural thyroid. And at that time I was taking Armour Thyroid and I started to feel better. I also started to learn more, which back in those days, this is the very earliest days of the internet, was an adventure. There was not a lot of attention paid to thyroid. And doctors often said, oh, it’s easy to diagnose, easy to treat. Just take one pill every day. Don’t worry about it. Well, I discovered after talking with other thyroid patients and connecting and forming community with them. Not the case. A lot of people still were struggling. And that was really the beginning of my journey into patient advocacy and writing books and articles and providing information and creating support groups and other components to really help empower thyroid patients to develop their own information, empowerment, and to seek out and work with the physicians who really understood hypothyroidism. So it’s been a 30-year journey, and I’m still on it and still working to advocate for myself and helping others stay well because that’s really the goal is we want to feel well, we want to live well. Joe 58:04-59:56 And you have done an extraordinary job educating not just patients, but also I think a lot of healthcare professionals. One of the things that Dr. Bianco shared with us just blew my mind, just to be honest with you. I was like, oh my goodness, that’s extraordinary. He looked at this gigantic database that he has, and apparently he and his colleagues have just published this data a couple of months back. And it showed that people who are on standard levothyroxine, Synthroid and other products, they don’t do as well as the, I think, endocrinology community thought they were doing in terms of things like mortality, in things like dementia. I mean, so, you know, the stuff that people really care about, these patients weren’t doing as well, even though their thyroid levels seem to be, quote unquote, in the normal range. And Dr. Bianco then compared the outcome of these patients over a long period of time with people who were on desiccated thyroid extract, natural thyroid. And those people did better. They did better than the people on synthetic thyroid in terms of longevity, in terms of brain fog, in terms of just cholesterol levels in the liver. And when I got done listening to him, I thought, wow, why hasn’t the endocrinology community recognized that there are long-term consequences in terms of general mortality rates and how people are feeling? And why hasn’t the FDA recognized what Dr. Bianco has discovered? Mary Shomon 59:58-01:03:02 It’s a good question. And I have to say, I have the most incredible respect for Dr. Bianco because he has been out there for decades, really thinking outside the box from the endocrinologist standpoint, because endocrinologists tend to be fairly hidebound. They stick with what they know. They’re slow to change. They’re slow to move into new ways of thinking. I mean, think about how it’s taken decades for the medical establishment to accept that blood sugar levels over 100 are problematic and that we need to watch those because people are on the way to potential type 2 diabetes. It used to be unless your blood sugar was over a certain level, you were fine. Now we know there are gradations on the way to blood sugar problems. And I think it’s the same thing for thyroid. We are just now starting to see the endocrinology community accept that there is a subset of patients who absolutely need the two hormones rather than just the T4 hormone. The understanding was always, oh, patients get T4, their body converts it to T3. Everything’s great. We’re copacetic. Now we do know that there are problems with genetic changes. There are incapacity to convert T4 into T3 that’s built in genetically in some people. And they’re just now starting to say, okay, well, that makes sense. It’s not just a patient preference issue. Well, they’re going to be moving slowly in this direction towards understanding that the T4-T3 combination therapy may in fact be better for the majority of patients. But that said, my philosophy for 30 years has been the best thyroid medication or best thyroid hormone replacement for you is the one that works best and safely for you. And having been in touch with thousands and thousands of patients over the years, I can tell you that there is a patient for every possible permutation and combination where that has been the best choice for them. For some, synthetic is perfect. For others, they need a particular brand of whatever drug they’re taking. Others do better on combinations. Some people need compounded mixtures. Some people like the T4 and T3. Others do well with T4. And we have a small subset that do better with just T3. So safest and best relief of symptoms for you is ultimately the best option for patients. And the key for me is making sure that the medical world makes those options available to us and doesn’t take away options that we may need, at least a subset of us, me included, because I’m a desiccated thyroid patient. I use desiccated thyroid for my hormone replacement. Don’t take away options that work for me and for other thyroid patients. Make sure we have options and let us know what the different pros and cons are of the different options. Terry 01:03:04-01:03:18 Mary, I wonder if you can tell us what you are doing as an activist to see if this action of the FDA, this proposed action, it can be counteracted. Mary Shomon 01:03:19-01:05:17 Well, I have been talking with several of the drug manufacturers, number one, because they are all obviously quite interested in trying to, in some cases, they’re applying for their BLAs, but the biologic license applications for their formulations of natural desiccated thyroid. But that is going to be a lengthy process. Some of them are already in progress, but it’s probably not going to come early enough if the FDA does in fact pull the medication off the market in a few months into the summer of 2026. But what we’re doing is I’m talking with the manufacturers, we’re talking with the patient organizations, other patient advocates, and we’ve got patients reaching out to their representatives, to the FDA itself, writing in, making complaints, talking about and sharing their stories. Because there are patients who have done every possible trial in the world on all of the different options, and natural desiccated thyroid is the only thing that has worked for them. And I’m an advisor with Paloma Health, which is a large medical practice that focuses on hypothyroidism, and our team of doctors have also been reaching out to explain situations, obviously without violating patient confidentiality, but saying, look, I have patients that will not survive if you take natural desiccated thyroid off the market because we’ve tried them on synthetics. We’ve tried them on every option and it doesn’t work for them. So I need this as an available option for some of my patients that rely on it for their very survival. Because for those of us who are hypothyroid, thyroid medication is not an option. We have to have it in order to function for our body to function, all of our organs, tissues, glands, and cells. Terry 01:05:17-01:05:39 Mary, I wonder if you could tell us a story about one or two of those people who are going to be just completely in terrible trouble if the FDA completes its action as proposed and the companies don’t yet have their biologic license in place. Mary Shomon 01:05:40-01:07:32 Absolutely. I’m thinking of one patient that I know who’s also a friend of mine, and she’s in her early 70s. She’s a widow, and she has tried every possible thyroid medication. She got no response taking synthetics. The doctors haven’t really ever figured out why her body would not absorb them. We’re not sure if it was a malabsorption or ingredient allergy or sensitivity. But once she started taking natural thyroid, which was more than 10 years ago, she was able to get her thyroid levels under control. The blood tests showed that the thyroid hormone was getting into her system, which it had not been doing on the Synthroid. It helped relieve depression, fatigue, exhaustion, brain fog, muscle pain, and weakness. And she basically said to me, if they take my natural thyroid away, I think I’m just going to let myself die. She’s that depressed about the concept of having her medication taken away. And I don’t blame her because it took her a long time. She went probably a decade or more trying to find something that worked and was dragging herself along, trying to function on a daily basis, barely. Once she got the natural thyroid, it felt like her life had come back. And she’s like, don’t take my life away from me again. So she’s one of the people I know who has been most active. I think she has called every member of Congress, every one of her representatives multiple times. She’s talked with them multiple times. She has sent letters to everyone at the FDA. She is a one-woman advocacy campaign unto herself because it’s so important to her. It is her life. And so I think she’s a good example of how passionate patients can be when we know that this is something we rely on. We cannot function without it. Joe 01:07:33-01:08:09 Mary, I wonder if you would be kind enough to just run through some of the very confusing numbers that people need to know about when it comes to assessing their thyroid function, because a lot of times they get a lab report. It’s confusing to them. Their doctor may not explain it. So what would you consider, based on all of your research and experience, normal or achievable goals for people who are using a natural thyroid, desiccated thyroid extract so that they feel well? Mary Shomon 01:08:10-01:11:32 Well, typically, we want to look at, I think, four numbers. Most of the physicians that I have worked with over the last 35 years that are really knowledgeable about thyroid will focus in on four particular parameters. They’re going to look at the TSH, which is thyroid stimulating hormone. This is a brain hormone, not a thyroid hormone, but it is a messenger to the thyroid gland telling it to make more or less hormone. We’re going to look really carefully at the free T4 and the free T3. That’s free thyroxine and free triiodothyronine. And there we’re looking at the actual available circulating amounts of thyroid hormone going through the bloodstream. And in many cases, because Hashimoto’s autoimmune thyroiditis is the primary cause of hypothyroidism in the United States, we’re going to look at Hashimoto’s antibodies or thyroid peroxidase antibody levels. And so that set of four tests is really the basics. And for most people that are dealing with autoimmune Hashimoto’s or hypothyroidism, that’s going to cover most of the bases. We’re looking for a TSH that is going to be in the reference range. And the reference range, depending on the lab, typically runs from about 0.3 to 4 or 4.5, but with the understanding that the majority of the population is not walking around with a TSH at the high end of that range. Most people feel best when it’s under 2.5 or under 2. The free T4 and the free T3, those are usually, we want to see those levels in the middle point or maybe a little bit higher of the reference range. But the free T4 can sometimes be a little bit lower in some people, the free T3 a little bit higher when they’re taking a natural desiccated thyroid because it does contain some extra T3 in it. So that helps to bump those T3 levels up a little bit. And then the thyroid peroxidase antibodies or TPO antibodies, we typically are looking for those ideally to be in the reference range, which means there’s no active autoimmune disease, or if they’re elevated, we want to be watching them so that any dietary medication, thyroid treatment, lifestyle changes are bringing them down slowly and to a lower level. I think the cutoff, it depends on the lab, but cutoff is like 32, 35. Anything above that is considered active evidence of thyroid antibodies. But as they creep up towards that cutoff point, that can sometimes be the indications that autoimmune activity is already starting to take place. So there’s this concept of the reference range or the normal range, but what most of the really savvy practitioners are using is what they consider the optimal range. So that would be the lower end of the reference range for TSH and the midpoint to the upper end of the range for the free T4 and free T3. And again, with antibodies, getting them down as low as possible. Joe 01:11:32-01:11:41 And what would those free T3, free T4 levels be in general to be on the optimal side? Mary Shomon 01:11:42-01:13:03 Well, it depends on the lab that you go to, but let’s see. I believe that free T4, if I’m remembering correctly, runs about 0.8 to like 2.2 at many range. That’s many labs have a range of that. And we’d like to see that like at about the midpoint there. But typically with people taking natural desiccated thyroid, you would see levels maybe in the 1.2, 1.3 level. And with the free T3 levels, typically there we, I believe they run from like 2.2 to 4.3, give or take, depending on the lab. And there, a lot of people are walking around with 2.4, 2.5. They’re at the very low end of the range and they don’t feel well. The people that feel the best tend to be 3.2, 3.3, 3.4, up in the upper half of the reference range, up to maybe about the 75th percentile. Too high of free T3, and you can start to feel like you’ve had too many espressos, and you can get jittery, you can feel nervous, your heart rate can go up, which is a sign that maybe there’s too much T3 on board. So we want people to be at a place where their T3 is good, but not that they’re getting over-medicated to a point where they’re feeling overstimulated. Joe 01:13:04-01:13:14 And just to remind people, what are some of the most common symptoms of hypothyroidism, the people that you serve most frequently? Mary Shomon 01:13:15-01:15:28 The most common symptoms are fatigue. And when we say fatigue, we’re not talking about, oh, I’ve had a busy day. I’m a little bit tired. We’re talking about having to go sleep in your car for 30 minutes at lunchtime to get through the rest of the day or having to have a nap when you come home because you can’t get up to make dinner. Uh, we’re talking about people that sleep 15 hours on the Saturdays, uh, mornings in order to get back to some level of energy after a busy week. This is bone numbing fatigue for many people. Uh, we also see brain fog, cognitive changes, difficulty remembering things, wondering, oh my gosh, do I have Alzheimer? Why am I having so much trouble remembering a particular word or a particular thing? People often see some weight gain, especially if there’s no change to diet and exercise like I did when I was first diagnosed. Just no change, but all of a sudden gaining weight. People will also have dry skin. They can lose hair. They can often lose, one of the most characteristic signs is the outer edge of the eyebrows will disappear, and they’ll have to be penciling it in. I always say to women, if you’re penciling in your eyebrows, I want you to get your thyroid checked. Dry skin, constipation, feeling depressed, sometimes anxiety. People can have a lot of, their nails can break. Their nails become brittle, dry. They don’t grow, they break. And this is just the tip of the iceberg. There are dozens and dozens of other signs and symptoms. For younger women, we can see fertility issues, menstrual changes. For women going into perimenopause, we can see issues with worsening perimenopausal symptoms. There’s a whole range of different types of symptoms. For men, we can see low libido and women too, but low libido is often a complaint in men along with hair loss. So there’s a whole range. It’s essentially anything that slows down your thinking, your processing, your organs, tissues, glands, and cells can be a symptom of hypothyroidism because [the thyroid hormone] is helping to provide energy to all of those components of your physiology. Joe 01:15:28-01:15:49 I’m wondering, Mary, if people will be able to access natural thyroid from Canada once the ban goes into effect. A lot of people do buy their medications from Canada online, and the FDA hasn’t prevented that. But in this case, what are you hearing? Mary Shomon 01:15:51-01:18:23 Well, what I’m hearing is that there is a lot of confusion about it, but that because in the past, it was that the Canadian drugs were allowed to come in, the Canadian natural thyroid was allowed to be imported for personal use. I believe that is the language that the cross-border medication issue was you can’t bring in giant volumes and truckloads of it, but you can bring in enough for your personal use and you can get it in Canada with a prescription. But now that it is going to be designated as a biologic, unapproved, non-approved natural desiccated thyroid will technically be illegal. And so I’ve heard that there may be a crackdown on trying to import Canadian or potentially natural thyroid from other countries that might potentially try to fill the gap. So it’s really up in the air. And that’s part of the big problem with this entire issue is what are they going to do? Are they going to enforce it in 2026? Are they going to let it slide? Are they going to keep us from importing meds from outside or from Canada? Or are they going to crack down and say, no, nope, or maybe say, yeah, we’ll let you do it until things change. It’s really a question mark. And the question mark also goes into the motivations of the government, because we know that we have a new HHS secretary that’s focused on more natural approaches to things, a little bit of a battle with the drug companies to some extent that we’re seeing between the FDA and the HHS and the pharma industry. And so I’ve heard some patients say, I don’t understand this. I thought they would like a natural, inexpensive drug that seems to work pretty well for us for over 100 years. Now they’re putting it in for this biologic status. And frankly, that’s one of the other concerns I have is how much is it going to cost? Because biologic drugs in general are extremely expensive. These are the ones we see advertised on TV all the time. The Humira and Stellara and all these drugs that sometimes can cost thousands of dollars a month. How much is natural desiccated thyroid, which most of us can get for $30, $40, $50 a month, how much is it going to cost once it’s gone through this big approval and becomes a biologic drug? Who knows? It could be many times the price that we’re paying now, or potentially it may be priced out to a point where it’s unaffordable for most people. Joe 1:18:23-1:18:23 Right. Terry 01:18:24-01:18:32 Mary Shoman, thank you so much for talking with us on The People’s Pharmacy today and for leading the charge. Mary Shomon 01:18:32-01:18:40 Thank you so much and appreciate getting the word out because patients need to be informed in order to feel well and live well. Terry 01:18:41-01:18:56 You’ve been listening to patient advocate Mary Shoman. She’s the author of “The Thyroid Diet” and 10 other books. She’s also a Paloma Health Advisor. You can find her newsletter: Sticking Out Our Necks: Hormonal Health News on Substack. Joe 01:18:56-01:19:16 We spoke earlier with Dr. Antonio Bianco, Senior Vice President of Health Affairs and Dean of the John Sealy School of Medicine at the University of Texas Medical Branch at Galveston. He’s the author of “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Terry 01:19:16-01:19:25 Lyn Siegel produced today’s show, Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 01:19:26-01:19:33 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Terry 01:19:33-01:19:51 Today’s show is number 1,452. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You could also reach us through email, radio at peoplespharmacy.com. Joe 01:19:52-01:20:09 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. The podcast this week has additional information we couldn’t squeeze into the broadcast with updates on Dr. Bianco’s latest research showing that people on natural thyroid live longer. Terry 01:20:10-01:20:33 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 get regular access to information about our weekly podcast. We’d be grateful if you would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you use. Joe 01:20:34-01:20:36 In Durham, North Carolina, I’m Joe Graedon. Terry 01:20:36-01:21:12 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 01:21:12-01:21:22 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 01:21:22-01:21:27 All you have to do is go to peoplespharmacy.com/donate. Joe 01:21:27-01:21:40 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.

Transcribed - Published: 14 November 2025

For decades, neurologists and pharmaceutical firms have been focused on amyloid plaque building up in the brains as the cause of Alzheimer disease. Drug companies have developed compounds to remove that plaque, and they have been successful. There are medicines, notably lecanemab and donanemab, that reduce the amount of amyloid plaque visible on a scan. They may also slow the rate of cognitive decline somewhat.  But they may not make a substantial difference in problems patients and their families care most about–confusion, memory loss, difficulty making decisions. Is it time for us to start rethinking dementia? 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, Nov. 8, 2025, 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 November 10, 2025. How Should We Be Rethinking Dementia? America is aging. Baby boomers, who make up a disproportionately large segment of the population, will soon be turning 80. That could be bad news as we imagine an enormous number of people disabled by dementia. There is a silver lining to that cloud, though. Compared to individuals born in the 1920s and 1930s, those born in the 1940s and 1950s have a lower risk overall of Alzheimer disease and other types of dementia (JAMA, May 13, 2025). Are there steps we can all take to reduce our risk of dementia even further? The Disappointing Results of Plaque-Removing Drugs: As we mentioned above, the FDA approved lecanemab (Leqembi) and donanemab (Kisunla) to treat Alzheimer disease (AD) because they reduce plaque in the brain. Family members may have had high hopes, but the only impact these drugs have on cognition is a slight slowing of the inexorable decline. They are, moreover, quite pricey and the scans to monitor potentially serious side effects are also expensive. Some people on these meds experience brain swelling or hemorrhage. Over the long term, they may be associated with whole brain shrinkage, although they seem to spare the hippocampus, known as the memory center. None of those reactions is desirable What Else Can We Do to Reduce Our Risk of AD? One approach we might consider as we start rethinking dementia is low-dose lithium. Lithium has long been used to treat bipolar disorder, but the doses used are large and can trigger adverse consequences, especially for kidney function. New research has shown that people with mild cognitive impairment, a possible precursor to AD, have low levels of lithium in their brains (Nature, Sep. 2025).  Studies in mice show that low lithium levels seem to lead to amyloid plaque and tau accumulation. These are signatures of Alzheimer disease. Can we prevent or reverse this with low-dose lithium, using a nontoxic formulation? That remains to be tested in a randomized clinical trial. Dr. Doraiswamy emphasizes that no one should be taking lithium, even at low doses, outside the context of a controlled study. Don’t try this at home. Rethinking Dementia May Mean Vaccines: An impressive body of epidemiological evidence links vaccination against influenza or shingles to a reduced risk for dementia. A natural experiment in Wales (Nature, May 2025) and another in Australia (JAMA, June 17, 2025) have confirmed the causal connection. Vaccination against shingles significantly reduces the chance of developing AD later. However, results from a trial of an antiviral medication were presented at a recent conference. Unfortunately, the medicine was not effective in preventing AD. Consequently, this strategy may not be as promising as we would like. People who get multiple vaccinations against the flu get a measure of protection from dementia, however (Age and Ageing, July 1, 2025). Another natural experiment in East and West Germany demonstrated that the BCG vaccine against tuberculosis unexpectedly led to “lower incidence of lymphomas and acute lymphoblastic leukemia in cohorts immunized by BCG compared to those non-immunized by this vaccine” (Frontiers in Pediatrics, July 31, 2025). There is also tantalizing evidence that people treated with BCG for bladder cancer are less likely to develop AD (PLoS One, Nov. 7, 2019). What Is Amyloid Plaque Doing in the Brain? Right from the start in 1906, when Dr. Alois Alzheimer described the condition, he flagged amyloid plaque in the brain as a distinctive feature. No wonder people thought of it as the cause of the disease. More recently, though, scientists have been rethinking dementia. They have found that beta amyloid has antimicrobial activity. Might the buildup of plaque indicate an infectious process? We still don’t know for sure, but it seems possible. Rethinking Dementia and Diet: Until now, scientists studying AD have paid very little attention to specific components of diet. They did not have much evidence that what we eat affects our risk for cognitive decline. There have been only a few large randomized clinical trials of diet. A recent trial of the MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay [MIND] diet) was disappointing. So far, none has lasted long enough to tell whether dietary changes in midlife might help prevent dementia. That said, Dr. Doraiswamy suggests that the Mediterranean diet has some supporting evidence. After all, what is good for the heart is also good for the brain. Physical Activity and the Risk of Dementia: There is some evidence that aerobic exercise can help reduce your chance of an AD diagnosis. Recent research shows that people who consistently rack up 5,000 to 7,500 steps a day are much less likely to develop dementia than those who are sedentary (Nature Medicine, Nov. 3, 2025). Likewise, those who habitually walk at least 15 minutes at a time during the day appear to be somewhat protected from cognitive decline. These results are from observational studies, however. Randomized clinical trials of movement to reduce the chance of dementia have not found benefits for memory. Executive function may improve, though. Dr. Doraiswamy cautions, in addition, that we should avoid sports that increase the risk for concussion or head trauma such as boxing, mixed martial arts, football or even soccer. He generally recommends walking for seniors because it offers aerobic physical activity with minimal risk of head injury. In fact, he suggests a walking book club would be ideal. Not only do you get the body in motion, you engage the brain and practice social connection. All of these can be helpful in keeping our brains in shape. Dr. Doraiswamy’s research shows solving crossword puzzles can improve their cognitive function over the course of more than a year (International Journal of Clinical Trials, April-June 2025). This could be an enjoyable approach to rethinking dementia and its prevention. Are There Drugs We Should Avoid? Certain medications work by interfering with acetylcholine, a crucial neurochemical. Such anticholinergic drugs, such as many urologists prescribe to treat overactive bladder, can impair cognition. One extremely common and potent anticholinergic is readily available without a prescription. Millions of seniors take it every night in the form of Tylenol PM, Advil PM or some other PM pain reliever. Diphenhydramine (Benadryl) makes people feel sleepy, so people often swallow it thinking that getting a good night’s sleep will help them stay sharp. Everyone concerned about preventing dementia should check with prescribers and pharmacists about all the drugs they take, including OTC pills. Reducing the anticholinergic burden is an important step toward protecting the brain. This Week’s Guest: Murali Doraiswamy, MBBS, FRCP, is Professor of Psychiatry and Behavioral Sciences. He is Director of the Neurocognitive Disorders Program in the Department of Psychiatry  and a Professor in Medicine at Duke University Medical School. He is a faculty network member of the Duke Institute for Brain Sciences. P. Murali Doraiswamy, MBBS, FRCP, Duke University Listen to the Podcast: The podcast of this program will be available Monday, Nov. 10, 2025, after broadcast on Nov. 8. 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 1451: 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. The CDC says nearly 7 million people in the U.S. currently have Alzheimer’s disease. How can we prevent it? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:44 Medications the FDA approved in the last few years have been disappointing. They are pricey, risky, and not very effective against Alzheimer’s disease. Joe 00:45-00:52 What else can we do to lower our chances of developing dementia? How could low-dose lithium be helpful? Terry 00:53-01:02 Could a vaccine against shingles help delay cognitive decline? What about diet and exercise? How many steps do we need every day to keep our brains healthy? Joe 01:03-01:10 Coming up on The People’s Pharmacy, Rethinking dementia: Is what we believe all wrong? Terry 01:14-02:42 In The People’s Pharmacy health headlines, scientists have long suspected that physical activity might help reduce the risk for dementia. Now they have proof, and it doesn’t take that much effort. A study published in Nature Medicine followed nearly 300 older Americans for almost 14 years. None of them had measurable cognitive problems at the start of the study. They wore pedometers to measure the number of steps they took. All the participants took tests to assess their problem-solving skills and memory at several points during the study. The researchers also scanned their brains to evaluate their levels of amyloid and tau. Over the course of the study, people who took at least 5,000 steps a day were significantly less likely than sedentary seniors to develop Alzheimer’s disease. People with relatively high levels of amyloid at the outset benefited most, but not because amyloid levels changed. Instead, more active people had significantly less tau accumulation, accounting for the benefits seen. Aiming for 5,000 to 7,500 steps daily is something most older people can manage to reduce their chance of cognitive and functional decline. According to the researchers, that level of activity slowed cognitive decline by the equivalent of seven years. Joe 02:43-03:33 Exercise may also 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 over 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. Terry 03:34-04:23 Many people take melatonin as a supplement to help them sleep. This hormone, which is available without a prescription, has been widely seen as innocuous, even if it doesn’t ward off insomnia. Now researchers are taking a new look at the supplement. An analysis of health records from several different countries identified some 65,000 people taking melatonin for at least a year. In a span of five years, 3,000 melatonin users were diagnosed with heart failure. That comes to about 4.6%, compared to 2.7% of non-users. The findings have been presented at the American Heart Association scientific sessions and have not been published in a peer-reviewed journal. Joe 04:24-05:09 Treating diabetes with a GLP-1 agonist seems to protect the heart. Previous research has found benefit with the use of injectable semaglutide sold under the brand names Ozempic and Wegovy. A new study demonstrates that the same semaglutide in pill form sold under the brand name Rybelsus also prevents cardiovascular complications. A sub-analysis of the SELECT trial found that the benefits of semaglutide do not depend upon weight loss. Even people who did not lose significant weight had lower risks of heart attacks and strokes. A decrease in weight size, however, was associated with the protective cardiovascular effect. Terry 05:10-06:17 Researchers have been considering how to keep people with prediabetes from developing the full-blown metabolic disorder. In a new study published in JAMA, investigators assigned over 300 participants to either an artificial intelligence-powered diabetes prevention program or a human-coach-led similar prevention program. The AI-powered invention involved a mobile app and a Bluetooth-powered digital scale. The goal was to get the volunteers to HbA1c below 6.5%. Roughly 32% of the participants in each group achieved the goal. The researchers concluded no significant difference between the two programs. 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. As America ages, people worry about their health. Of course, they think of heart disease and cancer, the two biggest killers, but many people are even more afraid of dementia. Terry 06:31-06:54 Today, we’re discussing how we can treat or possibly even prevent memory loss. What should we know about the drugs that FDA has recently approved to clear amyloid plaque out of our brains? Are there non-drug approaches that might reduce our risk for dementia in the first place? Is what we believed about Alzheimer’s wrong? Joe 06:54-07:23 Our guest today is an outstanding researcher in the field of cognitive decline. Dr. Murali Doraiswamy is professor of psychiatry and behavioral sciences. He’s the director of the Neurocognitive Disorders Program and a professor in medicine at Duke University Medical School. He’s a member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is a senior fellow of the Center for the Study of Aging and Human Development. Terry 07:24-07:28 Welcome back to The People’s Pharmacy, Dr. Murali Doraiswamy. Dr. Murali Doraiswamy 07:29-07:30 Thank you. Pleasure to be here always. Joe 07:31-08:01 Dr. Doraiswamy, I have to tell you, you are a specialist in the brain, especially neurocognitive disorders, whatever that means. But basically, you’re trying to figure out, A, what causes dementia and then what to do about it. But before we get into that really important subject, I would love to get your sense of how serious is this problem? It seems like America is getting older fast. Dr. Murali Doraiswamy 08:01-08:02 Absolutely. Joe 08:02-08:04 What does that mean for society? Dr. Murali Doraiswamy 08:05-08:57 Well, it’s not good news. As we get older, the risk for dementia disproportionately increases, so there’s fears of what we call a silver tsunami. So the original projections were that the number of cases of dementia, which is somewhere around 6 to 7 million today, might triple over the next 20, 25 years. But there’s a sliver of good news. We recently pointed out that there was an error in the projections. With consecutive birth cohorts, we’re getting healthier. Our cardiovascular risks are declining. Some of our risks for Alzheimer’s are also declining, but new risks may be emerging, such as obesity, diabetes, etc. But we believe the rate of increase over the next 20, 25 years is not going to be as high as feared, but it’s still going to go up. So we have to be very, very vigilant and invest in research. Terry 08:57-09:05 So it goes up in part just because there are so many more older people as the baby boomer moves into its 80s. Dr. Murali Doraiswamy 09:05-09:06 Correct. Terry 09:05-09:08 And later, even more. Dr. Murali Doraiswamy 09:08-09:09 Correct. Terry 09:09-09:16 But we baby boomers are not quite as likely as our parents or our grandparents were to develop dementia. Dr. Murali Doraiswamy 09:17-09:28 Absolutely. I think the risk for those born, like, say, in the 1920s or 30s was far higher than the risk for those born, say, 10, 20 years later for a variety of reasons. Joe 09:29-09:47 Now, Dr. Doraiswamy, the drug companies have seen a pot of gold. I mean, when you talk about 7, 10, 15 million Americans with this devastating condition called dementia, they go, well, let’s get some new drugs out there. Terry 09:48-09:49 We’re all for that, right? Joe 09:50-09:51 Absolutely. Dr. Murali Doraiswamy 09:51-09:52 100% We need it. Joe 09:51-10:09 We’re desperate, desperate for something that really, really works. They’ve been all in on amyloid: amyloid being the cause, and if we could just get amyloid out of the brain, problem solved. It hasn’t worked that way, has it? Dr. Murali Doraiswamy 10:09-10:31 It hasn’t, unfortunately. Probably about 30 to 40 failed trials. And for the first time, we have two drugs that were efficacious in clinical trials, but the degree of benefit is extremely small, and they come with a lot of risks. So we still haven’t achieved drugs that are highly efficacious and safe. Terry 10:31-10:38 So let’s talk a little bit more about these medications. They are effective at removing amyloid plaque from the brain, correct? Dr. Murali Doraiswamy 10:38-10:55 Correct. Very effective. Almost 70, 80, 90% clearance to the point where some people’s brains are free of amyloid. Technically, if you base it on the definition that you have to have amyloid to have Alzheimer’s, they would have essentially have been cured of Alzheimer’s pathologically, but nothing has improved in their cognition. Terry 10:56-11:00 So their brains are beautiful, but they’re still demented. Dr. Murali Doraiswamy 11:00-11:00 Correct. Terry 11:01-11:08 They still can’t do the things that ordinary people can and want to do. Dr. Murali Doraiswamy 11:08-11:35 Absolutely. So there are two ways of interpreting this. The skeptic would say this flatly disproves the amyloid hypothesis because if you cannot show that removing amyloid produces an improvement in cognition or slows the degeneration of the brain or slows the deterioration of cognition, then the hypothesis is wrong. But those who support the hypothesis say, oh, we’re giving these drugs too late. Had we given the drugs a lot earlier before the brain had been damaged, we might have seen a greater benefit. Terry 11:37-11:43 Now, there was a trial, wasn’t there, in which they gave, which one? Donanemab? Lecanemab? Joe 11:44-11:55 Well, it was one of the MABs, and they said, even before people really have symptoms, they’re just at potential risk, we’re going to start giving the drug early, early. Terry 11:56-11:57 And it was a big disappointment. Dr. Murali Doraiswamy 11:58-11:59 Yes, it was. Joe 12:00-12:14 So at the moment, let’s just say that the amyloid hypothesis hasn’t panned out the way we would have hoped if these drugs worked. What about side effects? Because the FDA has now issued some new cautions. Dr. Murali Doraiswamy 12:16-13:25 So the amyloid drugs have some very serious side effects. For the vast majority of people, fortunately, our tolerance levels are high. So they may just have infusion reactions. These drugs are given by infusion. We just reported a case that’s coming out this week on somebody who had severe urinary incontinence, almost permanent urinary incontinence as a result of one of these infusions. The most serious side effects are fortunately somewhat rare, even though we don’t know the exact rate at which they occur. The two most serious side effects are bleeding in the brain. They either take the form of what we call macrohemorrhages, means overt strokes, leading to serious clinical symptoms, or microhemorrhages, meaning small ditzels in the brain, which are areas of like ruptured blood vessels. We don’t exactly know what the consequences are. They may have cognitive symptoms, but in many of these people, they’re silent because we’re not testing them serially. And then the second type of side effect is called edema or swelling of the brain. And there have been several deaths. The FDA recently tightened the warnings because of six deaths. Terry 13:25-13:27 How did they tighten the warnings? Dr. Murali Doraiswamy 13:27-14:07 They require more frequent MRI scans to monitor the brain and at earlier time points to see if someone’s having these areas of small bleeding or edema. And if you spot those, then you’re supposed to either lower the dose, stop the dose temporarily till the person gets better. But the reality is we don’t know what to do. We don’t know when a bleed has totally gone away because the MRI only picks up like really, it’s a very crude indicator of if the brain has fully recovered from a bleed. And in many of these cases, probably the prudent thing to do is to stop their infusions and not treat them. We don’t have a good way of also predicting who is going to get it. That’s the other thing we’re shooting in the dark. Joe 14:07-14:27 These are pricey drugs. They cost twenty-some-thousand dollars, but the scans are also expensive. So these PET scans, which have to be done before you start treatment, and now the FDA is saying during treatment just to make sure something bad isn’t happening, the costs start to really add up. Dr. Murali Doraiswamy 14:27-14:44 Well, the costs definitely add up. Just to clarify, yes, the PET scans only need to be done before treatment to ensure that they have plaque buildup in the brain. The monitoring for bleeding is done using regular MRI scans. They’re not done using PET scans. Joe 14:44-14:45 But MRIs are not cheap. Dr. Murali Doraiswamy 14:45-14:51 They’re not cheap, and the average person has to have four, five, six MRI scans. That adds up quite dramatically. Joe 14:52-15:17 So let’s switch gears for a moment because clearly the anti-amyloid drugs have not been a revolution, and they do have side effects. There have been some new studies that are quite fascinating. And I know that you have been looking at lithium, not just for a few weeks or months or years, but going way back. Tell us what is lithium and why are you paying attention to this mineral? Dr. Murali Doraiswamy 15:18-16:40 Yeah. So, you know, lithium is absolutely fascinating. And, you know, America’s fascination with lithium goes back almost 80, 90 years, I think. So lithium, you know, for people who don’t know, is a metal, and it’s a very soft metal, like cheese that can be cut. It’s found in almost every body tissue. It’s found in rocks. It’s found in lots of water sources. Many of us are consuming large amounts of lithium without even knowing it. In fact, I just read an article that in Chile, South America, which is a very rich source of lithium batteries, everyone’s fighting for lithium batteries from there. The average person gets almost five or six times more lithium than, say, the average American. Almost at sub-therapeutic medical doses, that’s what that person in Chile is getting. So fascination with lithium started around 1940s when it was discovered that lithium can calm the brain and can be a useful treatment for people with manic depression, especially people who are very euphoric, very agitated, are hallucinating. It can calm them down. It was completely accidental discovery. And then America went crazy for lithium, and they started putting it in every soft drink imaginable. That’s how 7-Up came about, because one of the isotopes of lithium exists. 7-Lithium is the molecular isotope, and so 7-Up is lithiated lime soda. Joe 16:40-16:41 But no more. Dr. Murali Doraiswamy 16:42-16:57 No more. Well, yes, more, because every water contains lithium. So, yes, it just has very small amounts, but not the slightly bigger amounts that it used to contain. Coca-Cola used to have, there was a version of Coke that had lithium, and doctors used to prescribe it for all kinds of conditions. Joe 16:57-17:01 So, Coca-Cola had cocaine and lithium? Dr. Murali Doraiswamy 17:01-17:13 Well, okay, I don’t know about the, let’s skip the cocaine part. There was a version of cola with lithium marketed by that company. It was not called Coca-Cola, but it was a lithiated cola. Joe 17:15-17:32 So we’ve had a lot of experience. We just have about 30 seconds before we go to the break. There certainly is a lot of data to suggest that very high doses can be extremely helpful for people with manic depression, or what we now call bipolar disorder. Terry 17:32-17:33 But also toxic. Joe 17:34-17:55 Lots of side effects. And you can tell us more about those in a moment. Kidneys can be affected, a number of other organs. But low-dose lithium, that’s where all the excitement is right now. And when we come back from the break, let’s talk about the newest research. I think it was published in Nature, is that right? Dr. Murali Doraiswamy 17:55-17:56 Correct. Joe 17:56-18:00 Looking very promising, at least in an animal model. Terry 18:01-18:11 You’re listening to Dr. Murali Doraiswamy, Professor of Psychiatry and Director of the Neurocognitive Disorders Program at Duke University School of Medicine. Joe 18:11-18:19 After the break, we’ll learn more about lithium and its application against dementia. What are low doses of lithium compared to standard doses? Terry 18:20-18:24 We’ve just alluded to a study published in Nature. Why are people so excited about it? Joe 18:25-18:33 Is it a good idea for people to start taking low-dose lithium as a supplement, or do we need to wait for more definitive studies? Terry 18:39-18:55 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 18:55-19:12 And I’m Joe Graedon. Terry 19:12-19:27 Today, our topic is dementia. How can you reduce your risk of losing your memory? What can we do to keep our brains as healthy as possible as we age? Are there supplements that could be helpful or perhaps dietary choices? Joe 19:28-20:00 To learn more about preventing and treating Alzheimer’s disease and other dementias, we’re talking with Dr. Murali Doraiswamy. He’s professor of psychiatry and behavioral sciences. He’s director of the Neurocognitive Disorders Program and is a professor in medicine at Duke University School of Medicine. He’s a member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is a senior fellow of the Center for the Study of Aging and Human Development. Terry 20:01-20:13 Dr. Doraiswamy, we were just discussing lithium, and I’m hoping that you’ll be able to tell us about low-dose lithium and why it might be of interest against dementia. Dr. Murali Doraiswamy 20:14-20:44 Low-dose lithium has been of great interest to researchers because observational studies, what we call as epidemiological studies, have shown that people who live around certain water sources that contain naturally high levels of lithium have reduced rates of suicide, reduced rates of drug abuse, and even potentially reduced rates of dementia. So these suggest that it might have therapeutic effects at sub-threshold doses, not the high doses we use to treat bipolar depression. Joe 20:44-20:55 And let’s get some sense because as a psychiatrist, you are prescribing big doses. What do we mean when we say big for people who have bipolar disorder? Dr. Murali Doraiswamy 20:56-21:29 So, lihtium as lithium carbonate is usually given two or three times a day. So, we might give somebody 900 milligrams, 1,200 milligrams a day. So, a lower dose may be something a fifth of that or even lower. One of the problems has been that these forms of lithium that we use to treat psychiatric illness don’t get into the body and the brain. They’re not as bioabsorbable. So we needed different formulations of lithium that are more easily absorbed at lower doses so that they also don’t produce the same side effects. Joe 21:29-21:36 So tell us about this study in Nature and why people have gotten very excited. Dr. Murali Doraiswamy 21:36-22:43 So we’ve known about the links between metals in the brain and dementia for a long time, right? We originally thought it came from pots and pans. And then in the 90s, there were links between iron, copper, zinc, and Alzheimer’s disease. But more recently, there’s been a lot of excitement about lithium being an essential nutrient in the brain. And these researchers, it was a tour de force, their paper in Nature. They first showed that deficiency of lithium resulted in buildup of Alzheimer type pathology. The second thing they showed was that replacing or correcting that deficiency with a special form of lithium that is available over the counter that can be given in low doses that is easily bio-absorbable reversed some of those deficits. And which form is that? It’s called lithium orotate. And this is available over the counter. It’s, you know, you can give it at maybe like a fifth or a fifth of the dose that you would give and it’s, anyone can buy it, but it’s not recommended, of course, for manic depression. Joe 22:43-22:56 Right. But the side effects presumably would be much lower if you’re only taking, you know, two or three milligrams or five or 10 milligrams compared to 800 milligrams or in some cases even 1800 milligrams. Dr. Murali Doraiswamy 22:56-23:31 Correct. Now, of course, where you’re talking about the dose of elemental lithium, which has to be, which is what you’re talking about, when you eventually combine it as a salt, the dose becomes much higher, even for lithium orotated can be 100 milligrams, for example. So yes, the presumption and the hope is that the side effects are much lower and the tolerability is much greater because you want to treat someone with, say, at risk for dementia, you could be treating them for 10 years, 15 years. So you want a drug that’s really safe for an older person to take. Joe 23:31-23:33 Now, we need clinical trials. Dr. Murali Doraiswamy 23:33-23:33 Correct. Joe 23:34-23:39 Nobody can patent lithium. It’s out there. Who’s going to do the study? Dr. Murali Doraiswamy 23:39-24:10 There are actually companies that have come up with proprietary formulations of synthetic lithium that’s combined with other ingredients. So you can patent those versions. And, of course, if they do the study and the study is successful, somebody may say, well, why not just take the cheap version that’s available for pennies? But so the short answer is, yes, there are studies being done. There’s at least one company I know that has a proprietary formulation. And then government agencies can always fund studies of the generic version of lithium, which I hope that they do. Joe 24:10-24:11 That would be wonderful. Terry 24:11-24:20 It seems that it might be very tempting for people to start taking low-dose lithium on their own, but it sounds as though that might be premature. Dr. Murali Doraiswamy 24:21-24:33 I think it’s completely premature because we have more than 200 drugs to cure Alzheimer’s in mice, but none of them have worked so far, including the amyloid antibodies that are currently on the market. Joe 24:33-24:37 Let’s talk about another area that’s fascinating: vaccines. Terry 24:38-25:03 Well, we have seen a couple of studies now that demonstrate that specifically the shingles vaccine, and it wasn’t the newest shingles vaccine, the Shingrix, but rather the previous iteration, Zostavax, that quite significantly lowered the risk of people coming down with dementia. Can you tell us about that, please? Dr. Murali Doraiswamy 25:03-26:41 Yeah, it’s a very plausible study, and I’m very excited about it. I truly believe that there is an infectious particle that probably underlies dementia, especially Alzheimer’s disease. We know, for example, syphilis can cause a type of dementia. We know HIV, the AIDS virus, can cause a type of dementia. We know herpes encephalitis, which is a type of herpes virus that goes and attacks the memory centers in the brain. So it’s completely plausible that herpes zoster virus may be involved in Alzheimer’s. So this study that was done in the United Kingdom and one in Taiwan, both of which are quite convincing, again, amazing studies. They looked at a whole bunch of different explanations as to why someone getting the Shingrix vaccine had a lower risk for dementia. And they ruled out many of the spurious epiphenomenon type of causes. They were able to show that these people had a lower risk than those who had gotten a previous version of the vaccine, which was not the same, and also people who were unvaccinated. And they showed that they were not due to other explanations, such as simply getting better health care or leading healthier lives. So, I think it’s plausible. It still has to be demonstrated in a randomized controlled trial, but that’s going to prove very difficult because how do you stop someone in a placebo arm for three or four years from not getting a zoster vaccine? It’s possible, but I’m hoping that someone will do such a trial. Joe 26:41-27:20 Now, it’s not just Zoster, as you refer to it. We’re talking here about the virus that causes chicken pox and shingles. But there are some studies that suggest that BCG, which is a really old vaccine, probably one of the very first vaccines ever developed, might be beneficial as well. And there’s just something new that’s come out with RSV vaccine. So give us this sense of infections and dementia and vaccines. It seems like a whole new way of thinking about Alzheimer’s disease and dementia. Dr. Murali Doraiswamy 27:20-29:01 It is. If you look at the pathology in the Alzheimer’s brain, there are two types of pathology, the plaques and tangles. And both seem to propagate in the brain as though they were like infectious particles. The only thing different about Alzheimer’s, unlike, say, tuberculosis, You don’t catch it by standing next to someone and breathing the air that they are breathing or, you know, by having sex with that individual. You don’t catch it. It’s transmitted and propagates internally. We know that brain-specific viruses can hide in nerve cell ganglions for long periods of time and then suddenly get reactivated. We’ve known that about mad cow disease, for example. So could Alzheimer’s be caused by a slow-growing virus like that? It’s entirely possible. Last month at a conference, they just presented the results of a drug against herpes simplex virus, valacyclovir, and that study was negative. It was a randomized trial. There was similar evidence suggesting that people who took valacyclovir may have a lower risk, but in the randomized trial, it did not prove effective. Now, the BCG for bladder cancer, now BCG is used against tuberculosis traditionally, but in this case, it’s infused locally into the bladder to stimulate the immune system to attack cancer cells. And they found that people with bladder cancer who had received BCG had a much lower risk of developing dementia. So again, this is all very promising approaches. I’m hopeful that we can develop a vaccine to stimulate innate immunity to fight a viral etiology. We’re not there yet, but I think that’s where the cure is going to come from. Joe 29:02-29:03 Terry, let’s talk about diet. Terry 29:04-29:05 Well, let’s do it. Dr. Murali Doraiswamy 29:04-29:26 By the way, there is also a rich body of work suggesting that amyloid builds up in the brain and it’s antiviral and antibacterial, that it’s there not so much as the cause of the disease, but as a defense mechanism in the brain. That somehow this defense mechanism goes awry and overreacts and causes a friendly fire. Joe 29:26-29:30 So trying to get rid of amyloid in the long run. Dr. Murali Doraiswamy 29:30-29:31 Might be friendly fire. Joe 29:32-29:37 Right. It might be a mistake. So we’ve been hearing about the Mediterranean diet. Terry 29:38-30:38 Yes. There was a recent study showing that the closer people come to following, these are American people. This is the Health Professionals Follow-Up Study and the Nurses Health Study. So many, many people followed for three decades. And the researchers at Harvard who run this study check in with these people every couple years to say, how’s your health? And by the way, what are you eating? Fill out this very detailed dietary questionnaire for us. So what they have just recently published shows that people who come closest to following a Mediterranean diet, even though they’re living in Boston or Cincinnati or wherever they might happen to be, they’re not in the Mediterranean, they’re here in the U.S., those folks are less likely to be diagnosed with dementia. What can you tell us about diet and dementia? Dr. Murali Doraiswamy 30:38-32:00 Yeah, I’m not surprised by that finding. You know, the old adage, what’s good for the heart is good for the brain is true here for dementia as well. I believe Alzheimer’s and all types of dementias have a very strong vascular contribution. If you have blockages in your blood vessels, you’re much more likely to be diagnosed with dementia and cognitive impairment. So anything you can do to clear atherosclerotic plaques from building up in your blood vessels helps. And the Mediterranean diet has been shown to help in that regard, both in terms of body weight in terms of your risk for diabetes, in terms of your risk for hypertension, in terms of your risk for high cholesterol levels. Now, there is a slight twist there. There are two newer trials. There’s a large randomized trial of something called the MIND diet. The MIND diet is a version of the Mediterranean diet, but also includes components of the DASH diet, which is used to treat hypertension. So it’s kind of a hybrid. That large randomized trial did not find a protective benefit, even though a number of epidemiological studies had shown that. And more recently, an even larger trial called the POINTER study was just published in JAMA last year, and they found that combining the MIND diet with an active social lifestyle and aerobic exercise three or four times a week does help. It adds an extra one to two years of your cognitive longevity. Terry 32:00-32:03 So it can delay the onset of dementia. Joe 32:04-32:14 So let’s talk about exercise because people always ask us, well, what should I do for good health? And the one thing that always seems to stand out is exercise. Dr. Murali Doraiswamy 32:16-33:00 Yes. A little bit of exercise is great, [a] moderate amount. Too much is probably not good. And let me tell you, so the best exercise I recommend for people is a walking book club because you want to exercise your body and your brain. And you want to exercise at a level that, you know, is not stressful for your body. So, you know, the average 75-year-old, I’m not going to encourage them to run on a treadmill and then they slip one day and fall and break their hip or something. And there goes exercise for the next two years. So, yes, aerobic, moderate aerobic activity three to four times a week is very important. But also exercising your brain is equally important through cognitive training. Joe 32:58-33:03 Well, let’s talk about your research and crossword puzzles. Dr. Murali Doraiswamy 33:03-33:04 Yes. Joe 33:04-33:06 Exercising your brain. Dr. Murali Doraiswamy 33:06-34:23 Thank you. So, you know, the old thinking was that the brain in older ages cannot be changed. It doesn’t have neuroplasticity is the term we use to see if the brain can change and grow. And studies have shown that the older brain, the aging brain, retains its capacity to change. So then the question is, what is the best kind of exercise? Should we do these computerized video games where you’re, you know, like paying a monthly subscription and doing, you know, sitting in front of the computer? Or do you do more natural things that you, you know, been doing for a long time, like a hundred-year-old pastime, like crossword puzzles or bridge or, you know, Sudoku or whatever. So we did this randomized trial, and we found that if you already had memory impairment, we’re not talking about normal older people with healthy cognitive abilities. If you already had mild cognitive impairment, then doing something like bridge or crossword puzzles is better than playing video games because a lot of people struggle with the computer. They struggle with learning how these games play, and they’re not technologically savvy. And we found crossword puzzles actually beat those computerized video games. Now we’re doing a second study to see what is the ideal dose of crossword puzzles. Terry 34:23-34:24 Oh, I like it. Dr. Murali Doraiswamy 34:24-34:40 Do we do it four times a week? Do we do it just once a week? Do we do the Monday New York Times, which is easy, or the Thursday New York Times puzzle, which is challenging? So we’re trying to understand, you know, how do we actually scale it so that people don’t quit? Terry 34:40-35:10 Well, I think that’s a very interesting concept because we know that if you want to build muscle. In physical exercise, you need to take it right up to the limit and then keep expanding your limit a little bit. So if you could walk 15 minutes the first day, you might then the next week want to be walking 20 or 25 minutes. Is the same thing hold for cognitive exercise? Dr. Murali Doraiswamy 35:11-35:39 Yes, beautifully put, because you have to personalize it also for each individual, right? Because some people come with an eighth grade education and some people come with a PhD degree. So the crossword puzzle is not the same. How do you design the right words for that individual so that it challenges them and they continue to learn and grow? So that’s why we’re doing it through the computer, where the computer has an algorithm that automatically selects the right words and phrases based on their previous crossword puzzle completion and makes it challenging the next time around. Terry 35:40-35:51 Well, I know my mother loved doing the crossword puzzle, and she hoped that it would keep her from getting dementia. Sadly, she did develop dementia at the end of her life, but she was also quite old. Joe 35:52-36:05 Well, she was in her mid-90s, and she did very well in her early 90s. So maybe it was the crossword puzzles, maybe it was her excellent diet, maybe it was her exercise. It’s a package, isn’t it? Dr. Murali Doraiswamy 36:05-36:05 100%. Joe 36:05-36:09 It’s all these things together not just one single thing. Dr. Murali Doraiswamy 36:05-36:15 Correct, we call it multi-domain intervention. So yes, it’s the package. Terry 36:15-36:40 You’re listening to Dr. Murali Doraiswamy, professor of psychiatry and director of the Neurocognitive Disorders Program at Duke University School of Medicine. He’s a professor in medicine and a faculty network member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is also an affiliate in the Duke Center for Applied Genomics and Precision Medicine. Joe 36:41-36:52 You know, Terry, it’s not just the package. It’s also the genes. And, you know, your dad was not a big crossword puzzle guy, but he lived into his late 90s as well. Terry 36:52-36:55 He did. And for much of that time, his brain was good. Joe 36:56-37:04 We’ve just discussed how exercise benefits the brain. After the break, we’ll find out about exercise that might be bad for our brains. Terry 37:04-37:15 We always think about traumatic brain injury from football or boxing or soccer. But what about less obvious pursuits like tennis or pickleball? Joe 37:15-37:21 There are medications that can be harmful as well. Anticholinergics have been linked with cognitive difficulties. Terry 37:22-37:31 I think that’s why we discourage people from long-term use of PM pain medicines or the antihistamine diphenhydramine, aka Benadryl Joe 37:32-37:34 Do sleeping pills increase the risk of dementia? Terry 37:39-37:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:52-37:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:55-38:14 And I’m Terry Graedon. Joe 38:15-38:47 Recently, a study published in Nature Medicine showed that older people who are more physically active have less cognitive and physical decline. That held even for those who already had amyloid buildup in their brains, apparent on scans. The amount of physical activity wasn’t extreme. People took at least 5,000 steps a day to 7,500 steps. The amyloid in their brains didn’t change, but with that activity, they had less tau accumulation. Terry 38:49-39:05 Walking seems like a pretty safe activity, as long as we can manage it without risking a fall. Some other physical activities may be riskier for the brain. We’ll find out about the dangers of football or soccer, in which there are repeated blows to the head. Joe 39:06-39:23 In addition to non-drug approaches to reducing the likelihood of dementia, we should also look at drugs. In particular, which drugs should we avoid? You might be surprised how many common medications may impact the brain. Terry 39:23-39:49 Our guest is Dr. Murali Doraiswamy, Professor of Psychiatry and Behavioral Sciences. He is Director of the Neurocognitive Disorders Program and a Professor in Medicine at Duke University Medical School. He’s a member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is a Senior Fellow of the Center for the Study of Aging and Human Development. Joe 39:51-40:25 Dr. Doraiswamy, we’ve been talking about the benefits of exercise, among other things, for the brain. But there are some things that might be bad for the brain when it comes to exercise. And I’m thinking about football for younger kids, even with a helmet on. I’m thinking about soccer and heading the ball. I’m thinking about boxing, especially, or any place where you might injure your brain. It just doesn’t seem like such a great idea. What does the science say? Dr. Murali Doraiswamy 40:26-41:40 I think you’re absolutely right, because we don’t have any way to grow new brain cells once the brain’s been damaged, and we don’t convey that information with enough urgency to our children and athletes, frankly. So I would say boxing and mixed martial arts are obviously the most dangerous. It’s a well-known phenomenon called dementia pugilistica, where virtually a very high proportion of boxers end up with either Parkinson’s or some form of dementia later in life. The same, I think, the frequency is not as high with soccer and with American football. But still, people who have had multiple concussions definitely have a higher risk for a type of dementia that’s caused by a traumatic brain injury. And we don’t have a cure or a treatment for it. So 100%, I would recommend wear a helmet. Protect your head. You know, try to avoid high-risk sports. Even bicycling without a helmet, if you press the brake in the wrong place, you can do a cartwheel and fall over and hit your head. So you have to be really careful. And that’s another reason why I recommend walking for seniors. Joe 41:41-41:42 I’m thinking tennis. Dr. Murali Doraiswamy 41:43-42:17 Tennis is fabulous sport. You know, of course, tennis, you can have other kinds of injuries and, you know, but tennis is perfect. I think for a senior pickleball to me, especially if you can move from start with doubles playing, you know, gently and then move to singles and then, you know, maybe move from there to paddle or something like that. Because they’re more likely to engage and persist with it rather than tennis. If you’re starting late in life, it’s really hard. Now, ultramarathons is another. There’s some new findings suggesting that if you do ultramarathons, the shrinkage of the brain. Terry 42:18-42:22 So you’d say don’t do an ultramarathon. Dr. Murali Doraiswamy 42:23-42:39 Well, I mean, do it once in a while. It’s okay. Like it would be like going on a binge drinking episode once. You’ve got to do it in college as a rite of passage maybe to run the New York Marathon. So I’m not telling anyone don’t do it, but don’t do it super regularly because it’s a stressful experience for your body. Joe 42:40-43:13 I’d like to ask you about medications because we’ve talked about some of the medications that have been developed for dealing with Alzheimer’s. They haven’t been very effective, but we have a whole slew of drugs, some of which are available over the counter, that might not be good for the brain. So perhaps you could start with what we call anticholinergics. What are they and why might they be deleterious? Dr. Murali Doraiswamy 43:14-44:29 Sure. You know, anticholinergics are called that because they block the actions of a system in the brain called the cholinergic system. The cholinergic system is highly prevalent throughout the body. In fact, the vagus nerve is called the vagus because it’s a vagabond. It runs throughout the entire body. It controls your memory in your brain. It controls your breathing. It controls your heart. It controls the movement of your intestinal tract. It controls how often you’re constipated or how often you move bowels. It controls the contractions of your muscle, everything, right? So, acetylcholine, the chemical that’s used by this system, is crucial for memory in the brain. And anticholinergic drugs, if they block this chemical, they impact your memory. Many of the older medicines, especially older antidepressants, some of the older, sleeping aids, medicines that are used by a urologist to control frequent urination. All of these can have friendly fire on the brain. And so those are some examples of drugs that we, you know, it’s very hard because as a urologist, you want to give them to help a person with an enlarged prostate. But then as a brain doctor, you want to take people off these drugs to improve their memory. So there’s a constant tug of war. Let’s talk about antihistamines. Joe 44:29-45:28 There is what we call the first generation antihistamines. One of them is chlorpheniramine, but the one that is so popular these days is diphenhydramine. It’s the ingredient in Benadryl. And it has become so popular in all of the over-the-counter PM pain medicines because it makes people drowsy. Anybody who’s taken Benadryl during the day will often complain, yeah, it makes me sluggish. I can’t think as clearly. But now millions of people are taking Advil and Aleve and you name it with diphenhydramine. It’s a low dose, but it’s day in and day out. Because once you get into a sleeping pill cycle, you just take it in case I might not fall asleep tonight. So your thoughts about diphenhydramine? Well, I think you stated it pretty well. Dr. Murali Doraiswamy 45:28-46:23 I think if you use it persistently for long periods of time, it’s going to have deleterious [inaudible]. And whether or not the effects are reversible still are not fully proven. But generally, we believe that with anticholinergic drugs, if you can stop using it, you can reverse the drugs for the most part. You may not get back to where you were. But while you’re taking them, you know, you’re probably performing at 15, 20% lower than what you ought to be. So it could impact your driving, it could impact operating heavy machinery. If you’re taking an exam or a test or mission critical like a pilot, you know, you need to be extremely careful with these drugs. The same may also be true for some over-the-counter, you know, what shall I call it, herbal products that claim to mimic some of these antihistamines. Terry 46:24-46:28 So perhaps you don’t want to be taking an herb that is supposed to put you to sleep. Dr. Murali Doraiswamy 46:29-46:36 Yeah. We don’t know. I mean, it depends on the herb, but yes, some of them, yes. Like Valerian, for example, could potentially do the same thing. Terry 46:38-46:52 And my question is about prescription sleeping pills. I know it’s been controversial. Do they or do they not increase a person’s risk for developing dementia? And perhaps you have some insight on that. Dr. Murali Doraiswamy 46:53-47:55 I don’t have any additional insight. It still remains somewhat controversial and unproven. There’s a big range of sleeping pills, the newer sleeping pills versus the older ones. And of course, some of the antihistamines are used as sleeping pills as well. And some of the antidepressants are used as sleeping pills as well. So I would say, you know, the evidence is mixed. We continue to have to use them because on the one hand, sleep we know is crucial for memory archival. Sleep we know is crucial for immunity. There’s even new evidence suggesting that if you don’t sleep well, then the clearance of some of the toxic products in the brain is impaired through the glymphatic channel. So you want people to sleep well. And we don’t have a great choice. Some of the newer sleeping pills that are more expensive, so people who can’t afford them need to take the older version. So it’s a constant battle. Joe 47:56-48:21 There is a lot of controversy around the benzodiazepines, the benzos, anti-anxiety agents. Also, the proton pump inhibitors, the PPIs that you can now buy over-the-counter, omeprazole, esomeprazole, lansoprazole. And doctors are now prescribing the gabapentinoids, the gabapentin and the pregabalin for pain. Dr. Murali Doraiswamy 48:21-48:22 Correct. Joe 48:23-48:37 We want to caution people, never stop any of these drugs suddenly because it can precipitate something called discontinuation syndrome. That’s the sanitized version. It’s otherwise known as withdrawal. Dr. Murali Doraiswamy 48:38-48:39 Sure. Joe 48:39-48:51 So give us a quick understanding that even though there is a bit of a cloud on some of these drugs when it comes to cognitive function, no one should undertake stopping these drugs because they’re a little concerned. Dr. Murali Doraiswamy 48:51-49:23 Yes, absolutely. Drugs like this should be tapered off. You should talk to your clinician, physician, and gradually taper them off. It’s a little bit like if someone’s been drinking for a long period of time, the chronic alcoholic, we never advise them to go cold turkey. I know we usually have them come in, put them on a regimen of a taper before they go cold turkey. So I think it’s somewhat similar to this because you don’t want your brain to go from one state to another state when it’s dependent on a medicine like abruptly. Joe 49:23-49:26 Now, I will challenge you on that taper problem. Dr. Murali Doraiswamy 49:26-49:26 Yeah. Joe 49:27-49:43 We have been complaining for years that the drug companies haven’t come up with guidance. The FDA hasn’t come up with guidance. And many of the professional organizations haven’t come up with guidance. As everybody says, yes, slow taper. Terry 49:43-49:59 Well, the drug companies have no incentive to help people get off their drugs. FDA, on the other hand, you know, you could argue that it is a public health question, that perhaps they should have done it, but they have not. Joe 49:59-50:27 And the FDA would say, well, it’s not our job. So how does a psychiatrist such as yourself, who is treating a patient with an SSRI-type antidepressant or perhaps a gabapentinoid for some nerve pain or fill in the blank drug, and somebody says, well, yeah, I really would like to stop taking my sertraline. There’s no cookbook. How do you advise them? Dr. Murali Doraiswamy 50:27-51:09 Yeah, it’s a huge gap. Even more fundamental is that physicians need to know what is the half-life of a particular drug before they counsel people on how to taper. And most doctors, because there’s so many drugs now, nobody even remembers. So you almost have to ask AI for how do I taper off this person. That’s the only solution. Somebody has to build an AI chatbot into your electronic health record. So just how I do it, for a drug with a very long half-life, it’ll taper itself out of your body. Because if it has a 30, 40-day half-life, you don’t need to worry as much about a drug as with a short half-life causing abrupt withdrawal symptoms. Terry 51:09-51:19 So that would be, for example, the antidepressant fluoxetine, which is not nearly as difficult to discontinue as a short-acting drug like venlafaxine. Dr. Murali Doraiswamy 51:20-51:30 That’s right. Beautifully put it. I love the way you give these concrete examples. Yes. I think AI is going to take over all of these solutions that the drug companies and FDA don’t want to tackle. Terry 51:32-51:48 Well, what about the potential for AI to help people in your situation who are trying to help people with psychiatric problems or with dementia? What do you see as the role for AI? Dr. Murali Doraiswamy 51:48-52:36 I think it’s going to transform the field. Just in mental health, for example, children. I have seen surveys would say 80-90% of kids would rather talk to a bot rather than a human who is judging them, especially an older human that’s judging them. That’s one. A lot of crises that kids have happen late at night or teens and college students. There’s nobody for them to talk to. And in terms of dementia, you know, I mean, look, people want cognitive testing in the comfort of their home. It’s too intrusive to go to a clinic and have someone poke and prod you and ask questions like this. If you can get tested in the comfort of your home with a reliable evidence-based test, and then it tells you, you know, here’s what you need to do, then people can decide with their family. I think that’s where we’re headed. Joe 52:37-53:01 Dr. Doraiswamy, we are almost out of time. As you look into your crystal ball, what do you see for the future, especially when it comes to Alzheimer’s disease or dementia? What would your hopes be over the next decade or two for better treatments, new ways of thinking, perhaps some kind of a breakthrough? Dr. Murali Doraiswamy 53:03-54:10 Well, I think the first thing I would hope for is there are five or six million people in the U.S. and maybe 30 million people around the world already living with dementia. We shouldn’t ignore these people. Even some of the people who are advanced stages, there’s a human still in there. We need to make sure that we have adequate resources to provide for them, to support their caregiver, to make sure that their lives have high quality. We should not neglect them because a lot of the drug discovery is moving to earlier and earlier and earlier stages, neglecting the later stages. So that’s one. So the human element needs to be brought back in. Second is we need to really set the bar for drug development so that it’s unambiguous. A very high bar for efficacy and a bar for safety so that we don’t have to be doing regular PET scans and MRI scans to monitor people. Ultimately, I think we need more investment from society because it’s a huge problem. I think we’re going to have a combination of drugs, much like cancer and other specialties. I’m not optimistic we’ll find a cure, but I’m hopeful that we’ll have a lot of very, very highly efficacious drugs in the next five to 10 years. Joe 54:10-54:17 And in the one minute we have left, your recommendations for people who want to try and prevent the development of dementia? Dr. Murali Doraiswamy 54:19-54:30 What’s good for the heart is good for the brain. Heart healthy diet, exercise regularly, get seven, eight hours of sleep, be socially and cognitively very active. Terry 54:31-54:38 Dr. Murali Doraiswamy, thank you so much for coming to talk with us today on The People’s Pharmacy. Dr. Murali Doraiswamy 54:38-54:39 You’re welcome. Always a pleasure. Terry 54:40-55:05 You’ve been listening to Dr. Murali Doraiswamy, Professor of Psychiatry and Director of the Neurocognitive Disorders Program at Duke University School of Medicine. He’s a professor in medicine and a faculty network member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is also an affiliate of the Duke Initiative for Science and Society. Joe 55:05-55:14 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 55:15-55:23 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 55:23-55:42 Today’s show is number 1,451. You can find it online at peoplespharmacy.com. At peoplespharmacy.com, you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 55:42-56:16 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. There, you can also find our posts on the week’s health news. We’ve included links to articles that we’ve written about the possible association between some infections and the risk of dementia. Could vaccines against shingles, influenza, or tuberculosis help slow cognitive decline? Might amyloid plaque be part of the brain’s immune defense against infection? Joe 56:17-56:37 You know, Terry, I have been so fascinated with BCG. This is a vaccine that’s over 100 years old, but there was a recent study, sort of an analysis overview from Frontiers in Pediatrics last summer. And it really suggested that BCG might have an important role against some dementias. Terry 56:38-56:40 We’ll put a link to that on the website as well. Joe 56:40-56:55 At peoplespharmacy.com, you can 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. In Durham, North Carolina, I’m Joe Graedon. Terry 56:55-57:28 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.

Transcribed - Published: 7 November 2025

Heart disease is still our number one killer, even though 50 million Americans have been prescribed a cholesterol-lowering statin. Cardiologists pay a lot of attention to cholesterol in all its variety: total cholesterol, LDL, HDL, VLDL. Even blood fats like triglycerides and lipoprotein a [Lp(a)] are getting some attention. What else do you need to know to reduce your risk of heart disease or stroke? 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 EDT on 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 November 3, 2025. What Factors Shape Your Risk of Heart Disease? Our guest for this episode is a preventive cardiologist, a doctor whose practice is aimed at keeping people from getting heart disease. Even though heart disease ranks at the top of the list of reasons people die, it has been dropping. Dr. Michael Blaha points out that in some states heart disease has actually fallen below cancer as a cause of death. Presumably, that is not due to a dramatic increase in cancer mortality, but rather because we are successfully reducing the toll from cardiovascular disease. Cutting out smoking and removing trans fats from popular foods have helped a lot. Addressing obesity is also changing the equation. Treating Obesity Helps the Heart: We asked Dr. Blaha if the immensely popular GLP-1 drugs such as Ozempic, Wegovy, Mounjaro or Zepbound are making a difference in our risk of heart disease. He believes they are the biggest breakthrough since statins. Other medications that could help reduce obesity might also benefit the heart and cardiovascular system. Cardiologists have long been urging people to embrace physical activity and sensible diets. Now the medications can give them a head start on those efforts. What Can We Do About Lp(a)? About one-fifth of Americans have elevated levels of lipoprotein a, usually abbreviated Lp(a) and pronounced ell-pee-little-ay. This risk factor is considered stable and is an important predictor of cardiovascular complications. According to a meta-analysis of 18 studies, Lp(a) is an independent risk factor for calcified aortic valves (Frontiers in Cardiovascular Medicine, Oct. 13, 2025). Several pharmaceutical firms are actively developing agents that could lower Lp(a). That would certainly be welcome, since statins actually raise levels of this potentially troublesome blood fat. This means that many heart patients are in the uncomfortable position of driving with their feet on both the brake and the gas pedals. Getting Blood Pressure Right: High blood pressure is a very common risk factor for heart disease and stroke. Doctors need to pay attention to balancing control of hypertension with potential side effects. Especially for older patients, the risk of orthostatic hypotension could be serious. This happens when blood pressure drops suddenly after a person stands from a sitting or reclining position. If they faint and fall, the results can be serious. People with concerns about hypertension need to make sure their blood pressure is being measured correctly. Incorrect measurement techniques, possibly resulting in inaccurate readings, are shockingly common in busy clinics. Dr. Blaha discussed the correct procedures, along with the reasons that doctors may prescribe ACE inhibitors (such as lisinopril) or ARBs (such as losartan) as their first-line choice for blood pressure control. Using the Risk Calculator to Estimate Your Risk of Heart Disease: We asked Dr. Blaha about the new PREVENT risk calculator produced by the American Heart Association. The algorithms in this tool appear much less likely to overestimate a person’s risk of heart disease than those that cardiologists used previously. All of the cardiology guidelines now recommend its use. You can find it here, although you may not know all the numbers to plug in. https://professional.heart.org/en/guidelines-and-statements/prevent-calculator How Does CAC Score Illuminate Your Risk of Heart Disease? Lately, cardiologists have been turning to the coronary artery calcium score, or CAC, to help estimate patients’ probability of developing circulatory problems. This is a CT scan of the heart that reveals the location of calcified plaque in the coronary arteries. In general, a higher CAC score indicates a higher level of cardiovascular risk. This measurement may be helpful in determining risk for people who aren’t clearly in a very high-risk category (or a very low-risk category) already. Dr. Blaha suggests it may also serve as a motivator for people who need to change their lifestyles to ward off serious cardiovascular consequences. Can You Reduce Your Risk of Heart Disease? Dr. Blaha suggests that everyone can benefit from paying attention to lifestyle recommendations. Getting adequate physical activity is crucial. So is consuming a diet rich in vegetables and fruits, minimizing highly processed foods. But these recommendations are overly general. People at higher risk of cardiovascular complications need more personalized advice from their doctors. How can you remove the barriers to exercise? Does the diet need more soluble fiber? What nutrients might be needed in addition? Individuals with chronic infections such as HIV need even more personalized attention. For example, a person with high levels of inflammation may need an anti-inflammatory drug such as colchicine (American Heart Journal, Jan. 2025). This Week’s Guest: Michael J. Blaha, MD, MPH, is Professor of Cardiology and Epidemiology at Johns Hopkins School of Medicine. He is the Director of Clinical Research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Clinically, Dr.Blaha practices as a preventive cardiologist and in the interpretation of cardiac CT. Dr. Blaha has received multiple grant awards from the National Institutes of Health, FDA, American Heart Association, Amgen Foundation, and the Aetna Foundation. Michael J. Blaha, MD, MPH, Johns Hopkins University School of Medicine Listen to the Podcast: The podcast of this program will be available Monday, Nov. 3, 2025, after broadcast on Nov. 1. You can stream the show from this site and download the podcast for free. This week’s podcast contains a discussion of diuretics and their effects on critical minerals, home ECGs and Afib detection with smart phones, more details on the colchicine study he mentioned and further information on the hypertension drug the FDA just approved, aprocitentan (Tryvio). Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1449: 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. Fewer Americans are dying of heart attacks these days, but cardiovascular disease is still our number one killer. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:42 We’ll take a fresh look at blood pressure, cholesterol, calcium, and other risk factors for heart disease. Have you had a coronary artery calcium scan? Joe 00:42-00:51 Do you know what your blood pressure is? Was the measurement done properly? It’s surprisingly easy to make mistakes. Terry 00:52-00:59 Inflammation plays a significant role in heart disease. Could an anti-inflammatory drug usually prescribed for gout be helpful? Joe 01:00-01:08 Coming up on The People’s Pharmacy, Beyond Cholesterol. Rethinking your risk of heart disease. Terry 01:14-02:26 In The People’s Pharmacy health headlines. For a long time, American parents were careful to protect their infants from peanut-containing products for fear of triggering a potentially lethal allergy. Nevertheless, peanut allergies continued to rise. Then in 2015, a carefully conducted scientific study showed that infants introduced to small amounts of peanuts between four and six months were less likely to react badly to them. Pediatricians changed their recommendations after that. Now, a study of health records of children under 3 shows that the rate of peanut allergies has dropped pretty dramatically, from 0.8% in 2012 to 0.5% in 2019. That may not sound like much, but it is statistically significant and represents a 43% reduction in relative risk. Pediatricians are still cautious about advising parents on feeding peanut butter to babies who seem likely to develop allergies. But fewer peanut allergies could definitely make life less stressful for many youngsters and their families. Joe 02:27-03:56 Researchers have been arguing about how many steps you need to prevent cardiovascular disease. For years, we were told that 10,000 steps should be the goal. Then, scientists reported that 7,000 might be enough for older adults. Now, a new study in the Annals of Internal Medicine reports that getting your steps in a single long walk is better for cardiovascular health than accumulating steps in many shorter walks. The investigators analyzed data from more than 33,000 participants in the UK Biobank database. These healthy people averaged 62 years of age at the start of the review and were taking fewer than 8,000 steps daily. The periods of physical activity were classified as shorter than 5 minutes, 5 to 10 minutes, 10 to 15 minutes, or 15 minutes or longer. After 8 years, the volunteers who regularly walked more than 15 minutes at a time were 80% less likely to have died. They were 70% less likely to have a heart attack or stroke than the people who took shorter walks. 4.4% of people who took very short walks died during the 10 years of follow-up. Fewer than 1% of those taking long walks died during that time. The authors conclude that when people get most of their daily steps from longer walks, they do better. Terry 03:57-04:46 Some people like to sleep in total darkness, while others prefer to keep a nightlight on so they can see the path to the bathroom if they need to use it. A study of health records from the UK Biobank covered more than 88,000 people over nearly 10 years. The participants wore light sensors on their wrists for a week near the start of the study. Researchers compared outcomes for people with dark nights to those for people with the brightest nights. People exposed to bright light at night were significantly more likely to develop coronary artery disease, heart attacks, heart failure, atrial fibrillation, and stroke. Increased light exposure boosted the risk for women more than for men. The investigators recommend avoiding light at night. Joe 04:48-05:37 It’s estimated that nearly 400 million people suffer from knee osteoarthritis worldwide. Exercise is considered a cornerstone of knee osteoarthritis management, but what exercise is helpful and won’t damage sore joints? A new study randomized patients with knee arthritis to receive either online information about the benefits of exercise for arthritis or a Tai Chi program with a mobile app encouraging adherence to this kind of gentle exercise. The investigators report that this randomized clinical trial found that this unsupervised multimodal online Tai Chi intervention improved knee pain and function compared with control at 12 weeks. Terry 05:38-06:17 Irritable bowel syndrome can make life very uncomfortable. People often request dietary advice, and they’re told to avoid foods that bacteria can ferment, the so-called low FODMAP diet. Now scientists report that following a Mediterranean diet, which is easier, offers just as much relief. And that’s the health news from The People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:35 And I’m Joe Graedon. Heart disease has been our number one killer for decades. We’ve got dozens of highly effective drugs to lower cholesterol. What else should we be doing to overcome this widespread threat to public health beyond simply swallowing a pill? Terry 06:36-06:47 Today, we’ll be discussing ways for you to reduce the likelihood that you’ll have a heart attack or other serious heart problem. What should you know about keeping your heart healthy? Joe 06:47-07:28 Our guest today is an expert in preventing heart problems. To find out how you can reduce your risk of heart disease, we turn to Dr. Michael Blaha. He’s professor of cardiology and epidemiology at Johns Hopkins School of Medicine. Dr. Blaha is the director of clinical research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Clinically, Dr. Blaha practices as a preventive cardiologist and in the interpretation of cardiac CT. He’s received multiple grant awards from the National Institutes of Health, the FDA, and the American Heart Association. Terry 07:29-07:33 Welcome back to the People’s Pharmacy, Dr. Michael Blaha. Dr. Michael Blaha 07:34-07:35 Thanks for having me back. Joe 07:36-08:13 Dr. Blaha, the American Heart Association just recently reported that heart disease is still the number one killer in America. And that’s after almost 40 years of statins and all kinds of other cholesterol-lowering drugs. Atorvastatin is the most prescribed drug in America. It’s big number one at 30 million Americans taking that medication. What else should we be doing to reduce our risk of having a heart attack or other cardiovascular diseases like stroke? Dr. Michael Blaha 08:14-09:16 Well, there’s no doubt we’ve made tremendous progress over the last several decades, three to four decades, really driven by smoking reductions, more attention to blood pressure, as you mentioned, cholesterol reduction, both from diet, a reduction in trans fats, but as well as statins. But of course, residual risk remains. And as you mentioned, atheroscrotic cardiovascular disease remains the number one killer, really close to cancer now. In fact, some states, cancer is higher than ASCVD than atheroscrotic cardiovascular disease. But in general, atheroscrotic cardiovascular disease remains the number one killer. And really, the epidemic now is one of metabolic disease driven by obesity and diabetes. Those are the risk factors that we have yet had as big of a breakthrough on. So while statins are helpful, blood pressure reduction is helpful, of course, what we’ve learned about diet and exercise, we still need to do more about obesity and diabetes. Joe 09:17-09:31 Has Ozempic and Wegovy and Mounjaro and Zepbound, the GLP-1 agonists, changed the equation? There are a lot of people who say, wow, it’s like a miracle. Dr. Michael Blaha 09:32-10:51 Yeah, they’ve completely changed the equation. It’s probably the biggest breakthrough since statins as far as pharmacologic prevention goes. Yes, we’ve never been able to have meaningful weight loss in the office before with really with the diet and exercise strategy that’s consistent or with the drug. Now that we’ve learned more about the behavior of hormones from the gut and the way they interact with the brain, we’ve shifted the thinking around obesity towards one of a chronic disease rather than just a willpower problem. We understand some of the brain chemistry. It’s unlocked the ability to make meaningful weight loss. So these, yeah, these therapies can induce significant weight loss, significant fat cell reduction, fat mass reduction. They’re anti-inflammatory. Yeah, and they have cardiovascular benefits, but also benefits on the liver, on sleep and other things. So, yeah, this is that we’ve started to make progress in this regard. Of course, we need to still work on diet and exercise and how that fits in with these GLP-1 and the next generation of incretin-based therapies. But absolutely, the future is bright as far as treating obesity, but we need to prevent it in the first place, too. Terry 10:53-11:17 When it comes to heart disease, there’s another risk factor that we will soon be able to treat with medications. I don’t think that the FDA has approved any of these medicines yet, but pharmaceutical firms are working on drugs that will lower LP little a. Is that going to make a difference? Dr. Michael Blaha 11:18-12:33 Yeah, I hope so. So a quick primer on lipoprotein(a). So this is a cholesterol carrying moiety that when you measure your LDL cholesterol, it’s hidden within that LDL cholesterol measurement. To actually get your LP(a) levels, your lipoprotein(a) levels, you need to also measure it directly in the bloodstream, and it’s a measure really of genetic cholesterol risk. Your levels are 90% determined by your genetics, so it’s not much that you can do about it as far as diet and exercise goes. You inherit it from your family and it is causal and causing atherosclerotic cardiovascular disease and it’s the explanation of some of the heart disease that we see that happens in patients with no other risk factors, but this hiding behind the normal lipid profile, the lipoprotein(a) levels. But one in five patients in the world has an elevated lipoprotein(a) level. It can be higher in certain populations like South Asians, for example. So it’s common, it’s genetic, and it’s not treatable right now. And it’s a cause of, once again, some, not all, but some of the unexplained heart disease that we see. Joe 12:33-12:40 Well, hang on a sec, Dr. Blaha, 20%, one out of five, that’s a lot. Dr. Michael Blaha 12:40-13:08 It is a lot. Yeah, there’s no doubt about it. About four out of five patients have very low levels, but one in five can have extraordinarily high levels. And once again, you don’t know it unless you measure it. And as you mentioned, many pharmaceutical companies are working on therapies that do indeed successfully lower lipoprotein(a) levels. We won’t know until next year if those therapies actually reduce cardiovascular risk. We’ll know soon, though. Joe 13:09-13:46 You know, we have talked to Dr. Tsimikas, who has been studying LP little a for quite a long time, and he actually wrote a, I would say, a somewhat controversial article in one of the heart journals, an inconvenient truth regarding statins in that statins raise LP little a, not a whole lot, but a little bit. And so I’ve always been a little confused. It seems like you’re driving with your foot on the brake and the gas simultaneously. If you’re trying to reduce your risk of heart disease, but a statin is raising your LP little a levels. Your thoughts? Dr. Michael Blaha 13:48-14:38 Yeah, it’s true. These processes are quite complicated. So both LPA-lowering drugs, and it looks like many anti-inflammatory drugs can raise your LDL a little bit. This just goes to show the interconnection between inflammation, lipoprotein(a), and LDL, for example. So it’s true. Now, the good thing is the statins lower the LDL way more than the LPA-lowering drugs raise the LDL, And still, clearly, there’s a net benefit, hopefully, of both of these drug classes. But we’re going to have to understand how all these things interact. So once again, we’ll have to wait for the trials. And we’ll know as soon as next year if these drugs lower cardiovascular risk, despite raising LDL a little bit. Now, all of these studies of the LPA drugs are in patients taking statins. Right. Joe 14:39-15:13 I’ve got another question before the break. And it has to do with another class of drugs called beta blockers. They’re among the most prescribed drugs in America. There was a Nobel Prize to Dr. Black. He developed the first one, propranolol. But there’s a whole bunch of others. Metoprolol, there’s, let’s see, atenolol, there’s carvedilol. There are lots of beta blockers. Terry 15:13-15:15 Sotolol. There’s lot of ‘-olols.’ Joe 15:15-15:32 And, you know, there was a time, I’m sure, that you absolutely prescribed the beta blocker for just about everybody who had a heart attack. And it was like, if you don’t prescribe a beta blocker after someone has a heart attack, that would be considered malpractice. Dr. Michael Blaha 15:32-15:33 Yeah. Joe 15:33-15:56 The New England Journal of Medicine has just added to the literature that suggests if people have good heart function after a heart attack, and you’ll have to explain ejection fraction, that maybe a beta blocker is not such a great idea after all. Some patients will benefit if their hearts are damaged severely, but others, not so much. Could you give us a quick two-minute overview? Dr. Michael Blaha 15:57-16:16 Sure. Yeah, beta blockers are absolutely important drugs. You know, they reduce the autonomic nervous system stress on the heart, let’s call it. They reduce the impact of sympathomimetics, the neurotransmitters that stimulate the heart, so they relax the heart. Joe 16:16-16:20 You’re talking about the fight or flight reaction, the adrenaline reaction. Dr. Michael Blaha 16:20-17:36 Yeah, they start to blunt that, which helps to reduce the stress on the heart, which certainly is good, generally speaking, after a heart attack. But the way it turns out is these drugs really exert their effect by reducing that stress on the heart and reducing the subsequent risk of heart failure or ventricular arrhythmias after a heart attack. And those predominantly occur in people with substantial damage to the heart tissue. So if you’ve had a heart attack and your heart function is reduced, your ejection fraction, your heart squeeze is reduced, you’re at risk for heart failure and ventricular arrhythmias. And the beta blockers probably have a role there. In fact, they definitely have a role there. But there’s a lot of patients nowadays who have small heart attacks treated very well with a stent and other medicines, and they do extremely well. And they’re not really at risk for heart failure or arrhythmias, at least in the short term. And it turns out after a short course of beta blockers, these patients probably don’t need to stay on beta blockers long term because they’re not at high risk of heart failure, not at high risk of arrhythmias. And beta blockers can have side effects. So really, after maybe a year of a beta blocker, in the chronic phase of atherosclerotic cardiovascular disease, we probably don’t need beta blockers in most patients who have normal heart squeeze, normal heart function. Terry 17:37-17:53 You’re listening to Dr. Michael Blaha, professor of cardiology and epidemiology at the Johns Hopkins School of Medicine. He’s the director of clinical research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Joe 17:54-17:58 After the break, we’ll talk about blood pressure. It’s an important risk factor, Terry 17:58-18:07 but how low should it go? Sometimes when blood pressure medicines work too well, people may get faint and fall when they stand up from sitting or lying down. Joe 18:08-18:14 Blood pressure measurement can be trickier than it seems. Is the clinic doing it correctly? Terry 18:14-18:31 Do you have white coat hypertension? Find out about the best technique for blood pressure measurement. Is your arm supported? Joe 18:22-18:25 Is the clinic using the right size cuff? Terry 18:25-18:31 New machines have the guidelines built in. Joe 18:32-18:33 The AHA recently introduced a new risk calculator. Why does it matter? Terry 18:39-18:55 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 18:55-19:12 And I’m Joe Graedon. Terry 19:12-19:30 Today, we’re talking about how to reduce your chances of developing heart disease. One important risk factor is blood pressure. The CDC estimates that nearly half of all American adults have hypertension. That’s about 120 million people. Are you one of them? Joe 19:30-19:58 To learn more about preventing heart disease, we turn back to Dr. Michael Blaha, professor of cardiology and epidemiology at Johns Hopkins School of Medicine. He’s the director of clinical research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Clinically, Dr. Blaha practices as a preventive cardiologist and in the interpretation of cardiac CT. Terry 19:59-21:17 Dr. Blaha, we know that one of the risk factors that we’re always reminded we need to keep under control is blood pressure. And we can ask, and probably will, about the various levels of blood pressure and exactly what is a really good blood pressure. Does it vary from one age to another? But what I’d like to ask you about right now is balancing blood pressure control against the potential side effect of someone feeling dizzy. Especially, there’s something that doctors call orthostatic hypotension. And what it amounts to is a person on such a medication stands up from sitting or from lying down, and they just basically fall over. They get faint. And that clearly is not a desirable situation. Can you tell us a bit, please, about how a doctor and patient can work together to balance these risks? Dr. Michael Blaha 21:19-23:22 Yeah, you bring up a really important point. And one of the longstanding debates in cardiovascular disease is what’s the best blood pressure? And clearly, we’ve decided that the higher your risk of atherosclerotic cardiovascular disease, the lower your blood pressure [should] be or the tighter your blood pressure control should be. And we’re really looking for in our high risk patients, normalization of the blood pressure. This reduces cognitive problems later on, reduces heart failure and heart disease risk over time, but it does come with side effects. Blood pressure drugs do blunt auto-regulation of the blood pressure. As you mentioned, when you stand, part of that auto-regulatory response is blunted and you can get dizzy. You can get low blood pressure when you stand. And this is something that we are always working with our patients. It’s something we talk to our patients about when they start blood pressure drugs. It’s something we talk about when we set aggressive blood pressure goals, and it’s a common reason we have to back off on blood pressure therapy too. So you’re right, we need to talk to our patients about what our blood pressure goal will be. If your risk is not so high, your blood pressure can be more lenient. If your risk of cardiovascular disease is high, we need to be very aggressive with the blood pressure and really need to talk about potential for orthostatic hypotension. We do tend to avoid the beta blockers just for blood pressure. They’re not really good antihypertensive drugs. They’re a fourth or fifth line choice. They can cause orthostatic hypotension, but really any blood pressure drug can cause orthostatic hypotension. So it’s part of the discussion and it’s part of the complex juggling act, as you mentioned, between getting the lowest blood pressure we can to reduce your risk while balancing side effects. And some patients are just going to have to deal with a little bit of orthostatic hypotension, which means when you rise from standing, you wait for a moment before you walk. You rise from standing a little slower. You maintain hydration. And this is some of the give and the take of everyday blood pressure management. Joe 23:23-23:27 Dr. Blaha, I’d like to talk about blood pressure measurement for a minute. Terry 23:28-23:29 Measurement rather than management. Joe 23:29-24:55 Exactly. Because we get a lot of messages on our website from people who say, holy cow, you know, I’ve seen the American Heart Association’s guidelines. These are people who are really dedicated to getting their blood pressure correct. And they’re taking their blood pressure at home and following the guidelines. But when I go to the clinic, the first thing that happens is I’m stuck in traffic and I’m almost always getting late and I’m always feeling rushed and I’m always a little anxious. And then as soon as I get taken back from the waiting room, the technician or the nurse, they immediately take my blood pressure. I don’t get to relax. I don’t get to go to the bathroom. And they sometimes put me on the exam table and my legs are dangling and my arm is dangling and they’re talking to me. And all of those things mess my blood pressure up. I have this thing called white coat hypertension anyway, and that just makes it worse. And so my blood pressure may be 150 or 160 over 95 in the doctor’s office. But as soon as I get home, it’s back around 120 over 80. So can you share with us the correct way to have a blood pressure taken when you’re at a clinic? Dr. Michael Blaha 24:55-26:56 Yeah, this is an enormously important question because blood pressures commonly aren’t checked well in the clinic, and it’s the result of a busy practice. Really, it takes a lot of time to make a good blood pressure measurement. And a quick segue to saying this is why we find home blood pressures from patients extraordinarily important. We always want our patients checking their blood pressure at home and bringing in a home blood pressure log. But when you come to the office, yeah, the ideal way of checking the blood pressure is being put in a quiet room, sitting down, waiting for three to five minutes before anything is done in this quiet room, and then using an automated blood pressure cuff with your feet on the ground and your heart, excuse me, your arm at the heart level, so elevated but at the level of your heart and checking that blood pressure probably in duplicate and checking for consistency of that blood pressure across two measurements and either averaging them or taking the latter of the two measurements. And honestly, in most patients or in many patients with hypertension, we should be checking that blood pressure in both arms. Now, the reality is we can’t do this in every busy practice. That alone will take 10 minutes, but we should be doing it more often than we are now. But what we should also be doing is encouraging all of our patients to take these high quality blood pressure measurements at home too. You check it at home, you can check it with less stress. You can check it in that quiet situation. You can check it at the same time every day. So they’re more comparable measurements compared to the random blood pressure that you get in the office. And the reality is the physician, the patient should be making decisions based on all the above information. The blood pressure in the clinic and the blood pressure at home and the blood pressures throughout the day, whether it be morning, night, or afternoon. All of these add up to what your true blood pressure really is. And in my clinic, I’m routinely making blood pressure decisions with a combination of all these data points. One single blood pressure measurement in the office is insufficient to characterize someone’s blood pressure trajectory. Terry 26:56-27:36 I think that’s really important for people to know. And there are a couple of other questions or issues about blood pressure measurement that I’d like us to touch on. When I take my blood pressure at home, Dr. Blaha, I have a piece of furniture nearby that supports my arm at exactly the level of my heart or close enough. When it’s taken in the clinic, the last time I had my blood pressure taken at my doctor’s office, the nurse just had me hold my arm out. It was not supported at all. What difference does that make? Dr. Michael Blaha 27:38-28:21 Yeah, these probably make small differences, but all of these little elements that we talk about add up to potentially making big differences. If you talk about supporting your arm, if you talk about resting, if you talk about feet on the floor, all these can add up to substantial blood pressure variation. So you’re hitting at really important points. And I think we both want to measure the blood pressure well, but we also want to measure it consistently. So when we compare measurements from visit to visit or morning to afternoon or day to day, we’re measuring it the same way each time. That can be as important as doing the blood pressure in the perfect way. But you’re absolutely right. Feet on the ground, arm supported at the level of the heart is the ideal way to measure the blood pressure. Terry 28:21-28:41 And one other thing I could do at home is make sure my blood pressure cuff is the right size. If my arm is super skinny or extra fat, I can get a cuff that is adjusted to my arm size. In the clinic, they’re much less likely to change those cuffs when a patient has a non-standard size arm. Dr. Michael Blaha 28:41-29:13 Yeah, absolutely. Another critically important point, arm size varies tremendously. We try to change the cuff as much as we can in practice. We try to supplement this with a manual blood pressure check, but we can’t do it in reality in every situation. But blood pressure cuff size is another extremely important variable. Blood pressure is extremely hard to measure. I think we consider it sometimes as one number, but really it needs to be averaged. It’s the area under the curve, so to speak, of your blood pressure over your entire week, your entire month, your entire lifetime that matters the most. Joe 29:14-29:55 You know what really drives me a little crazy, Dr. Blaha? The new blood pressure machines have built into them what I’ll call the guideline targets. And every once in a while, well, if I take my blood pressure and it shows up at, let’s just say, 121 over 79, which I think, yeah, that’s pretty good. It says stage one hypertension. And I go, whoa, that’s just not fair. Come on, guys. But it’s like if you’re not below 120 over 80, you get dinged. What’s the deal with that? Dr. Michael Blaha 29:56-30:52 Hmm. Well, you raise an important point about these normal values. It’s the same thing on your lab slip, when it shows your LDL cholesterol being too low, or maybe your LDL cholesterol too high when it’s actually fine for your risk level. Tricky. These things are tricky. Yeah, I prefer probably if you didn’t, if it didn’t say something like stage one hypertension, it just said you’re in the yellow zone, perhaps not the green zone on that measurement. But yes, it gets to the main point that is really about the integration of many blood pressure checks. If you check it again and you don’t have stage one hypertension anymore, of course, you don’t indeed have a clinical diagnosis. You just had one blood pressure measurement that was high. So yeah, I think we could probably use different terminology there. I like the color coding of blood pressure measurements. You had a yellow, or I’m consistently in the yellow. I’m certainly not want to be in the red, but you’re right. We can’t be making diagnoses based on one measurement. We never do that. Joe 30:53-32:04 Let’s switch gears a bit and talk about blood pressure medications. The number one blood pressure pill in America is lisinopril. It’s what we call an ACE inhibitor, angiotensin converting enzyme inhibitor. These were originally derived from the jararaca snake in Brazil, if I’m not mistaken. I think Captopril was the very first one. And they are extraordinarily effective. And most people do really well on them. But there are some side effects. So tell us about the lisinopril cough. And I have to tell you, we have heard from people who say, oh, man, I went to my doctor. I got lisinopril. Six weeks later, I started coughing my head off. And then I was referred to an allergist. And then I had to go see an asthma expert. And then, and then, and then, and I was taking all these other drugs for the cough when it was really the lisinopril. So tell us about that cough and then tell us about something called angioedema, rare, but potentially deadly. Dr. Michael Blaha 32:04-34:11 Yeah. The ACE inhibitors are a good class of medications for blood pressure. They reduce the blood pressure. They protect the kidneys. They can protect the heart. They reduce cardiovascular events when you lower the blood pressure using them. But like any medicine, they have side effects. And the number one side effect with the ACE inhibitors besides hypotension, besides low blood pressure, can be this cough. Turns out the way that these drugs influence metabolism of hormones in the body, they do increase a moiety called bradykinin. This can cause cough. So this is well known that it can cause cough. And I don’t know, 5% to 10% of patients, probably in my experience, can develop a cough. It can be subtle, as you mentioned. It’s not obvious. It doesn’t pop up the first dose you take the pill. It can be subtle and a very kind of a light cough that gets misinterpreted as other things. It doesn’t get connected with the ACE inhibitor always because it doesn’t always pop up on that first or second dose. It usually goes away when you switch to a different blood pressure class of drugs like angiotensin receptor blocker or another class of medications. But yeah, this is something we should think about when we give our patients ACE inhibitors. Now, in some patients, you can get a more extreme reaction, almost like an allergic reaction called angioedema, where you don’t just get a cough, but you actually get swelling of the face, hands. You can even get swelling of the airway, which can be a high risk. This occurs more often in black patients than other race, ethnic groups. This is something to be aware of. And it’s one of the reasons why most of us for blood pressure, at least select an ARB, an ARB instead of an ACE inhibitor as the first choice. But both of them are similar and both great blood pressure drugs, but like any drug, it doesn’t come free. It always comes with some risk of side effects and low blood pressure and cough and rare risk of angioedema is the thing to be worried about when you start an ACE inhibitor like lisinopril. Terry 34:11-34:35 Dr. Blaha, you’ve mentioned a couple times that the patient’s overall risk has an impact on the selection of intervention. And I think that recently that risk calculator has been updated. Can you tell us briefly about that, please? Dr. Michael Blaha 34:35-36:10 Yes. Risk is the number one concept in preventive medicine. We want to make sure all of our therapies are selected based on risk. We don’t want to overtreat low-risk people. We want to treat our patients that are high-risk more aggressively. So risk is everything, but risk can be hard to estimate. We start with doing something called a risk calculator, as you mentioned, and the most recent one is called the PREVENT risk calculator, PREVENT, P-R-E-V-E-N-T, like PREVENT. And this calculates the 10-year risk of both atherosclerotic cardiovascular disease or total cardiovascular disease, including heart failure. And there’s also an option of including a measurement for 30-year risk. And it’s really using traditional risk factors that we measure in the clinic, but also can add in the hemoglobin A1C, urine albuminuria, also includes your zip code. It can include your zip code because it turns out where you live influences your risk. And it takes race, ethnicity out of the equation that was in prior equations. And it calculates your 10-year risk. Now, honestly, the prevent equations aren’t that different than our prior set of equations, the pooled cohort equations. But for some patients, they can be more accurate. But most importantly, they don’t overestimate the risk like our prior calculators do. This one is better what we call calibrated, so that the risk estimates actually numerically match what we observe in the real world better. That’s the biggest innovation with the PREVENT risk score. It’s a better calibrated risk score, and it’s now recommended across all the ACC/AHA guidelines. Terry 36:10-36:48 You’re listening to Dr. Michael Blaha, professor of cardiology and epidemiology at the Johns Hopkins School of Medicine. He’s the director of clinical research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Clinically, Dr. Blaha practices as a preventive cardiologist and in the interpretation of cardiac CT. Dr. Blaha has received multiple grant awards from the National Institutes of Health, the FDA, the American Heart Association, the Amgen Foundation, and the Aetna Foundation. Joe 36:49-36:59 After the break, we’re going to talk about a different risk factor for heart disease, coronary artery calcium score, or CAC. Terry 37:00-37:03 What is it, and why is it important? Joe 37:03-37:13 You can see calcium on a scan, but should you worry more about the plaques with calcium or the goo inside the lining of the arteries? Terry 37:14-37:18 What should we all be doing to reduce our risk of heart disease? Joe 37:19-37:26 What lessons should we take from people who have heart attacks, even though they’ve seemingly done everything right? Terry 37:39-37:43 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 37:55-38:13 And I’m Terry Graedon. Joe 38:14-38:31 Most people have had blood tests to determine their total cholesterol, their LDL cholesterol, their HDL cholesterol, and triglycerides. Some have even had a test for lipoprotein(a) or LP-little-a [LP(a)]. Terry 38:32-38:47 Others may have had a CAC scan. That stands for coronary artery calcium, and it shows up on a CT scan of the heart. What does a CAC score tell you about the health of your heart? Joe 38:47-39:13 To find out, we’re talking with Dr. Michael Blaha. He’s professor of cardiology and epidemiology at Johns Hopkins School of Medicine. He’s the director of clinical research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Clinically, Dr. Blaha practices as a preventive cardiologist and in the interpretation of cardiac CT. Terry 39:14-39:37 Dr. Blaha, one of the factors that we sometimes hear recommended to help us determine our risk is the calcium, let’s see, coronary artery calcium, the CAC score. Can you tell us what is it and is it important? Dr. Michael Blaha 39:38-40:49 Yeah, the calcium score is super important. It’s guideline recommended now across the world. In fact, new guidelines are embracing it more than ever before. And what it is, it’s a simple, rapid CT scan of the heart. It’s so-called gated to the cardiac cycle. In other words, you put electrodes on your chest. So it takes the pictures only during part of your heart cycle when the heart’s in between pumping. So you can get a still image of the heart, even though your heart is active. And that picture of the heart reveals the heart anatomy. But it also reveals calcium within the heart, because the calcium stands out on x-rays on CT scans. It stands out. It’s easy to see. So on these heart scans, we look for calcium deposits within the coronary arteries because we know that as plaque in the arteries ages, it becomes calcified. So if we see calcium within the coronary arteries on one of these simple rapid CT scans, we know that you have plaque in the arteries. In fact, the more calcium you have, the more plaque you have in the arteries. So effectively, this is a simple test for how much plaque you have in your arteries. The calcium score is a plaque burden test for the heart. Terry 40:49-40:59 Who needs a calcium artery score? Who needs to undergo this test? Because I’m assuming it’s not appropriate for everyone. Dr. Michael Blaha 41:00-43:40 Yeah, it’s not appropriate for everyone. It really needs to be done in the setting of risk assessment. I mean, if you don’t need your risk further assessed, you’re either a very low risk patient or you’re already a very high risk patient that’s being treated aggressively, you don’t need this test. This is a great test for initial risk assessment as we’re deciding on both the initiation or intensity of preventive therapies, or even the intensity of lifestyle recommendations. So it’s a great way to figure out your personalized risk. The risk scores that we talked about give a population risk estimate. If there was a thousand patients like you, what percent of them would develop disease. This is a test actually of your arteries. So it tells you in your body, in your arteries, how much plaque do you have? In other words, all those risk elements, risk factors, how do they impact your arteries? So it’s really a personalized risk assessment of you, of how much plaque you have in your arteries. And it’s appropriate for patients who are either borderline to intermediate risk with one of these risk scores where they’re in the middle, so to speak. It’s appropriate for patients who have so-called risk-enhancing factors, factors that aren’t accounted for in these risk scores, but are common, like family history, South Asian ancestry, the metabolic syndrome, chronic kidney disease, inflammatory disorders like rheumatoid arthritis, elevated lipoprotein(a), which we talked about earlier, all risk-enhancing factors that indicate a calcium score could be helpful. Calcium score can also be helpful in patients who are uncertain about therapy. Let’s say that the risk score says they probably should be on therapy, but they’re uncertain. They say, well, I don’t know. I want to get a better assessment of my risk and how likely I am to benefit. That’s a great reason. Calcium score can also be motivating. It can change a patient’s perspective on their lifestyle and maybe motivate lifestyle change. That’s actually a good reason for a calcium score too. So whenever it might change your lifestyle, change your treatment decisions, change the intensity of treatment decisions, that could be cholesterol, that could be aspirin, blood pressure, and the risk is uncertain, it’s indicated. And currently in the guidelines, there’s a so-called class 2A recommendation for these patients to get a calcium score. That means it’s favorable to do a calcium score, but it’s not mandatory. So just as you mentioned, it should be part of the physician-patient risk discussion. And if a patient says, I don’t want to take a medicine regardless of my risk, they don’t need a calcium score. But the more common scenario is a patient says, I really want to know what my risk is, doc. How can I figure that out? And a calcium score is one of the best ways of doing that. Joe 43:40-44:32 Now doctor, Dr. Blaha, we spoke with a cardiologist several years ago who said, you know, calcium, calcium carbonate, it’s like chalk. It’s hard. And yeah, it’s in that artery plaque, but it’s not that big a problem. The problem is in the softer tissue. And so it’s like when the plaque fractures and that goo that’s inside the coronary artery oozes out, that’s what causes the clot. And he was making the case for, you know, don’t worry so much about the calcium in your arteries, it’s the other stuff that’s inflammatory. How would you respond to him? Dr. Michael Blaha 44:33-45:51 Well, the good thing is I can counter that by citing international guidelines around the world that recommend the calcium score. So this is really a minority opinion, but actually there’s a lot of truth to that too. It’s true that it’s the soft plaque or it’s the partially calcified plaque that tends to rupture and cause heart attacks. So it’s true that we don’t fixate on the calcium so much, but we use calcium as a marker of your total plaque burden. You know, you can’t see soft plaque on a routine x-ray. You need a more sophisticated scan to see that, but you can see calcium on a simple scan. You can see it even on a chest CT that you get to rule out pneumonia. So we use calcium as a marker of your total plaque burden, realizing that we can’t see the non-calcified plaque. But if you have calcified plaque, you have the non-calcified plaque too. We can guarantee you that. So yes, it’s a good marker of risk. It’s a good marker of your total plaque burden, but it shouldn’t be fixated on. The calcium isn’t the problem. In other words, it’s not like how much calcium you’re eating in your diet, or I need to avoid drinking milk. That has nothing to do with it. The calcium is just a marker of your total plaque burden. It just happens to be the best marker, the most successful and cheap marker that we can use in practice. That’s why we use it. And that’s why the guidelines recommend it. Terry 45:51-46:13 Dr. Blaha, you have mentioned that one of the reasons that people might want to know their CAC score is so that they can adjust their lifestyle. And I’d really like to ask about lifestyle. What are the non-drug approaches we should all be doing to lower our risk of heart disease? Dr. Michael Blaha 46:15-47:56 Great question. I mean, I like to think of lifestyle as a two-staged approach. I mean, there are certain things that everyone should be doing, right? Everyone should be eating a generally heart-healthy diet. Everyone should be getting appropriate amounts of physical activity. Everyone should be at least conducting some moderate to vigorous physical activity. This is something that everyone should be doing. Now, I recommend this to all of my patients regardless. But really, there’s a second tier, so to speak, a second level of lifestyle intervention, right? So if a patient comes to me and they get a calcium score done and it’s very high, I’m going to sit them down and say, well, let’s really revisit that lifestyle. Let’s talk about specific ways of improving your lifestyle. Let’s talk about going further. Let’s dig into the diet and talk about specific additional changes you can make beyond the general heart healthy diet. Do we need to be moving more towards plant-based? Do we need to be removing more saturated fat from the diet? Do we need to be getting a physical trainer or a dietitian to look at you and figure out how to lower your risk? Do we need to increase your physical activity with a step counter or get some more feedback on your physical activity levels? Do you need to be increasing the soluble fiber in your diet, which can also lower the LDL? So I like to think of it as recommendations we make for everyone, and then in-depth, detailed recommendations we make for our high-risk patients. So yes, even lifestyle, we’re going to cater to the risk of the patient. High-risk patients, we’re going to do everything we can to dive into that lifestyle, to make all the recommendations to improve that risk. Now, if a patient’s low risk, we’ll probably just stick with the basics. Heart-healthy diet, get your exercise, and just maintain that for life. Joe 47:57-49:18 What I’d like to ask you about is very controversial, and it has to do with people who have done everything right. I can’t tell you how many messages we get from people who say, you know, I’m a vegetarian or I eat very, very healthy food. I exercise, I walk or I run on a regular basis. I don’t smoke. I never have smoked. My cholesterol levels are fabulous. but I had a heart attack last year. How could that be? And when we’ve heard from other people who say, I’ve been taking statins for 30 years and I had a heart attack. Come on, that wasn’t supposed to happen. And I guess, you know, I think about James [Jim] Fixx, the runner who, you know, had really cleaned up his lifestyle and he was running and boom, he dropped dead of a heart attack almost instantly. And there are a lot of people who do experience what’s called cardiac arrest with no chest pain, no elephant on the chest, no jaw pain. Can you tell us about those, what I would call sudden onset heart attacks where you can’t get them to the emergency department in time and theoretically they were doing everything right? Dr. Michael Blaha 49:18-50:50 Yeah. These are really important. This is really the goal of the preventive cardiologist. I’m a preventive cardiologist, is to reduce these life-changing heart attacks that were so-called unexpected. Now, it turns out, of course, that many heart attacks are preceded by risk factors. But some heart attacks do occur in patients without risk factors. But patients almost never experience heart attacks like this if they have no plaque in their arteries. This is why we need to use, in most patients, both risk factors and an assessment of their plaque burden, like a calcium score, for example, for risk assessment. Because we’ll see this. We’ve done studies in populations of people with no risk factors. And you know what? Some people still have highly elevated calcium scores. We’ve done calcium scores in groups of patients who have multiple risk factors. Some of them have no calcium in their arteries at all. The reality is at the individual patient level, it’s still extremely complex. And complex environment, gene, risk factor interactions that lead to your vulnerability. And that’s why we like to personalize that risk assessment with imaging. Now, there’s even a few patients who will have events even without any plaque in their arteries, but that is rare. The combination of knowing your risk factors and knowing how much plaque is in your arteries will give us the best chance of preventing these sorts of heart attacks. In our population studies, when we follow patients up and find these patients who’ve died suddenly, nearly all of them had significant plaque in their arteries up to a decade or even two decades earlier. Joe 50:50-51:47 Well, let me ask you about one other risk factor that cardiologists don’t always talk about, infections. There are now a substantial number of studies that have demonstrated that upper respiratory tract infections like COVID or influenza or pneumonia or even other infections like, oh, you might run into it with a urinary tract infection or periodontal disease where you have a gum inflammation infection. And the researchers say, well, it’s an inflammatory reaction from the infection. And that kicks off a cascade of events that leads to heart attacks and even strokes. That’s not something that cardiologists usually think about that they can do anything about, you know, preventing pneumonia or preventing the flu. Terry 51:48-52:01 But there is some data suggesting that getting vaccinated against the flu or getting vaccinated against RSV can actually lower your risk for heart disease. Dr. Blaha? Dr. Michael Blaha 52:02-53:18 Yeah, you’re speaking to really this kind of inflammatory hypothesis of cardiovascular disease, which is definitely maturing. And there’s just no doubt about it, that low-grade inflammation is a risk factor for heart disease. And I would say actually the paradigm of what you’re talking about really comes from the HIV literature. Patients with HIV have an increased risk of cardiovascular disease. And that seems to be largely explained by low-grade inflammation. So HIV is considered a risk factor for heart disease. Now, and we will treat it with a statin in all cases of HIV, regardless of other risk factors, because we know that HIV puts you at risk for cardiovascular disease. Now, it’s harder to piece together these acute infections, like you mentioned, for example, a respiratory infection or kidney infection, but multiple acute infections probably do something similar to a chronic infection or something like HIV. Put it this way: inflammation, chronic inflammation, or multiple bouts of acute inflammation are not good for the body. They raise the risk of cardiovascular disease. So to make a quick segue there, of course, one of the next big generations of therapies that hopefully will come to fruition for cardiovascular disease are the specific targeted anti-inflammatory therapies that are under development right now. Joe 53:18-53:26 I was hoping you’d say that. We only have a minute left. Can you give us a quick overview in about 30 seconds about your study of colchicine? Dr. Michael Blaha 53:26-54:05 Well, colchicine is one of those, and there’s multiple biologics on the way for inflammation. But yeah, colchicine is a drug that interacts with the so-called NLRP3 inflammasome. It’s a kind of an organelle that forms in the body in response to stress and inflammation. And this chronic inflammation can be suppressed by colchicine, and you can lower your cardiovascular risk. You also lower your risk of gout and even your risk of needing a hip replacement or osteoarthritis. So it’s linking together all this chronic wear and tear, this inflammation and cardiovascular disease together. And there’s many therapies beyond colchicine, which is great, coming for potentially be the next wave of new cardiovascular therapies. Joe 54:06-55:40 Well, colchicine has been around for decades. It’s been used for gout for a very long time. And it’s cool that you’ve done some research showing it may be beneficial for cardiovascular disease as well. Dr. Blaha, I’d like to ask you about a category of medications that people pretty much take for granted. And I won’t say everyone with high blood pressure gets put on a diuretic, but boy, a lot of people do. And they’re often combined with drugs like lisinopril, for example, or as you mentioned earlier in the show, the ARBs. So we’re talking about hydrochlorothiazide and other thiazides. There are several other kinds of diuretics as well. The idea of sodium and potassium and other minerals, which may be depleted, zinc, magnesium, when you take these diuretics, it’s a very complicated story. And it’s been our experience that not everybody gets monitored on a regular basis. They may see their doctor once a year, and they might get a blood test just before they see their doctor, but then they may go for six months or a year without getting checked for their, for example, potassium levels. And as a cardiologist, you are very much aware of what happens when potassium gets too low or too high. So tell us about diuretics and some of the possible side effects, including skin cancer. Dr. Michael Blaha 55:41-56:54 Yeah, diuretics are an important part of blood pressure therapy because many times patients with high blood pressure have so-called volume expansion. They essentially have too much volume, too much pressure, water within the vasculature, and it needs to be depleted. And a diuretic, by inducing the kidney to essentially pee out water and salt, can decrease the blood pressure. But like anything, that can come with side effects, particularly patients who have kidney disease or patients who have pre-existing electrolyte disorders. You can either be depleted in your sodium, you can retain potassium depending on the diuretic we’re talking about. All these things do need to be monitored. Usually those show up within the first several months of taking the therapy, but they can show up later too. They’re generally safe. Millions of patients take diuretics safely, but it should be checked after you start one of these therapies, your electrolyte should be checked– and should be checked on a routine basis going forward with routine labs. Once again, all medications have side effects. And with diuretics, we need to be aware of the higher risk of electrolyte disorders. And with the hydrochlorothiazide, a rare instance of skin disorders can happen. That’s also true. Joe 56:54-57:01 Can you share with us what the symptoms of low potassium and high potassium would be? Because they’re very similar. Dr. Michael Blaha 57:02-57:40 Yeah. And most of the time talk about low-grade reductions in potassium or elevations of potassium, which can be asymptomatic, but they can cause gastrointestinal problems. They can cause neurologic problems or problems with sensation. They show up with things like changes on the electrocardiogram as well. But I think I really want to make the point here that low-grade changes in your electrolytes are usually asymptomatic. So we can’t rely on symptoms to tell us. We need to check our labs. In patients on diuretics to make sure that these electrolytes aren’t getting out of whack. There can be symptoms, but there can be no symptoms too. Joe 57:40-58:25 Dr. Blaha, a lot of people have seen commercials for what I’ll call home electrocardiograms without mentioning any brands, but even the phone, iPhones, for example, can measure for something called atrial fibrillation. Sure. Why is it important to, number one, detect AFib, and B, what are the possible complications of AFib? And if you can, what can you as an interventional cardiologist do to prevent something bad happening if somebody does have AFib? Dr. Michael Blaha 58:26-01:00:16 Yeah, so atrial fibrillation is the most common arrhythmia in older adults. It’s when the top chamber of the heart starts beating irregularly, erratically. It’s fibrillating. And in some patients can cause palpitations or rapid heart rate. But in a lot of patients, actually, atrial fibrillation is asymptomatic. We have to stress that. In many patients, atrial fibrillation is asymptomatic. Now, atrial fibrillation can cause blood clots in the heart and can cause, by virtue of those blood clots going to the brain, they can cause stroke. In fact, it’s one of the largest risk factors for stroke. So this is a tricky situation. We have a very common arrhythmia that can be asymptomatic, but is associated with stroke, which is why we go out of our way to try to identify it. We’re trying to find new ways of identifying atrial fibrillation in asymptomatic patients. But this is tricky too. So things like home EKG monitors can find atrial fibrillation. They can be extremely helpful in certain patients. But in other patients, they can lead to false positive results, too. So we need to recognize all these home measurements are not as good as the EKG in the office. But many patients can show up and say, hey, I’ve seen atrial fibrillation on my home monitor, let’s check it out. I might need to be on a blood thinner. That’s what we do. For patients with atrial fibrillation, they need to be on a blood thinner to reduce that risk of stroke. It dramatically reduces the risk of stroke. But of course, it doesn’t reduce the risk of stroke if you don’t know you have AFib and you’re not taking a blood thinner. So early detection of AFib is very important. But there’s caveats there. We don’t routinely recommend low-risk patients check their heart rhythm at home. That’s probably not useful. But if you’re higher risk, or maybe you have some early palpitations, we do think it’s a reasonable idea to come get an EKG or check your rhythm at home and share that with your doctor. Joe 01:00:16-01:00:27 Dr. Blaha, can you tell us a little bit more about colchicine, this gout medicine that’s been around for decades? What did you find? Dr. Michael Blaha 01:00:28-01:01:41 Yeah, low-dose colchicine taken at a low dose in a chronic way, as opposed to the acute bouts of colchicine you take for gout, can suppress inflammation and appears to lower cardiovascular risk. One of the studies we’ve done most recently after the FDA approval of colchicine for cardiovascular risk reduction is to look to see how many patients are taking it. And it turns out colchicine has been very slowly uptaken by physicians. I think they’re still trying to get their mind around this idea of an anti-inflammatory drug for cardiovascular disease, but it appears to work on top of things like a statin and blood pressure control. So low-dose colchicine is a good option for patients who have inflammation, high cardiovascular risk, and they want to reduce their risk further. Now, there’s some side effects with colchicine too. Some patients get gastrointestinal upset. You can’t take it if you have severe kidney disease, but for other patients, the low-dose daily colchicine is a great way of lowering cardiovascular risk, but it’s not being used much. We’re still doing studies on it to understand it more. It’s in the guidelines, it’s FDA approved, but it’s still so new. We’re trying to get used to who benefits the most from this really exciting old therapy. Terry 01:01:41-01:01:51 Dr. Blaha, we understand that the FDA has recently approved a blood pressure medicine in an entirely new category. What can you tell us about it? Dr. Michael Blaha 01:01:52-01:03:08 Yeah, this is pretty exciting because we haven’t had a new mechanism of action for blood pressure in a long time. So particularly in patients with resistant hypertension who need the fourth or fifth drug, we didn’t really have any new innovations. So aprocitentan is a dual endothelin receptor antagonist. It blocks a mechanism in the body that raises blood pressure in a new way. And it lowers blood pressure, even in patients taking three or four drugs who are still having elevated blood pressure. So really it’s a resistant hypertension drug, a brand new class when we’re looking for new options. You can pick a drug like this and we have another couple drugs coming down the pipeline for resistant hypertension. So patients who have a hard time getting to go on multiple drugs didn’t used to have many good options. They could lean on an old drug or they could try to change within classes, but they didn’t have any new mechanisms of action. Now with aprocitentan or new drugs coming for aldosterone synthase inhibitors, they’re going to have new options for resistant hypertension. So resistant hypertension is in a hot new area. We’re going to have brand new options, new ways to get patients to goal. Joe 01:03:08-01:03:22 Dr. Blaha, our listeners want to know what medicine you’re talking about. Those generic names can be hard to pronounce and hard to spell. Is there a brand name associated with this new blood pressure pill? Dr. Michael Blaha 01:03:22-01:03:39 Yes, absolutely. This drug that’s a dual endothelin receptor antagonist is called Tryvio. Tryvio, T-R-Y-V-I-O. Joe 1:03:30-1:03:33 T-R-Y-V-I-O. Terry 1:03:33-1:03:36 Because you’re going to try to get your blood pressure down. Joe 1:03:36-1:03:37 Right. Dr. Michael Blaha 1:03:36-1:03:39 I guess so. I guess we all need to get more experience with this brand new drug. Terry 01:03:40-01:03:46 Dr. Michael Blaha, thank you so much for talking with us on The People’s Pharmacy today. Dr. Michael Blaha 01:03:47-01:03:48 My pleasure. Thanks for having me. Terry 01:03:50-01:04:29 You’ve been listening to Dr. Michael Blaha. He is professor of cardiology and epidemiology at the Johns Hopkins School of Medicine. He’s the director of clinical research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Clinically, Dr. Blaha practices as a preventive cardiologist, and in the interpretation of cardiac CT. Dr. Blaha has received multiple grant awards from the National Institutes of Health, the FDA, the American Heart Association, the Amgen Foundation, and the Aetna Foundation. Joe 01:04:29-01:04:38 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. BJ Leiderman composed our theme music. Terry 01:04:38-01:04:46 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 01:04:47-01:05:04 Today’s show is number 1,450. You can find it online at peoplespharmacy.com. At peoplespharmacy.com, you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 01:05:04-01:05:47 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, there’s some information that wouldn’t fit in this broadcast. You’ll hear about the pros and cons of diuretics, especially their impact on minerals like sodium and potassium. Can you detect AFib at home? And should you? We discuss the technology that could make this possible. We also get more details on the colchicine study, as well as the new drug FDA recently approved for hypertension. What makes it different from other blood pressure pills? Joe 01:05:47-01:06:13 At peoplespharmacy.com, you can 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. And we’d be grateful if you would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:06:13-01:06:50 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 01:06:51-01:07:00 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 01:07:01-01:07:05 All you have to do is go to peoplespharmacy.com/donate. Joe 01:07:06-01:07:19 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.

Transcribed - Published: 30 October 2025

Losing weight is hard. That’s probably why almost three-fourths of American adults are overweight or obese. On this episode, we speak with a distinguished doctor and former FDA commissioner who has personal experience struggling with the scale. In this discussion of popular weight-loss drugs like Wegovy, we tackle the biology of weight. We also interview an evolutionary anthropologist about some human populations that don’t have problems with obesity. Is their active hunter-gatherer lifestyle burning more calories? 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 EDT on 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 October 20, 2025. Has the Food Industry Hijacked the Biology of Weight? While Dr. David Kessler (our first guest on this episode) was FDA Commissioner, from 1990 to 1996, the agency made some major strides towards helping people understand what they are eating. That is when Nutrition Facts labels were standardized and required on all packaged food. In the US, if you buy food that is in a package, that Nutrition Facts label will tell you how big the serving is, how many calories per serving, and also data like the amounts of protein, carbohydrates, fat, and certain vitamins and minerals are supplied by each serving. If information were all that we needed to choose exactly what and how much to eat, there would be no weight problems. Yet Dr. Kessler’s own difficulties with the 10 pm cravings will not sound strange to many of us. The biology of weight may appear straightforward, but the allure of fat, salt and sugar to our reward centers may bypass rational decision-making. One of Dr. Kessler’s great achievements as FDA Commissioner was holding the tobacco industry to account. How has the food industry escaped similar scrutiny? It seems that the ultraprocessed foods that seem convenient and affordable are contributing to the toxic fat making us sick. GLP-1 Drugs to the Rescue: Given the difficulties people have trying to lose weight, it is no surprise that the GLP-1 receptor agonists like semaglutide (Wegovy and Ozempic) or tirzepatide (Zepbound and Mounjaro) have become popular. They seem to reduce the urge to eat and calm the food noise in people’s heads. Those 10 pm cravings Dr. Kessler describes disappear under the influence of these weight loss drug. He has taken such a medication himself to drop the 40 pounds he gained during the intense work period of the COVID-19 pandemic. These medications will be very helpful for many people, but they do have some serious side effects. (You can learn more here.) Healthcare should utilize them as a powerful tool, but just one in a toolbox that should have several. How Does Exercise Affect the Biology of Weight? The famous mantra, calories in calories out, suggests that we might be able to exercise our way to a healthy weight. After all, if you burn more calories than you take in, you should lose weight. But anthropologist Herman Pontzer, PhD, has studied people’s energy expenditures around the world. He and his colleagues used a sophisticated technique called double-labeled water to track the energy people burn. According to their data, humans’ daily energy needs don’t vary as much as we’d think, even when physical activity is vastly different. The Hadza, who get their dinner by tracking, hunting with bow and arrow and running after the injured animal, somehow use roughly the same amount of energy as Americans shopping at the grocery store. Their physical activity is enormously higher, though. (Check out this publication at the Proceedings of the National Academy of Sciences.) Apparently, we need to pay more attention to the calories (actually kilocalories) we consume if we want to understand the biology of weight. This Week’s Guests: David A. Kessler, MD, served as chief science officer of the White House COVID-19 Response Team under President Joe Biden and previously served as commissioner of the US Food and Drug Administration under Presidents George H.W. Bush and Bill Clinton. Dr. Kessler is a pediatrician and has been the dean of the medical schools at Yale and the University of California, San Francisco. He is the author of the New York Times bestsellers The End of Overeating and Capture and two other books: Fast Carbs, Slow Carbs and A Question of Intent. Dr. Kessler’s latest book is DIET, DRUGS, AND DOPAMINE: The New Science of Achieving a Healthy Weight. David A. Kessler, MD. Photo copyright Joy Asico Smith Herman Pontzer, PhD, is Professor of Evolutionary Anthropology and Global Health at the Duke Global Health Institute. Dr. Pontzer is the author of Burn: New Research Blows the Lid Off How We Really Burn Calories, Stay Healthy, and Lose Weight. His latest book is Adaptable: How Your Unique Body Really Works and Why Our Biology Unites Us. Herman Pontzer, PhD, Duke Global Health Institute 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, Oct. 20, 2025, after broadcast on Oct. 18. 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 1449: 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. Have you ever worried about your weight? Have you considered the new GLP-1 drugs? Do they help control cravings? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:46 Today we talk with a former FDA commissioner. Like many of us, Dr. David Kessler has had trouble controlling his weight over the years. He’s utilized the new drugs to overcome his nighttime food cravings. Joe 00:47-00:53 Dr. Kessler’s new book is Diet, Drugs, and Dopamine, the New Science of Achieving a Healthy Weight. Terry 00:53-01:01 You’ll also hear from anthropologist Dr. Herman Pontzer. His research shows that people around the world have very similar energy needs. Joe 01:02-01:10 Coming up on The People’s Pharmacy, the biology of weight. Insights from the GLP-1 drugs and hunter-gatherers. Terry 01:14-02:28 In The People’s Pharmacy Health Headlines: If the U.S. follows the epidemiological patterns from Japan and Great Britain, we should expect flu season to go into overdrive soon. Japan is experiencing an early and unexpectedly severe start to its flu season. By early October, more than 4,000 people had been hospitalized with influenza, and many schools and daycare centers were closed to slow the spread of the virus among children. Some health experts worried that the virus is mutating to become more of a threat. The early arrival of influenza in Japan should not have come as a big surprise. That’s because Australia also experienced an early and severe flu season. It peaked between June and July much earlier than usual. RSV, or respiratory syncytial virus, and SARS-CoV-2 were also rampant at the same time, putting the health care system under stress. British authorities report that the viruses that cause colds are also prevalent in the UK. Flu is on the rise there. As infections rise in Europe and Asia, America may not be far behind. Joe 02:29-03:10 Viruses are not the only pathogens worrying public health authorities. The World Health Organization released a report this week alerting doctors that common bacterial infections are increasingly resistant to antibiotics. One in six bacterial infections in the study were no longer susceptible to the usual medications. More than 40% of antibiotics have lost potency over the last seven years. Infections that are harder to treat include gonorrhea, urinary tract infections, and some GI infections such as E. coli. If we don’t develop new ways of treating these pathogens, millions are likely to die in the coming years. Terry 03:10-04:03 Measles is spreading around the country. Cases reached a three-decade high this week. The very large outbreak in Texas has been declared over. However, there are pockets of infection in Minnesota, South Carolina, Utah, and Arizona. In several communities, students are being quarantined to prevent the spread of infection. In South Carolina, for example, 150 school kids have been quarantined because children in Spartanburg and Greenville counties were exposed to kids with measles. There have been nearly 1,600 cases reported in the U.S. this year. That’s the highest number in three decades. This virus is highly contagious, and vaccination is the only way to prevent its spread. The MMR vaccine against measles, mumps, and rubella is 97% effective against measles. Joe 04:04-04:50 New guidelines for COVID vaccinations have a lot of people confused, including pharmacists who administer the shots. At first, the FDA only approved the new immunizations for people at very high risk, or those over 65. Then, the CDC suggested that anyone who wanted a COVID vaccine would need to consult a healthcare professional first to learn about risks and benefits. Some pharmacists interpreted that guidance as meaning that people would need a prescription before a shot could be administered. Then there was confusion as to whether insurance companies would pay for COVID vaccines. To make matters worse, different states may be adopting different guidelines. At the moment, though, most insurance companies are paying for COVID jabs. Terry 04:51-05:35 Life expectancy has returned to pre-COVID levels. That’s because COVID deaths have fallen from the number one cause of mortality in 2021 to number 20 in 2023. Worldwide, life expectancy is now 76.3 years for women and 71.5 years for men. In 1951, female global life expectancy at birth was 51.2 years, and male life expectancy was 47.9 years. So we have made progress over the last 70 years, but there is an alarming trend. Death rates are climbing among young adults and adolescents. This increase appears to be linked to depression, anxiety, suicide, alcohol, and drug abuse. Joe 05:35-05:57 A new study in JAMA suggests that preteens who spend more time engaged with social media have a harder time learning in school. Those who increase their time on social media had more difficulty with reading, memory, and vocabulary as assessed by standardized tests. 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. For the last several decades, Americans have been getting heavier. Nearly three-fourths of adults have been categorized as overweight, with 40% of us in the obese range. Why do we have so much trouble managing our weight? Terry 06:33-06:55 We’ll be talking today about the biology of weight. The enormous popularity of GLP-1 drugs like Wegovy or Ozempic can shed some light on this question. We’ll also hear from an anthropologist whose research shows that our couch potato ways may be bad for our health, but they’re not solely responsible for our weight problems. Joe 06:55-07:26 First, though, we’re talking with Dr. David Kessler. He served as chief science officer of the White House COVID-19 response team under President Joe Biden and previously served as commissioner of the Food and Drug Administration under Presidents George H.W. Bush and Bill Clinton. Dr. Kessler is the author of “The End of Overeating” and “Fast Carbs, Slow Carbs.” His latest book is “Diet, Drugs, and Dopamine: The New Science of Achieving a Healthy Weight.” Terry 07:28-07:31 Welcome to The People’s Pharmacy, Dr. David Kessler. Dr. David Kessler 07:32-07:33 Thanks for having me. Joe 07:34-08:26 Dr. Kessler, it is such an honor to be speaking with you, but I would like to take issue with the very first sentence of your new book. You state, and I quote, “I am average.” And I would argue that you are far, far from average. You are a pediatrician. You’re also an attorney. And you have been commissioner of the Food and Drug Administration under President George H.W. Bush. And you’ve been chief science officer of the White House COVID-19 response team. And that’s just for starters. You’ve also been dean of medical schools. So far from average. But I suspect that in that first sentence, you’re talking about body weight. So what do you mean when you say you are average? Dr. David Kessler 08:26-09:22 I’ve struggled with my weight my entire life. I have suits in every size. I’ve gained and lost my weight at the end of, you know, had the privilege of, as you mentioned, co-leading Operation Warp Speed. COVID was an intense period of time. You know, I was working seven days a week, 18 hours a day. I turned around and I found myself 40 pounds heavier. And I had, you know, I had gained weight. I had lost weight. But this mystery of weight, why was it so hard? You know, no one could say, I think, you know, I was able, you know, to do these other jobs. I mean, no one ever accused me of not having, you know, adequate discipline. But when it came to weight, there I was, I think like many other people, this struggle, this mystery. Terry 09:24-09:32 Dr. Kessler, you suggest that the food industry has hijacked our health. Would you expound on that a little bit, please? Dr. David Kessler 09:33-10:57 Well, certainly, you know, let’s just start with what I think you mentioned, which is the real key for me. You know, it’s about our health. This is not about our weight. The fact is the American body is ill. Only 12% of Americans are healthy. Only 12% when you look at measures of blood pressure, blood lipids, waist circumference, glucose, just basic metabolic measurements. And the culprit there, I mean, again, this is not about weight. right? I mean, it’s about toxic fat. That fat that accumulates around our abdomen, that invades our liver, our pancreas, our heart, our skeletal muscle, that toxic fat is causing many cardiac, renal, metabolic diseases that lead to chronic disease. I knew that weight wasn’t good for us. Even as a doc, I knew it wasn’t good for us, but I didn’t know it was causing these chronic diseases. So the problem is this toxic fat. And then the question is, what causes that toxic fat? And that gets in to, you go back upstream to that, that’s our diet, that’s the food supply, that’s the food industry. Joe 10:59-11:38 Well, you know, Dr. Kessler, you’ve given us a statistic that is mind-boggling because you’re saying that most of us are not healthy, the overwhelming majority of us. I mean, we have, as you pointed out, hypertension. Half of the population, adult population has high blood pressure, but we also have blood sugar problems. We also have all kinds of other metabolic issues going on. Is that true in some of the places that you’ve visited around the world? Are other countries also suffering the way we are? Dr. David Kessler 11:38-13:55 I think, I mean, it’s fair. We’ve always led the world when it comes to public health in good ways. And I think we’ve also leading the world when it comes to, you know, this issue. I think many, many countries are maybe not quite at the extent of the morbidity and mortality that we have, but I think, unfortunately, they’re catching up. Understand, in our lifetime, right, in our lifetime, 25% of us are going to go on to develop heart failure. You know, some 30 to 40% of us are going to go on to develop diabetes. 25%, you know, are going to have a stroke. And, you know, much of that, all those major killers, that chronic disease, right, those things that cause in our senior years, you know, yes, we may live as long, but we’re going to be in a more disabled state because of that. We’re not going to be as productive. You know, that is all, I mean, we are coming to realize, I think medicine is waking up to the fact. I mean, cardiologists, endocrinologists, obesity medicine, doctors, you know, I mean, some neurologists, even oncologists. Many of these diseases, cardiac, kidney, endocrinological, metabolic, about 13 forms of cancer, some of the neurodegenerative diseases, they have a common core. And it’s this metabolic adiposity, this metabolic toxic fat that is causing it. And for the first time, I mean, the good news is for the first time, we have the tools that can fix that. No magic answers, right? No magic pills, right? But we do have tools that we can reclaim our health if you want to. Terry 13:56-14:27 Well, we do want to talk about that in just a moment, but I asked you about the food industry, and we actually have a government agency that is supposed to be looking out over oversight, supposed to be doing oversight on the food industry. It’s an agency you’re very familiar with. We call it the Food and Drug Agents Administration. So what did the FDA get wrong about public health and nutrition? Dr. David Kessler 14:28-15:36 So back in the 90s, when we had the opportunity to be at the agency, you’ll remember we did, you may remember that we did the nutrition facts panel, right? I mean, go pick up any, I don’t know if there’s any packaged food in the studio, but that nutrition facts panel, that few inches has calories, fat, sugar, protein. And it was hailed as a major advance, right? And it was for its day, right? And still many people rely on that when they look at food that they buy. What they did not, what we didn’t get, and I don’t think anyone really got, were the consequences, the biological effects of that fat, sugar, and salt in our bodies. What was it doing to our insulin levels? What was it doing to the way we deposited fat? We didn’t understand the consequences fully of what we were putting in our bodies. Joe 15:37-16:00 Dr. Kessler, you are renowned for going after the tobacco industry and the impact of nicotine. Tell us how the food industry evolved its own, shall we say, addictive power when it came to food. And we just have a couple of minutes before the break. Dr. David Kessler 16:02-17:09 So in order to feed a hungry nation back in 1930s, 1940s, food industry learned to process food, to create this sort of alternative food system, this industrial food. It was able to extend shelf life. It extracted certain very cheap chemicals from food ingredients, took those, took out the water, were able to ship things over long distance, added in palatability, added fat, sugar, and salt. These other modified starches and other chemical ingredients, right. And this was the modern industrial processed ultra food supply. And the advantage, it was cheap, it fed a hungry nation, it was convenient, and it replaced traditional foods. We took fat, sugar, and salt, put it on every corner, made it available 24-7, made it socially acceptable to eat anytime while living in a food circus. And the consequences? Consequences is this toxic fat. Terry 17:10-17:12 And what makes that fat so toxic? Dr. David Kessler 17:14-17:48 It gets into your organs. It gets into your pancreas. It gets into your liver. That liver releases these inflammatory substances and hormones and free fatty acids. And fat goes in places where it’s not supposed to be. It’s not supposed to be in your heart. It’s supposed to be a little in your liver, but it gets into your muscles and your pancreas. And it causes major significant cardiac endocrinological renal disease. Terry 17:50-18:12 You’re listening to Dr. David Kessler. He’s a former commissioner of the Food and Drug Administration under President George H.W. Bush. Dr. Kessler has also been dean of the medical schools at Yale University and the University of California, San Francisco. His most recent book is “Diet, Drugs, and Dopamine: The New Science of Achieving a Healthy Weight.” Joe 18:12-18:18 After the break, we’ll find out what Dr. Kessler means by the 10 p.m. cravings and why they’re so dangerous. Terry 18:18-18:21 How do GLP-1 drugs help people achieve their desired weight? Joe 18:22-18:28 How can we make choices today that will help us achieve a healthy weight in the future? 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 18:54-19:04 And I’m Terry Graedon. Today, we’re talking about the biology of weight. Why are so many of us having trouble achieving and maintaining a healthy weight? Joe 19:04-19:23 Americans have fallen in love with GLP-1 receptor agonist medications. You’ve probably heard of drugs like Ozempic, Wegovy, Mounjaro, and Zepbound. They’ve captured the imagination of millions of people. How do they help people lose weight? Terry 19:23-19:53 We’re talking with Dr. David Kessler, who served as chief science officer for the White House COVID-19 response team under President Joe Biden. He’s a former commissioner of the Food and Drug Administration under President George H.W. Bush, and he’s also been dean of the medical schools at Yale University and at the University of California, San Francisco. His most recent book is “Diet, Drugs, and Dopamine: The New Science of Achieving a Healthy Weight.” Joe 19:55-20:19 Dr. Kessler, we’re going to talk in a moment about this revolution called GLP-1 drugs. But first, you are very personal in your book, and you talk a little bit about this idea of 10 p.m. cravings that was your enemy. Tell us what happened at 10 p.m. for you. Dr. David Kessler 20:19-22:20 For me, 10 o’clock at night, if I’m working 18, 19-hour days, certainly during COVID, or even going back to when I was in school, I think many of us can remember medical school. I had to study for the next exam or do that paper, and at 10 o’clock, I’m tired, I’m fatigued. I need to make it through the next three or four hours. And I go, yeah, should I go down to the refrigerator? Should I have something? Maybe it’s not so good for me. This struggle, right? So, I mean, there are these, understand that these are, I’m not, 10 o’clock at night, I had just eaten dinner. I mean, I wasn’t doing this for fuel. I was doing this to change how I feel. I mean, and I think that’s what is so important to understand that food, I mean, in essence, I mean, changes how we feel. I mean, it works on the reward centers of the brain. I mean, it’s psychoactive. Those reward centers of the brain, you know, are really, they are the addictive centers of the brain. We think about addiction as for the weak or the downtrodden, but the human brain evolved to deal with scarcity, not abundance. And for much of human history, there was no guarantee when our next meal would come, when it would arrive. So our biological systems are designed to seek out that sweetness, that most energy-dense food. And we’re wired to focus on the most salient stimuli. And the way this works, I mean, when you think about, when you understand addiction, we have just, I mean, addiction is part of all of us, those circuits. It’s this cue-induced wanting. So 10 o’clock became the cue, right? That fatigue became the cue. So that 10 o’clock at night, I’m not eating for fuel. I’m eating to change how I feel. Terry 22:21-22:28 So Dr. Kessler, how do these GLP-1 drugs help people achieve their desired weight? Dr. David Kessler 22:29-24:39 They are highly effective. But bottom line is they work. there’s no real magic, right, to them. I mean, they work by keeping food in our stomach longer. You know, there is this spectrum, right? I mean, we’ve all, this sort of satiety spectrum. And I think we’ve all experienced this. You get the flu, your GI tract doesn’t work as well, food’s staying in there. When food stays in my stomach longer, I don’t want to put anything else in. I mean, look, the thing, whether it’s diet or drugs or surgery, get you to lose weight, they all do it by decreasing appetizing, getting us to eat, put less in our mouths to eat less. Look, that mantra, that fail, eat less, exercise more. Absolute failure, right? Didn’t work. It didn’t work because of the addictive circuits. But what these drugs do is they help you to eat less. How do they do that? Right? I mean, it’s these addictive reward circuits that are at play, this wanting this 10 o’clock at night. But those feelings, right? I mean, these feelings, the GI brain access, I mean, there’s another set of circuits beyond the addictive circuits. They’re called the aversive circuits. I mean, so this food staying into my stomach longer, that’s in part controlled by the hindbrain, not the reward circuits, the area postrema, the nucleus solitarius, those circuits counterbalance. So those feelings counterbalance, those aversive feelings counterbalance to reward circuits. I don’t want to put anything else in my stomach. I learn to eat smaller. Maybe I do that unconsciously. But you have this balancing, these aversive circuits, these reward circuits, and they dictate how I feel at the moment and whether I want to eat or not. Joe 24:40-25:30 Dr. Kessler, a lot of people now, because, well, Novo Nordisk, the manufacturer of Ozempic and Wegovy, has made billions and billions of dollars. There are a lot of people who say, well, this is simple, all I have to do is take the shot. Or in the case of some of these drugs, now they’re taking the pill. I don’t have to think about food choices, I don’t have to think about exercise. All I need is a GLP-1 agonist. So it seems like this is just part of the equation. It may be the dopamine part. You feel that satiety. You don’t feel like I need to snack at 10 p.m. But what about the food choices and the exercise? Dr. David Kessler 25:31-27:39 So how long are you going to stay on that pill for? That drug is going to work while you’re on it. Now, look, it has, let’s just agree, these drugs have real adverse events, right? I mean, this is no walk in the park. This notion that these are not be-all and end-all, right? The fact is that if you look, the average person is on these drugs today for about eight, nine months, right? These drugs work while you’re on them. They don’t work. You don’t expect them to work when you go off them. But what’s going to happen? People are going to spend thousands of dollars, go on these drugs, lose this weight, stay on this for eight to nine months. When you lose weight, you lose muscle also. You go off these drugs and then people are going to gain back that weight and say, we’re going to turn around in three, five years and go, hey, this is one big, massive failure. So what are you going to do? There is no end game when it comes to weight. It’s a chronic, relapsing condition. Once you’ve gained that, yes, let’s protect that next generation from this. But if I’m going to go off these drugs, or if I don’t want to be at a dose, we’ve got to get the information how these drugs can be used in the real world. But what are you going to do when you go off these drugs? And that’s why what these drugs, the greatness about these drugs is they allow you to recondition your relationship with food. So while you’re on these drugs, you can learn to eat. And what you hope is that if you want to go off them, maybe you want to stay on them, but if you want to go off them, you’ve changed that relationship with food, right? So that you then off these drugs can maintain the weight because losing the weight is not the hard part. It’s maintaining that weight. Terry 27:41-27:51 So, Dr. Kessler, how do we reshape our relationship with food during the nine or ten months that we are using Ozempic or Wegovy, for example? Dr. David Kessler 27:52-29:40 That’s one of the great questions we’re learning a lot. Watch people on these drugs. Ask them how their food preferences change. I mean, if you don’t want to put, you know, imagine this now. You feel like there’s a lot more in your stomach, you’re satiated much quicker. So you don’t want to put certain foods in your stomach. But the taste preferences, you know, for me, I mean, it was the first time I was eating vegetables, right? I just did for some reason, and I’m not sure I fully understand the biology, these taste preferences change for some people. Look, I am humbled because the one thing we have to recognize is there’s great variability, great variability in responses, how much people wait, what their adverse events are, what do they feel? I mean, does it make them, does it push them to the edge of nausea? Do they feel anything? Do they not feel anything? We all, I mean, are different, but there is, there’s something about when you’re, when you’re, for me, I was just eating much smaller portions. And I learned to want to do that. I didn’t like eating large portions while I’m on this because I wouldn’t feel good. And I try to carry that over. But understand that can fade. You go off these drugs, you condition yourself, you have that new learning. But over time in this environment of fat, sugar, and salt on every corner, those addictive circuits are going to pop back up and maybe I have to go back on these drugs. But again, my old agency has to do a better job working with the companies to get data on how can we use these drugs in the real world. Can I use these intermittently? Will they work intermittently? Terry 29:40-30:02 Dr. Kessler, I would love to spend the next 10 minutes or so just talking about how people can use these marvelous new tools to actually get healthier. So let me ask you, how can we optimize nutritional quality while we’re cutting calories? Dr. David Kessler 30:04-32:26 Once you start, once you’ve gained weight, right, and have the weight to lose, right, your body’s going to work against you. Those reward circuits, those metabolic circuits, right, are there, right? And you have to understand you’re trying to get the body to do something it doesn’t want to do, right? I mean, and so those addictive circuits are at play, right? And I mean, if those addictive circuits want it, I have to, I really have to, in the end, change my relationship with food. I got to change what we want. What was the, I mean, if you look at the great public health success, right? I mean, certainly of our lifetime was cigarettes. The great public health failure? Obesity. What did we do in cigarettes? I mean, at the turn of the previous century, the fact is that the cigarette industry took these products and made it seem sexy and glamorous and adventuresome. There was a march down Fifth Avenue for emancipation, women’s rights, voting rights. Right? Um, that they so these were positively valence what did we do in tobacco what we we changed the valence of that product we had this critical perceptual shift we began as a country to look at these products not as something that was sexy glamorous something that I wanted something that was going to make me feel better but for what they were they were deadly disgusting addictive you know products and you know if something’s sexy and and it’s positively valence I’m going to approach it. If it’s negatively valanced, I’m going to avoid it. Food is much harder. The problem is not food. The problem is this ultra processed food, this industrial food, these large portions. I got to change what I want. I got to change how I perceive it. Once you understand that food is going to result in that heart failure, is going to result in that diabetes, is going to result that I can’t pick up my grandkids. It’s going to result in years of disability later on in life. I mean, that’s the goal. We have to change what we want. Terry 32:29-32:46 Of course, humans are not that great at imagining what we’re going to want in the future and making that overcome what we’re doing right now. The potato chips right now might sing a little louder than the idea of picking up your grandchild in 10 or 15 years. Dr. David Kessler 32:48-33:50 Well, you know, you’ve just, that whole field of behavioral economics, delayed discounting, you’ve just summarized and just perfectly in 10 seconds. Look, the fact is, I mean, we didn’t get this as docs. Medicine didn’t get this. Again, we always thought weight just wasn’t good for us. We didn’t understand this toxic fat is causal. Once we wake up to that fact, once we see, and I think this is starting to occur. I think that people really understand the diet and what we’re eating. This ultra-formulated food is at the core of this. Again, these drugs can be one tool to get us to eat less, exercise more. They help with it. They calm down those addictive circuits. But we really have to change. Look, if someone came down from Mars and looked at what we were doing, We have one industry making billions of dollars that make us sick. And we have another industry making equal profits, trying to treat what that former industry does. Something’s wrong with that picture. We got to get to the root cause. But I can’t wait for the food industry or for people to change my food environment. We got to be able, the real choice, you talk about willpower, is do you want to make a decision? Do you want to reclaim your health? Because if you do, then get help, right? I mean, these addictive circuits, you can’t expect to do these yourself. Get a good dietician. Get somebody who is skilled in taking care of this toxic fat, I mean, who understands about obesity and weight. Joe 34:34-35:05 And Dr. Kessler, I know that our listeners want to know, how are you doing? You gained weight, understandably, during the COVID crisis when you were working 18 hours a day and trying to make a difference in the public health of the American population and the world. So now that you’ve actually tried the GLP-1 agonist-type drugs, what does the new Dr. David Kessler look like in the mirror? Dr. David Kessler 35:06-36:11 I’m good for now. I’m good today, you know, dramatically reduced my percent body fat, but it’s a journey. I can’t tell you about tomorrow. But I think, you know, my percent body fat right now, again, as I said, it’s about half. Metabolically, much better. I mean, that 40 pounds is gone, and an additional 20 pounds is off. Is it easier? Sure, but it’s no picnic. For me, I mean, I was sick, my body was sick. You looked at all metabolic, I was pre-diabetic. I didn’t want to be there. But that’s a choice. I mean, the most important thing is can we prevent, can we give our children the gift of not having gained the weight in the first place, gaining this toxic fat in the first place, so they don’t have to struggle with it? That’s our job. Terry 36:12-36:18 Dr. David Kessler, thank you very much for talking with us on The People’s Pharmacy today. Dr. David Kessler 36:19-36:19 Thank you. Terry 36:20-36:58 You’ve been listening to Dr. David Kessler, who served as chief science officer for the White House COVID-19 response team under President Joe Biden. He’s a former commissioner of the Food and Drug Administration under President George H.W. Bush, and he has also been dean of the medical schools at Yale University and at the University of California, San Francisco. He has written several books, including “The End of Overeating,” “Fast Carbs, Slow Carbs,” and his most recent, “Diet, Drugs, and Dopamine: The New Science of Achieving a Healthy Weight.” Joe 36:59-37:07 After the break, we’ll hear from an anthropologist. His intriguing research suggests that people around the world use roughly the same amount of energy a day. Terry 37:08-37:14 Some of the people in his study hunt their own meat and gather their own plant foods. Doesn’t that take a lot of energy? Joe 37:14-37:20 If you were a hunter-gatherer tracking antelope across the savanna, how many more calories would you burn? Terry 37:21-37:26 His study suggests that the main cause of obesity in America is what we’re eating. Joe 37:26-37:32 What should we be doing for our health? Are there lessons from anthropology that can help us achieving a healthy weight? Terry 37:39-37:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:51-37:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Joe 38:12-38:24 We’re considering the biology of weight today. Usually, any discussion of weight has to include the idea that calories in and calories out must balance. Terry 38:24-38:36 That has led to suggestions that we need to be more active. If only we walked or ran or cycled a lot more instead of riding or sitting, wouldn’t we be able to manage our excess pounds? Joe 38:36-39:06 To find out, we turn now to Dr. Herman Pontzer. He is professor of evolutionary anthropology and global health at the Duke Global Health Institute. Dr. Pontzer is the author of “Burn: New Research Blows the Lid Off How We Really Burn Calories, Stay Healthy, and Lose Weight.” His latest book is “Adaptable: How Your Unique Body Really Works and Why Our Biology Unites Us.” Terry 39:07-39:10 Welcome to The People’s Pharmacy, Dr. Herman Pontzer. Dr. Herman Pontzer 39:10-39:11 It’s great to be with you. Joe 39:12-40:07 Thank you, Dr. Pontzer. It’s nice to have you here. We just got done talking with Dr. David Kessler. He was former FDA commissioner, and he is author of “Diet, Drugs, and Dopamine, The New Science of Achieving a Healthy Weight.” But we’d like your perspective on this issue. You’ve tackled this controversial topic of weight control by traveling to Hadzaland in Tanzania. Please, can you explain why you went all that way to understand the balance between energy intake and energy expenditure? You know, I think a lot of us who don’t really understand all this metabolism stuff very well just call it calories in, calories out. Why did you go so far away and what did you do? Dr. Herman Pontzer 40:07-41:15 Yeah, thanks. So, you know, my training is as an anthropologist. I’m interested in how our bodies evolved, how they got to be the way they are today, and then how that kind of interaction between our evolved bodies and our modern lifestyles plays out for each of us in terms of health and the way our bodies work today. And I focus, you know, my lab focuses on energy expenditure, calories in, calories out, because that is the currency of life, right? The game of life for any organism is to take energy from its environment and survive and reproduce. That’s the game of life that all organisms play. Now, our species, we evolved as hunter-gatherers, right? So for over 2 million years, we’ve been hunting and gathering. And that’s the lifestyle in which our bodies evolved. So that’s kind of the ecologically relevant context to understand our bodies. And for a long time, up until we did this work with the Hadza in northern Tanzania, we didn’t understand how our metabolisms looked in a hunting and gathering lifestyle, right? We had some data from the U.S., Europe, you know, westernized, industrialized places. But we didn’t have any data on the most relevant context for our species, hunting and gathering. Terry 41:15-41:29 And there really aren’t that many places on Earth where people are still doing hunting and gathering. The opportunity to study it, as well as the opportunity to live that way, has diminished a lot. Dr. Herman Pontzer 41:29-41:33 That’s right. Most of these populations have been moved to cities or towns. They’ve been developed. Joe 41:34-41:36 Tell us a little bit about the Hadza. Dr. Herman Pontzer 41:36-42:16 Yeah. So they’re a hunting and gathering community in northern Tanzania. Now, what does that mean? That means every morning they wake up and men hunt for wild game, or sometimes they go and collect wild honey. The women go out and collect wild plant food. So sometimes that’s picking berries. Sometimes that’s digging for wild tubers. And they do that every day. They don’t have any cars or electricity or plumbing or anything like that. They live in grass houses in the middle of the open savanna in northern Tanzania. So they’re focused on food. That’s right. Their whole economy, their daily life is focused around getting calories, right? And then, of course, living their lives, burning those calories on all the things they do all day. Joe 42:16-42:20 And I suspect that getting food takes a lot of calories. Dr. Herman Pontzer 42:20-42:33 Well, that’s exactly it. So we had this idea when we started this project that being so active as they are, right, they get more physical activity in a day than most Americans get in a week, right? We know that. Men get 19,000 steps a day. Joe 42:33-42:34 Whoa! Dr. Herman Pontzer 42:35-43:05 Women get 13,000 steps a day and often with a kid on their back, right? So it’s a really physically active way to make a living. And all hunting and gathering groups, we think that’s pretty typical for them. And then that means it’s pretty typical for us in the pretty recent past. And so we wanted to ask the question, is that more traditional lifestyle, does it burn a lot more calories every day than our modern lifestyle does? Because we’ve all heard the story. These modern lifestyles that we live in, you know, they’re too comfortable. They’re too easy. We don’t get enough activity, and that’s leading to obesity, perhaps, because we’re not burning enough calories. Terry 43:06-43:07 We’re couch potatoes. Joe 43:06-43:11 Yeah, sitting or lying down or just not doing anything. Dr. Herman Pontzer 43:12-43:48 That’s exactly right. So we wanted to understand what that gap is. How many more calories do you burn as a hunter-gatherer? And so we use this state-of-the-art technique called doubly labeled water. It’s this isotope tracking technique that allows us to really measure how much carbon dioxide the body makes all day. You can’t burn calories without making carbon dioxide. You can’t make carbon dioxide without burning calories. So it’s a really accurate physiological way of measuring calories burned. And we do it over about a week or 10 days. And we went there to kind of document how many more calories they’re burning because, again, they’re so physically active. And the shock was we got home and we analyzed our data. They don’t burn any more calories. Joe 43:48-43:49 Whoa, wait a minute. Dr. Herman Pontzer 43:50-43:56 I know it. I couldn’t believe it either. And, you know, we did all the the first thing we assumed was that we’d gotten it wrong. Right. Terry 43:56-43:57 That would be a logical assumption. Dr. Herman Pontzer 43:58-44:26 That’s right. So we have other ways of double checking these data. We had a heart rate monitoring project that we did along with this. We had a whole other way of estimating energy expenditures. Everything lined up to where these are solid data, right? For this hunting and gathering population, something that looked a little bit like the past would have looked like for all of us and what traditional lifestyles look like, you know, the world around. They are burning no more calories every day than folks in the U.S. and Europe and other industrialized countries. Terry 44:27-44:29 So we’re very profligate with our calories. Dr. Herman Pontzer 44:30-44:44 Well, that’s right. I mean, what it suggests is our bodies are adjusting to lifestyle in interesting ways, in ways that we kind of hadn’t appreciated before this study. So you and I, and well, I don’t know about your lifestyle, but I know mine. I’m not as physically active as a Hadza man. I don’t get 19,000 steps every day. Terry 44:44-44:45 Definitely nowhere close. Dr. Herman Pontzer 44:46-45:34 And so my body is burning energy on physiological tasks that their bodies are not. I’ve re-juggled the way I spend my calories, right? It’s like living on a fixed economy. It’s the same number of calories coming in and out. We’re just spending them on different things. And so if you’re a Hadza man or woman, you’re spending more of that energy on physical activity. That’s definitely true. We measured some, we did some tests to study like the cost of walking, for example. There’s no magic going on. They’re still burning those calories walking. But they’re burning more on walking and more on activity and less on other things. And we’re doing the opposite. We’re spending more energy on things like perhaps things like inflammation, things like stress response, things like having reproductive hormone levels that are quite high. All these things kind of ramp your body’s metabolism up. And we can do that here in this lifestyle, but we’re not doing it if we were in that lifestyle. Joe 45:34-45:58 Let me see if I’ve got this right. So here are these people who are, in the case of men, nearly 20,000 steps a day, every day, day in and day out. And yet the calorie expenditure is very similar to ours where we may only be walking 5,000 or 6,000 steps a day. We’re sitting in front of our computers. Terry 45:59-46:02 And if you hit 10,000 steps a day, you pat yourself on the back. Joe 46:02-46:25 Yeah, it’s like, oh, yeah, I played tennis and then I went for a walk and then, oh, boy, 12,000 steps, I’m great. But let’s cut to the chase: It’s really about the weight. That’s what we’re concerned about. It’s about the obesity epidemic in the United States. Were there very many obese Hadza? Yeah, there’s none, as you can imagine. Dr. Herman Pontzer 46:25-47:13 Now, they’re not, you know, they’re a healthy weight, right? So there’s not malnutrition or anything like that. There’s a healthy weight population. But yes, obesity, non-existent in this group. You know, people often ask if there are periods when the Hadza are starving, basically, they don’t have any food. And you might think that if you look at the pictures there, you see an empty landscape. And that’s what I see, too. But they don’t see that. They see a landscape that’s full of food if you know what to look for. Now, so they might not have access to their favorite foods all the time. They like to eat meat. They like to eat particular kinds of plant foods that taste nice. So they don’t always have their preferred foods all the time. But they can always get food. I’ve never seen a Hadza camp that wasn’t, you know, where the people were unable to get enough to eat every day. Terry 47:13-47:16 So you haven’t seen malnourished children, et cetera? Dr. Herman Pontzer 47:17-47:32 No, you really don’t see that. And in fact, we’ve done things like we’ve tested for ketone levels in urine tests, right? Which would be one indicator, physiological indicator of starvation. We’d never see that. We never see ketone bodies in the urine. Now, that’s not the most precise test. Terry 47:32-47:33 But it is an indication. Dr. Herman Pontzer 47:33-47:38 But it’s an indication for sure. If you just look at heights and weights of kids and adults, these are healthy folks. Joe 47:39-47:42 So the difference, please, open that envelope. Dr. Herman Pontzer 47:42-48:05 Right. Obesity in the U.S. has to be a question of diet, right? That has to be the main problem. We’re bringing too many calories in. Because if the energy expenditure that we’re all experiencing, no matter what our lifestyle is, is kind of all the same. If you can’t move the needle on energy expenditure, then obesity, which is this balance between energy in and energy out, has to be about your diet and taking too many calories in. Terry 48:05-48:25 Now, Dr. Pontzer, you and your colleagues have just published a paper in the Proceedings of the National Academy of Sciences, looking at this same question, but with a bigger data set. You didn’t just look at the Hadza, you looked at a bunch of other groups as well. Tell us about it, please. Dr. Herman Pontzer 48:26-50:04 Yeah, that’s right. So, you know, in the years since that Hadza study, we’ve had the chance to do this with a couple other populations here and there around the world. And we find similar results in sort of isolated other populations. But we didn’t have an opportunity to ask, OK, let’s put our arms around all the populations that we have data for, try to get a really broad idea of energy expenditure versus lifestyle across the whole globe. And the reason we hadn’t done that before, nobody had done that before, was that this isotope tracking technique we use to measure energy expenditure, it’s expensive and it’s technically a challenging thing to do. There aren’t many labs that do it. And so there had been no huge multi-population study to look at this yet because it just wasn’t feasible. Since about 2016, my lab and several others across the globe have collaborated, put all of our data together from all the studies that we’ve done over the years. And now finally, we have this huge data set, 10,000 plus individuals total, that we can ask questions with big samples, looking across lifestyle, across age, all these sort of big data kind of questions we can finally ask using this technique. For this study, we had 34 populations. The Hadza were there, U.S. is there, countries in Europe, Asia, countries that have low economic development, middle, rich countries, farming communities, really the full economic spectrum of human existence. And we could ask the question, OK, with a really broad sample, with a really big data set, can we see an effective lifestyle and especially economic development on energy expenditure and obesity risk? Joe 50:05-50:06 And the envelope, please? Dr. Herman Pontzer 50:06-50:41 Right. So just like the Hadza study, we don’t see a big effect of economic development on expenditure. In fact, if you just look at total calories burned per day, people in rich countries burn more. Why is that? Because they’re bigger, right? We tend to be bigger in more developed countries. And your total body size is the biggest predictor of how many calories you burn. If there’s more of you, you’re going to burn more calories. But even after we correct for body size—which we always do in these analyses—we see the same things we saw with the Hadza study. No effect of economic development on energy expenditure, hardly at all. Joe 50:41-50:44 And so what really matters is? Dr. Herman Pontzer 50:44-51:17 It is diet, right? The big driver of obesity across these 34 populations has to be the calories that we’re eating. And we were able to do additional analyses asking things like, well, what is it about the diet? Maybe it’s the amount of meat that people are eating. That doesn’t seem to be a factor. What is it? Maybe it’s the amount of ultra-processed foods. And there we do see an effect that populations that are eating more ultra-processed foods tend to be the populations with the highest levels of obesity in our sample set. So, you know, the study wasn’t designed to look at that specifically, but it’s a good direction to go next. Joe 51:18-51:43 So what can we learn from this research? Because, like you say, I mean, no one has ever done anything of this size before across this many cultures. Is there a take-home message about the food? And what should we and what shouldn’t we as a population be doing? Well, let’s start with the exercise portion first, right? Dr. Herman Pontzer 51:44-51:57 It’s still important to exercise and get physical activity. There’s nothing about the study that says exercise doesn’t matter. On the contrary, we know exercise is still really important. It’s good for us. It’s good as we age. It’s good for mental health. There’s so many good things about exercise. But… Terry 51:57-52:00 Because human bodies were meant to move. Dr. Herman Pontzer 52:00-52:47 That’s exactly right. That hunting and gathering past that we all share, when our ancestors were getting 10 or 20,000 steps a day, that is the way that we evolve. That’s what our bodies expect. And so if we don’t do that in our lives today, we set ourselves up for illness. Okay, but exercise is not going to fix the obesity crisis. And the obesity crisis is not because of a change in physical activity and lifestyle. It’s because of a change in diet. And so when we want to tackle obesity specifically, we need to be focused on diet. What are we putting in our supermarkets? What are we putting in our school cafeterias? What are we putting in our baskets as we go shopping? What are we putting in our cupboards, right? We have to think about diet and controlling, trying to find a way to eat healthier and limit how many calories we eat so that we don’t over-consume. Joe 52:49-53:49 Dr. Herman Pontzer, you look fabulous. I mean, you are a thin guy, but you’re not scrawny. You look like you’ve been practicing what you’ve been studying. That is to say, you look like you’ve been careful about what you eat for a long time. When we spoke with David Kessler, he sort of admitted as how he’s been overweight for most of his life and that it’s been a challenge. And he has been a, I’d say, an advocate for the GLP-1 agonist drugs. You know, you’ve all heard about the Ozempics and the Zepbounds and the Wegovys. And, you know, these drugs have, quote, unquote, revolutionized weight control. So just on a personal level, how do you maintain your excellent body weight? Dr. Herman Pontzer 53:49-54:04 Well, I appreciate that. You know, I like to be physically active, I like to run, I like to rock climb. Those are my two big outlets for getting activity in. I like to be outdoors. So that’s never been, you know, it’s never been hard to push myself out the door. Terry 54:04-54:08 But based on your research, that’s not the primary thing, right? Dr. Herman Pontzer 54:08-54:37 No, that’s right. So that’s not what’s keeping me thin. What’s keeping me thin is that I also have been lucky to have a pretty good relationship with food. I am not the kind of person who has food cravings all day. I know some people who do, people close to me who do. And that sounds like a much harder way to sort of manage what you’re eating. I enjoy food. Of course, I enjoy food with friends most of all, but I don’t feel pushed to over-consume. And so I’ve been lucky that way because I know that not everybody has that same wiring. Joe 54:38-54:44 So you’re not tempted to have seconds, or thirds, or another dessert? Dr. Herman Pontzer 54:44-54:46 Not particularly. And if I miss lunch, I don’t mind. Joe 54:48-55:01 So what can we learn from your example, especially when it comes to that really big deal these days about ultra-processed foods? Dr. Herman Pontzer 55:01-55:10 Yeah, well, you know, I think everybody loves snack foods and junk foods. I mean, come on, they’ve been chemically engineered and focus group tested to be delicious. Terry 55:10-55:23 You don’t even have to be human to love a snack food. Our dogs like those crunchy things that we get in packages, cod crisps. Dr. Herman Pontzer 55:23-55:23 Oh, yeah. Terry 55:24-55:27 They like these things. I think it’s just cods and fruit. Dr. Herman Pontzer 55:27-55:28 Yeah. Terry 55:28-55:32 But they crunch, very satisfying for dogs. Dr. Herman Pontzer 55:32-55:32 Yeah. Terry 55:33-55:36 And, you know, a lot of crunchy stuff is satisfying for humans, too. Dr. Herman Pontzer 55:36-56:19 That’s right. So, you know, what I’ve noticed, so, you know, I’m 48 years old. I have certainly noticed the last 10 or 15 years that I appreciate you saying I look good, but I feel a lot different than I did in my 20s. That’s for sure. And so, you know, I have made an effort to say, well, look, I can’t control what they put in the supermarket, but I can control what I put in my basket. And I’m not going to have a lot of soda and, you know, snack foods that I know I’ll eat the whole thing in my house, right? And, you know, I’m lucky enough to have good supermarkets nearby that I can make those decisions. But I do that so that my personal environment doesn’t tempt me to over-consume, because there are certainly foods that I would absolutely love to over-consume. Joe 56:20-57:05 Dr. Pontzer, I would love to get a sense of what it was like to hang out with the Hadza. These people are, as you have described them, real hunter-gatherers. Food is critical to their survival. And so they spend a lot of time going out and searching for food. What are they eating first? And how close to the edge are they? In other words, do they have times when it’s kind of hard to find food and other times when it’s plentiful? Give us some sense because you kind of went back in time. Dr. Herman Pontzer 57:05-57:26 Hmm. Well, I’m going to push back a little bit there and just say, I know what you mean by that. But I think some people listening to this would think, oh, well, that means the Hadza are some kind of, you know, stuck in amber kind of, you know, community from the past. And of course, you know, that’s not true. Every culture today is we’re all equally here. We’re all equally modern. Terry 57:25-57:26 It’s today. Dr. Herman Pontzer 57:26-59:34 And with us today. But, you know, you’re absolutely right that a population like the Hadza provide an opportunity to ask, you know, what it was like back then because they share so many elements of a lifestyle that we think was common in the past. And so what’s it like? Well, you know, if you’ve been able to travel and see other cultures internationally, you’ve probably had this experience. The first thing you notice are all the differences, right? It’s a different language. It’s a different way they’re dressed. It’s a different kind of, you know, all the differences. And then if you have a chance to stay there for a while, pretty soon you start to notice, oh, wait, that looks, you know, this is like, you know, kids playing kids games is the same no matter where you are on Earth. Husbands and wives arguing about something, that’s the same no matter where you are on Earth. Friends telling stories is the same everywhere. Even if you don’t understand the language, you understand the laughter, right. So I think that’s what I take away when I go now is they feel like it feels a little bit more like home. And I see our commonalities. I see what’s shared there. Now, what’s absolutely not shared is that when they wake up in the morning, they have to find their breakfast, right? I mean, maybe they have some stuff left over from the night before, but they don’t just crack open the fridge and have a yogurt, right? That doesn’t happen. And so what kind of foods are they eating? Well, men are eating wild game. And so in that part of the world, you’re talking about zebra, giraffe, different kinds of antelope, smaller game as well. Men also, when they’re not hunting, they’ll bring home, they’ll kind of chop into this. Every hodge a man leaves the camp with a bone arrow that they make themselves and a hatchet. And so if they’re not hunting with the bone arrow, they’re using the hatchet to chop into trees and get at wild honey. The bees make their hives in trees there. And so honey is a big part of the diet. It’s delicious. Meat is, you know, maybe sort of 40 or 60 percent of the diet, depending on the time of year and that kind of thing. And then the women are getting plant food. So that could be wild tubers. That could be berries. That’s kind of baobab fruits, that kind of thing. Terry 59:34-59:44 Now, you said that the men are hunting and they’re eating wild meat. I’m assuming, and I shouldn’t assume. So let me ask you, are they sharing the food with the women? Dr. Herman Pontzer 59:45-01:00:39 Thank you so much for that. Yes, everything is shared, right? And that’s a real commonality that we see across hunting and gathering groups. Sharing is what makes it work. I’ve been teaching anthropology and human evolution for a couple decades now. What I always tell my students is the big change that put us on our path to being human and not being like the other apes is hunting and gathering. And it’s not the hunting or the gathering that’s so important in that equation. It’s the ‘and,’ right? And by having some folks hunt and some folks gather and you share the food at the end of the day, you get the advantages of being, you know, thinking about this sort of ecologically, the advantages of being a plant eater and the advantage of being a carnivore, you get them together. And that’s why our species and our ancestors have been so successful because that’s, you know, it’s unlike any other species in the way that we make a living. Joe 01:00:39-01:00:57 Tell me about the hunting piece, because I’ve seen the arrows, which are really cool, and the bows and how good they are with the bow and arrow. So you’ve been out on a hunting expedition. Give us a description. Dr. Herman Pontzer 01:00:58-01:01:01 It’s remarkable. So it’s a lot of walking. You walk and walk and walk. Joe 01:01:01-01:01:02 And there are dogs. Dr. Herman Pontzer 01:01:0301:01-56 Sometimes. So that’s, yes, sometimes they have dogs. I would say maybe 10 or 20 percent of the time that I’ve been in Hadza camps, there have been dogs. Often it’s just a man that’s just walking. They typically go out alone unless, you know, you’re able to talk your way along with them. And, you know, they’re very good at what they’re doing. So they’re very quiet. They’re very attentive. They’re seeing things that you’re not seeing on that landscape. And they notice the game before the game notices them. And then they’ll stalk and try to get a shot. They’re so good with their bows and arrows. It’s a fun one. When my first trip to Hadza camps, of course, it’s a big camping trip for us, basically. We fill a couple Land Rovers with camping gear and science gear for, you know, maybe you’re there for a couple weeks or a couple months. And so one of the essential pieces of camping gear is a tin full of instant coffee. Terry 01:01:56-01:01:57 Okay Dr. Herman Pontzer 01:01-57-01:03:25 That’s an absolutely essential piece of research gear there because you can’t get up in the mornings without some instant coffee. And so we had this empty tin of instant coffee. It’s called Africafe. And I don’t know, we got into our heads one day. Let’s have a—because we were so impressed at watching these guys shoot bow and arrow—let’s do a competition to see, you know, who can hit the can from pretty far away. And, you know, whoever wins, you know, they can keep the can or whatever, because it’s a nice tin can. It’s a valuable thing to have. And so we set it up while the guys were all out hunting, and we set it up was probably 20 or maybe even 30 yards away. It was a good distance. I grew up, you know, in a rural part of Pennsylvania hunting and shooting bow and arrow a little bit. And so it looked to me to be a very far distance to hit a pretty small tin. And before the guys even came back from camp, their kids were lining up and having a laugh and hitting that can every time they shot these bows. And I thought, oh my God. And so we had to move it twice as far out to hold the actual competition. And even then the guy, it was like, it was, it was too easy. So, you know, these, they’re remarkable shots. They’re remarkable trackers. They, you know, if you think about it this way, they’re remarkable ecologists, biologists. They know each of those species so well and they know their habits and it’s, it’s just, it’s feels so special and you feel so lucky to be able to hang out with them. Joe 01:03:25-01:03:51 What was it like to hang out with the Hadza? I found one of your sub-chapters very intriguing. It’s titled, “Urine for a Surprise.” And urine was U-R-I-N-E. How in the world did you get people to give you urine samples? Dr. Herman Pontzer 01:03:51-01:04:44 Yeah. Well, that brings up a larger issue is how do you do community work ever in these, you know, it’s not my community, right? We travel there. And so the answer is you have to build up a relationship. And so I’m lucky to work with a guy, Brian Wood, another anthropologist at UCLA. And he’s been doing work with the Hadza his whole career. And he speaks Hadza. I should say that when we would go and work with the community, we typically speak Swahili. So you have to learn Swahili to go there. And they grow up speaking both their own Hadza language and Swahili. And so, you know, you have to build these personal relationships and these community relationships. And then once you’ve got that and you’ve got these sort of friendships and people you know, then they’ll trust you like any community would to, you know, if you want to do these research projects that they can kind of get behind, then that’s how that works. You don’t ever just parachute in. You can’t do that. That’s not how it works. Terry 01:04:45-01:04:56 I think you probably have some sense of that, Joe, based on our initial exposure to field work, which was in Santo Tomas, Mazaltepec in the Oaxaca Valley. Joe 01:04:57-01:04:58 In Mexico. Terry 01:04:58-01:05:30 Yes, in Mexico. And they grow up speaking both Spanish and Zapotec because the Zapotec is the mother tongue. But nowadays, I think pretty much everybody speaks Spanish as well. When in the early 1970s, when Joe and I stayed there, there were a lot of the older women who didn’t speak Spanish, which was a little inconvenient for me because I hadn’t yet learned Zapotec. The only thing we learned really in Zapotec was how to drink. Joe 01:05:31-01:05:34 [phonetic Zapotec] “Los-en chute juba umbali.” Terry 01:05:34-01:05:35 [phonetic Zapotec] “Kee-in juba umbali.” Joe 01:05:37-01:05:56 Drink up. But I am curious how you convinced folks to give you a urine sample, to participate in your study, to even begin to comprehend what it was that you were trying to do. Dr. Herman Pontzer 01:05:56-01:07:58 Sure. So, you know, anthropologists have been working with the Hadza community for decades now. You know, that goes back to the 1960s even. And so they’re used to people showing up in Land Rovers and saying, ‘Hey, I’d love to hang out with you guys in your community for a few weeks. And do you mind? And here’s what we’d like to do.’ And they understand, too, that they’re a special community. I think the closest thing we have in the States is something like the Amish, right, who are very aware that the people that they live around are not Amish, but who are very proud, and rightfully so of their lifestyle and want to maintain that culture. And so, you know, in the same way that the Hadza know that other groups around them are not hunting and gathering, they know that that makes them special. And they understand when somebody says, look, you know, this is so unique what you’re doing. We’d love to understand, how do you make it work? How do you make a living doing this? So having people follow along on hunting trips or on gathering trips or, you know, we often write down and weigh the foods that come into camp, for example. And we, of course, we explain all this and we ask permissions to get all and we compensate them for their time, to say too. We’re not just, you know, taking advantage. And so they’re kind of used to folks wanting to come up and work with them. This particular study of asking for urine samples, which is part of this isotope tracking technique we use to measure calories. Look, if you can explain, look, we want to understand how your bodies use the food that you collect to burn off by walking, moving, surviving. They get that immediately. I mean, that’s an easy conversation because it’s a calorie economy, right? They’re used to, they know that they have to wake up in the morning and get those calories. They know that their bodies are burning them all day. Of course, they have not had any formal schooling, many of them, or not much, but just intuitively they understand that. And so that’s actually a pretty easy conversation to have. The urine, you know, anytime you get asked for a urine sample in a doctor’s office, anything like that, that’s always a little weird. I imagine it’s a little weird for them too, but they are able to understand that for sure. Joe 01:07:59-01:08:04 And did you eat with them? And if so, what were you eating and how was it? Dr. Herman Pontzer 01:08:04-01:08:44 So we bring our own food because we don’t want to, you know, burden them by expecting them to sort of feed us. But I have tried a number of Hadza foods: zebra, you know, different kinds of antelope, all the different kinds of plant foods, the tubers, the berries. It’s all pretty good, I guess. I don’t know, it’s not very flavorful. They don’t really use much, you know, there’s hardly any spices or anything like that. Salt is one thing that we actually use to compensate them because it’s what they would trade for, but they’re pretty sparing with it. So it’s not like a typical steak you’d get here at a restaurant in the States, something like that. It’s pretty, you know, tough. Often it’s a few days old. They don’t have any refrigeration, right? Terry 01:08:44-01:08:45 Right, right. Dr. Herman Pontzer 01:08:46-01:08:59 Often they’ll, they’ll, so if it’s a big animal, like a zebra, they’ll eat a lot right when it’s killed. Of course, they cook their food, but then the stuff that’s not eaten gets cut into strips and hung over tree branches to kind of dry. Terry 01:09:00-01:09:02 So it comes out a little bit like jerky. Dr. Herman Pontzer 01:09:03-01:09:11 A little bit. A little too soft and pink for my taste, frankly. But, you know, I’ve never gotten sick eating Hadza food, I’ll say that. Terry 01:09:13-01:09:50 One of the topics that you broach in your book, “Adaptable,” is how our lifespans affect our health. And you describe the results of the famine that the Dutch suffered at the very end of World War II when the Germans were punishing the entire population. And there was tremendous famine. Babies born during that time had a different health career than babies born before or after. Can you tell us about that, please? Dr. Herman Pontzer 01:09:50-01:10:19 That’s exactly right. So the context is, you know, you’re in the Netherlands in World War II. They get cut off from all food supply into the country. And, you know, people are starving. And mothers are starving, too, of course. Pregnant mothers are starving. And that experience of starvation in the womb affected those babies into the whole course of their whole lives. So those babies are now, they’re born in the 40s. Terry 01:10:19-01:10:22 So they’re 80 or getting close. Dr. Herman Pontzer 01:10:21-01:10:57 Something like that, now. Right. And people have been tracking their health outcomes since the 90s, at least. And so we know that those babies born in what’s called the Dutch hunger winter were more likely to develop heart disease, cancers, other medical problems that you normally wouldn’t assume have anything to do with you know, what happened in the womb, right? These are things that manifest in your 60s, 70s, 80s often. And you think it’s lifestyle and your adult choices that you make. And of course, we know that it does affect it. But there is an echo of what happened very early in life, that somehow that programmed the way that their bodies are working. Joe 01:10:58-01:11:09 Well, I think we’re talking about epigenetics. And I’m curious as to whether or not those changes were passed on to their kids. Dr. Herman Pontzer 01:11:09-01:12:06 Yes! So that is the big question. So epigenetics is, if people haven’t heard of that or heard the term and don’t know what it is, basically your genes aren’t getting changed themselves, but they’re getting turned on or off. So there’s these little chemical markers that will turn a gene off or even can also turn it on. And those epigenetic changes are the environment kind of pushing your genes around. And so we think that’s happened to the babies that were born in the Dutch hunger winter. And we think it was passed on to their kids because those kids are now often in their 30s or 40s, right, that generation. And we do see higher BMI, some more obesity in that group. These are now the grandkids of the mothers who were starving in the 1940s, right? So their grandchildren are showing some effects of this. One particular event over the course of one year in the 1940s, we’re seeing those. Again, it’s sort of an echo of the past in the way that these people’s bodies are working today. Joe 01:12:07-01:12:11 So what lesson can we learn from that experience? Dr. Herman Pontzer 01:12:13-01:13:30 Well, there’s so much to learn from that. One is that our environments affect the way our bodies work probably more than we appreciate. And it doesn’t just affect, you know, did I eat too much or did I exercise enough? Those are ways that we know that we can affect our environments. But they can also, our environments can affect the way our genetics are expressed. And those effects can last at least a whole lifetime and perhaps even get passed on. So what that means from a kind of societal point of view is that, you know, let’s think about trying to solve, you know, health differences between communities here in the States. We have people, you know, minorities, other groups who have been disadvantaged. And we try to, there’s a big civil rights, of course, movement to try to address a lot of that in the 1960s. We might think, oh, well, you know, we fixed those problems in the 60s. So by now, everything should be fine. No, because if something that happened in the 60s can be echoing, sorry, if something that happened in the 1940s can be echoing still today, then surely things that began to change, of course, it didn’t completely change in the 1960s. We can still be dealing with those environmental effects, even though we’ve done a, you know, we can be happy with the progress we’ve made. But it’s not going to erase the past in a way that we often think it might. Terry 01:13:30-01:13:37 And we know we still have food deserts and so forth. So that is probably still having an impact. Dr. Herman Pontzer 01:13:38-01:13:49 For sure. For sure. And so, you know, it isn’t just one thing, but that’s right. So we have to be aware, of course, the modern environments, of course, but, you know, also cognizant of these past effects that we’re still dealing with. Joe 01:13:50-01:14:45 So this is a little off track, and you may not have an answer. I think of you as anthropologist slash biologist because you really do pay very close attention to the biology of calories in and calories out and exercise and all the rest of it. What about psychology? The Hadza, in particular, it’s a very close-knit community, and there are social interactions. And I’m curious about how that experience during the end of the Second World War affected people, not just biologically, but psychologically, and how that might be passed along epigenetically. Dr. Herman Pontzer 01:14:45-01:15:53 Yeah, I’m glad you brought that up. I often wonder how much the kind of the psychological health of the Hodge community, which seems to be very robust, very good, plays into the fact that we don’t see heart disease there. We don’t see diabetes there. We don’t see obesity there. You know, the factors that we know can push people to overeat and develop other unhealthy habits here in the States, loneliness, stress, you know, feeling of being kind of left behind and it’s kind of social inequality, that kind of thing. We know that those are factors that push people to make unhealthy choices. We don’t see those in a Hadza camp. You don’t see that in a community that’s egalitarian. Right. Nobody really has more than somebody else. Those differences are really small. They’re socially connected. You never go a day without having a good conversation with somebody you’ve known for a long time. You are physically active in getting the health and psychological benefits of that activity every day. You never feel like you’re alone or left out. And those are all really important, too. And it’s not something that my research focuses on. But, of course, you can’t help but be aware of that when you’re there. Joe 01:15:55-01:16:05 My last question has to do with how your research, how your interaction with people all over the world has impacted you personally. Dr. Herman Pontzer 01:16:08-01:16:43 It has made me just feel incredibly lucky both to be able to have those experiences. I mean, I can’t imagine a better job, but it also makes me feel really fortunate to be here in the States. You know, I mean, I think we have a lot of debate and angst about the state of things in this country today. And I get that. But I feel a lot of those things, too. But we are pretty darn lucky to be here and to have the resources available to fix a lot of these issues and deal with them. And so it makes me optimistic and happy to be where I am. Joe 01:16:44-01:17:48 Dr. Pontzer, I have to tell you that our time in Mexico was magical. We were there for almost two years. And it changed my attitude and perspective about a lot of things. And I thought a lot about Peace Corps volunteers and other anthropologists who travel the world and hang out with people in all kinds of different places. And sometimes I think, you know, if we could just give people that experience so that more Americans could see the world maybe from a slightly different perspective by just hanging out with people, whether it’s the Hadza or whether it’s somebody in New Zealand or, you know, the Maori, whatever, that it might change the way in which we think about the other and ourselves. Have you had an opportunity to reflect on that? Dr. Herman Pontzer 01:17:49-01:18:48 Absolutely. And I think it’s one of the things I try to share in my writing and in my classes I teach and opportunities like this is to kind of share that broad perspective that you get from travel. And again, when you go to these communities, you have a chance to live there for a while. At first you notice the differences and then you notice all the shared humanity and you bring all those threads and those pieces back with you and you see home again in a different way right that’s I forget what the famous line is to travel is to come home and see it with new eyes something like that and i think that’s exactly right you know maybe we could do a better job making that a possibility for more folks here in the states or maybe uh social media will do a good job advertising the rest of the world to everybody. I’m not so optimistic about that. But no, I agree with you that travel really makes that, broadens your perspective on this and gives you a new appreciation for what you have here and also what we can sort of learn. Terry 01:18:49-01:18:59 Well, certainly Americans are not going to be able to eat the way the Hadza eat. We are not going to go out and dig up tubers that we will be consuming as our main staple. Dr. Herman Pontzer 01:19:01-01:19:09 No, that’s right. And, you know, not only that, but you couldn’t live like that. We couldn’t live on wild foods if we wanted to because there’s no wild foods in your supermarket. Terry 01:19:09-01:19:24 Exactly right. And there’s not enough wild land for us to collect wild foods from, even if we knew how, which we don’t, most of us. So what should we be doing for our health and to maintain a healthy weight? Dr. Herman Pontzer 01:19:24-01:20:18 No, that’s right. I really appreciate you bringing that up because, you know, the importance of doing this work across cultures isn’t that we’re going to somehow, you know, try to bring those cultures home, right? Every culture kind of fits into its own space. We don’t have to pretend to be hunter-gatherers. What we do is we have to learn the lessons that they’re teaching us. And the lessons that populations like the Hadza are teaching us are these. You know, try to eat whole foods that you recognize as whole foods. Try to stay away from the, you know, modern engineered foods that push us to overeat. Make sure you’re getting physical activity every day. Anything counts. It doesn’t have to be the kind of things that they’re doing. Any activity is good activity. And, you know, that sounds simple and it sounds like the story you’ve heard before and you probably have. But I think, you know, what this does is it clarifies, okay, the exercise is good for a lot of aspects of our health. The diet is what we really need to focus on for obesity. These are two different tools for two different jobs. Joe 01:20:18-01:20:28 And if we can’t pronounce those chemical names on the label, and there are like a dozen of them, maybe we should avoid those foods. Dr. Herman Pontzer 01:20:28-01:20:42 Yeah, people always ask, well, what’s an ultra-processed food? And, you know, I think, well, if it’s got a shiny package and an advertising campaign, it’s probably an ultra-processed food. And if the ingredients list is a paragraph long, that’s another clue. Terry 01:20:42-01:20:50 Yeah, that’s a pretty good clue. Dr. Herman Pontzer, thank you so much for talking with us on The People’s Pharmacy today. Dr. Herman Pontzer 01:20:50-01:20:51 Thank you for having me. Terry 01:20:53-01:21:22 You’ve been listening to Dr. Herman Pontzer. He is Professor of Evolutionary Anthropology and Global Health at the Duke Global Health Institute. Dr. Pontzer is the author of “Burn: New Research Blows the Lid Off How We Really Burn Calories, Stay Healthy, and Lose Weight.” His latest book is “Adaptable: How Your Unique Body Really Works and Why Our Biology Unites Us.” Joe 01:21:23-01:21:32 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:21:32-01:21:40 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 01:21:40-01:21:58 Today’s show is number 1,449. You can find it online at peoplespharmacy.com. At peoplespharmacy.com, you can share your comments about this episode. You can also reach us through email, radio, at peoplespharmacy.com. Terry 01:21:58-01:22:34 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, there’s some information that would not fit into this broadcast. You’ll hear about a healthy relationship with food, as well as what it’s like to work with the Hadza. How did Dr. Pontzer convince people to provide urine samples? We also discuss how food deprivation at certain critical points in life, such as in utero, can affect health in adulthood and even the next generation. Joe 01:22:34-01:22:56 At peoplespharmacy.com, you can 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 would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:22:56-01:23:28 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 01:23:29-01:23:38 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 01:23:39-01:23:43 All you have to do is go to peoplespharmacy.com slash donate. Joe 01:23:44-01:23:57 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.

Transcribed - Published: 16 October 2025

If you have ever suffered with sinusitis, you know how terrible it can make you feel. Breathing is difficult; smelling and tasting anything is impossible. What are the causes of sinusitis and what can you do about it? Joe and Terry talk with a leading physician who does research on how to treat sinusitis to find out how you can stop suffering with sinusitis. 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 our goal with these conversations is 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 EDT on your computer or smart phone (wvtf.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 October 13, 2025. Why Are You Suffering with Sinusitis? According to the CDC, almost 30 million American adults have been diagnosed with sinusitis. What are sinuses and why do they cause so much trouble? We asked Dr. Zara Patel to explain. She let us know that we have multiple sinus cavities within our skull filled with air and lined with mucus membranes. Sinusitis indicates that there is inflammation in those membranes. It might be caused by an allergic reaction or an infection. This may interfere with the ability to smell (and consequently, to taste). It might also lead to congestion, drainage or post-nasal drip. People feel crummy. They may have brain fog or low stamina. The cardinal symptom of sinusitis is a feeling of facial pressure. The suffering from chronic sinusitis is just as severe as that from heart failure or diabetes. Sinuses Have Their Own Microbiome: Just like most other parts of the human body, the sinuses are inhabited. Healthy sinuses have a microbiome of bacteria, viruses, fungi and archaea that stays in balance, more or less, and doesn’t cause trouble. When that microbiome gets thrown out of whack for one reason or another, the result can be an infection. To determine that, doctors occasionally culture the drainage. That’s not very accurate, however. A PCR test works better to find out what is in there that could be problematic. Infections are not the only cause of sinusitis, however. The mucus linings may be reacting to environmental irritants or pollutants. Small particulates such as those in automobile exhaust or wildfire smoke (PM2.5) can lead to a lot of inflammation. People who develop polyps in their sinuses may be especially vulnerable to some of these triggers. Irrigation to Stop Suffering with Sinusitis: One way of managing sinus problems is irrigation with clean water. (That would mean distilled water or water that has been sterilized by boiling before cooling to room temperature.) A neti pot is a very old-fashioned way of doing this, based on Ayurvedic medical tradition. That provides a low-pressure, high-volume irrigation in which water is poured into one nostril and exits the other, washing the sinuses along the way. For her patients with chronic sinusitis, Dr. Patel recommends irrigation with a squeeze bottle. (NeilMed would be one example.) This offers high-pressure, high-volume irrigation that can be very helpful in calming inflamed sinuses. She urges people to stay away from motorized devices. They may seem tempting, but it is far too difficult to clean them thoroughly. Other Medications That Can Help You Stop Suffering with Sinusitis: Dr. Patel may prescribe or recommend other medicines for her patients with sinusitis. Topical steroids such as fluticasone can be useful. Antibiotics are useful when there is an acute infection. In other cases, a medication like ipratropium could be called for. She warns, however, that some nasal sprays are bad for people with sinusitis. Decongestants could make a chronic condition worse, even though the immediate effect feels like relief. There are cases when sinus surgery is appropriate to help a patient who has been suffering with sinusitis. This should generally be a last resort, though. The surgeon should take into account how patients responded to medical treatment before surgery and will want to visualize the sinus with nasal endoscopy or a CT scan. The patient needs to understand that post-surgical care with rinses and sprays will be crucial for at least six months. This Week’s Guest: Zara Patel, MD, is Director of Endoscopic Skull Base Surgery, Director of the Stanford Initiative to Cure Smell and Taste Loss, and Director of the Neurorhinology – Advanced Sinus and Skull Base Surgery Fellowship. She is Professor of Otolaryngology in the Dept. of Otolaryngology-Head and Neck Surgery at the Stanford School of Medicine. You may be interested in her informational YouTube videos. Here is one on how to rinse your nose and sinuses: https://www.youtube.com/watch?v=kBIvzfx7ulo Zara Patel, MD, Stanford School of Medicine Listen to the Podcast: The podcast of this program will be available Monday, Oct. 13, 2025, after broadcast on Oct. 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 1448: 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 00:00-00:26 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. Have you ever suffered from a sinus infection? It can interfere with both taste and smell. What can you do about it? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:44 Today, we’re talking with one of the country’s leading sinus experts. She’ll explain why we have sinuses and what can go wrong that results in sinusitis. Joe 00:45-00:56 Sinusitis can linger for weeks and make people feel miserable. It’s not just the congestion, headache, and pressure. Some people develop troublesome post-nasal drip. Terry 00:57-01:01 What treatments work? When should someone consider surgery? Joe 01:02-01:07 Coming up on The People’s Pharmacy, how to stop suffering from sinusitis. Terry 01:14-02:17 In The People’s Pharmacy health headlines, older individuals who feel that they have a purpose in life are less likely to develop cognitive impairment. The data comes from the Health and Retirement Study with more than 13,000 volunteers over 45 years old. They all had normal cognitive function at the beginning of the study and responded to a validated seven-item survey to measure purpose in life. Over the course of the 15-year study, 13% of the participants developed cognitive impairment. Those who scored higher on the purpose-in-life measure were 28% less likely to become impaired. Purpose can vary. For some people, it consists of spirituality or faith, while for others it may be linked to work, volunteering, or helping others. Relationships with family or close friends can also provide a sense of purpose. One of the investigators notes, it’s never too early or too late to start thinking about what gives your life meaning. Joe 02:18-03:04 Many chronic health conditions begin long before symptoms appear. The thickening of arteries leading to heart disease can develop many years before someone has a heart attack. Neurodegenerative conditions such as Alzheimer’s disease also create changes in the brain long before people noticed cognitive impairment. Now, scientists have found early indications of rheumatoid arthritis. Three to five years before people experience swollen and painful joints, they begin developing elevated levels of autoantibodies. The authors of the study suggest that preemptive intervention in at-risk individuals might prevent or delay future tissue damage from rheumatoid arthritis. Terry 03:05-04:17 Researchers reported a new approach to treating knee osteoarthritis can ease pain. Korean scientists compared low-dose radiation to sham treatment. This is a type of treatment that’s already being used in Europe, but studies of low-dose radiation are scarce. In this one, investigators recruited 114 people with knee osteoarthritis and randomly assigned them to one of three groups. Low dose radiation of 3 gray, very low dose of 0.3 gray, or sham radiation. All groups received six sessions. Four months later, volunteers rated their pain. 70% of the patients in the group that received 3 gray got significant pain relief. Almost 60% of them had improvements in stiffness and physical function as well. 58% of the very low-dose group got results. That was not significantly better than the placebo group at 42%. The researchers hoped this could help people delay joint replacement. There were no serious side effects from the low-dose radiation. Joe 04:18-05:27 A surprisingly large number of Americans suffer chronic pain. In 2010, the most prescribed drug in America was an opioid called hydrocodone. Some of those prescriptions were inappropriate, but clearly a lot of citizens were in severe pain. Opioid prescriptions have dropped dramatically over the last 15 years. Today, the most frequently prescribed medicine for pain is gabapentin. An article in the Annals of Internal Medicine describes the rapid increase in gabapentin prescriptions. Last year, it was the number five most prescribed medicine in America. In 2010, 5.8 million people were taking gabapentin. Last year, that number had jumped to 15.5 million. Most of the prescriptions were off-label. That’s because gabapentin has only been approved for treating partial seizures and the lingering pain after a shingles episode. A downside to relying on gabapentin, especially for older people, is that it may increase the risk for falls. Side effects such as dizziness, drowsiness, and trouble walking elevate that danger. Terry 05:28-06:17 Doctors have begun to worry about the long-term risks of sleeping pills, so they are looking for alternatives. A new meta-analysis of 67 randomized clinical trials shows that a technique called cognitive behavioral therapy for insomnia is effective for people with chronic disease. Most volunteers were pleased with the treatment, which does not have adverse effects. 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. Have you ever suffered from sinusitis? If not, you’re fortunate. The CDC says that almost 30 million Americans have been diagnosed with this condition. That’s over 11% of the population. Terry 06:32-06:42 How would you know if a sinus infection were causing your symptoms? Could your stuffy nose and head pain be allergies or a cold instead of sinusitis? Joe 06:42-07:17 To learn more about sinuses and the trouble they can cause, we’re talking with Dr. Zara Patel. She’s professor and director of endoscopic skull base surgery at Stanford School of Medicine. She’s also director of the Neurorhinology Advanced Sinus and Skull Base Surgery Fellowship in the Department of Otolaryngology Head and Neck Surgery at Stanford. Dr. Patel is also director of the Stanford Initiative to Cure Smell and Taste Loss, something more important now than ever before thanks to COVID. Terry 07:19-07:23 Welcome back to The People’s Pharmacy, Dr. Zara Patel. Dr. Zara Patel 07:24-07:26 Hi there. Thank you so much for having me again. Joe 07:27-07:49 Well, we’re delighted to be able to talk to you about something that affects millions and millions of people, sinuses. What are they, where are they, and–after you’ve given us a little anatomy lesson–we’ll ask you what they do. So first of all what and and where? Dr. Zara Patel 07:50-09:45 Sure. So the sinuses what we also call the paranasal sinuses are these pockets of air-filled cavities that are basically in the face and And the reason we have them has been debated, but what they do is they pneumatize or create air spaces in the head. And what that does is it creates a potential crumple zone if your head ever had trauma that could absorb the impact of that trauma before your brain gets hit with that trauma. That’s a lot of people’s theory as to why we have these air-filled spaces around our nose and in our facial skeleton. There’s also other theories as to why we have them, which have more to do with other sort of evolutionary theories, such as it makes our heads lighter. And that may have been a crucial component in what allowed us to start standing up and walking as a way of getting around. And finally, there’s some theory that the sinuses lend more resonance to our voices, and that led to improved and more complex communication between human beings. So all different evolutionary theories as to why we have these sinuses. Now, the final theory is maybe the most important, and probably we’ll talk a lot about today, And that is there is a local immune system in the lining of your nose and sinuses that is a crucial component of your overall systemic immune system. And that is one of the first leading defenses of keeping your body healthy when you breathe in any sort of potential irritants or allergens or toxins in the air. Joe 09:46-10:16 Dr. Patel, pretend that I’m really, really dumb. And I think sometimes Terry would attest to the fact that that’s probably true. But when it comes to the anatomy of these sinuses, first of all, how many are there? And where precisely? You say around the nose, the face. I assume they sort of protrude up into the brain. But can you give us a little bit more of an anatomy lesson? Dr. Zara Patel 10:16-12:33 Sure. So if you were to look at the face, beneath the surface of the skin are muscles and bones. And beneath those bones are the air-filled pockets. So you have the frontal sinuses, which are in your forehead region. You have the ethmoid sinuses, which is a little honeycomb of little cells and septations, so multiple cells, but we call them one group of cells, the ethmoid sinuses, that are kind of between your eyes. And the maxillary sinuses, which are in your cheek region below your eyes and on the sides of your nose. And then at the very deepest point, which is kind of located right in the center of your head, are the sphenoid sinuses, the deepest sinuses. And these sinuses are most of the time paired, although there is some anatomic variation where some people won’t develop frontal sinuses or just develop one. But most of the time people have bilateral, meaning on both sides of their head, these paired sinuses. And they all open and drain into the nasal cavity. And that is how they aerate also with air coming through the nasal cavity. And I make a point to make sure you understand that they’re not directly under the skin. There is that layer of muscle and bone because sometimes people will say, oh, I’m swollen. They touch their face underneath their eyes or on their cheeks and they say, oh, my sinuses, I’m swollen. That’s not your sinuses. What you’re feeling in that sort of moment is the soft tissue of the skin and subcutaneous tissue itself, which can swell due to things like allergy, but that is not directly from your sinuses. Only when a sinus infection gets really, really bad and actually can break through the bone, that’s the only time that you would have a swelling related to sinusitis. And that’s very, very rare. And you would know that you’re having a major problem at that point. Terry 12:34-12:35 It definitely sounds terrible. Joe 12:37-13:17 So, Dr. Patel, you are a professor of otolaryngology and head and neck surgery, and that means that you have performed surgery on a lot of people’s sinuses. I’m guessing that anyway. And I have a good friend who says he has giganto-sinuses and gets terrible, I mean, just unbearable sinus infections and sinusitis. and we’ll get into all of that in a minute, but you’ve probably seen a lot of variability in the size of people’s sinuses, or am I making that up? Dr. Zara Patel 13:18-14:26 Yeah, so I think when people say they have giant sinuses, that may be because they have actually seen a CT scan of their own sinuses, and they know they’re really big, but although there is some variability in size, that’s not the thing that varies most. The sort of complex pattern of cellular septations and drainage pathways, that’s where the variability comes in most. So the size is not that variable, but the complexity of the pattern of drainage and pneumatization in the face of that bone, that is very individualized. And yeah, I’m a professor of otolaryngology, head and neck surgery, but even more specifically of rhinology, which is, you know, the subspecialty of just the nose, sinuses, and skull base above, that bone that separates the sinuses from the brain. And so I have done, you know, over 6,000 of this type of surgery. So yes, I’ve seen a lot of different sinuses and a lot of different variability in sinusitis, but the size is not the thing that varies most. Terry 14:26-14:41 Well, let’s talk about the sinusitis. What is sinusitis? We know that generally speaking, if we put itis on the end of a word, we’re talking about inflammation. So is that true for sinusitis? Dr. Zara Patel 14:42-16:31 Yes, that’s exactly right. So sinusitis, or what we sometimes call more specifically rhinosinusitis, which includes the nose in that inflammation, is really this end state of mucosal inflammation within those sinus cavities and often the nasal cavity. And that can come from many, many different etiologies or reasons. We used to think of sinusitis, and I think a lot of people and even general practitioners may still think of sinusitis as sinus infections. But that’s only one small reason why people end up with sinusitis, an infection that causes swelling of the lining and mucous production, that that’s one reason why you might lead to that end state. But there’s also a lot of reactivity that goes on to our environment now that leads to that end state of inflammation. So whether that’s reactivity to true allergens in the air, as people sort of are familiar with thinking of allergens like pollens or grasses or weeds, but also reactivity to non-allergens, but things that are irritants. So there’s about a zillion things in the air now. There’s pollution, there’s particulate matter from forest fires. There’s a whole field of study and research on PM 2.5 that stands for particulate matter that’s 2.5 microns, because that very tiny size of particle can enter into your respiratory pathway and sort of land in both the upper respiratory path, which is the sinuses and nose, as well as the lower respiratory path, which is your lungs, and cause a lot of inflammation, which we’re just starting to learn more about. Joe 16:32-16:41 Dr. Patel, how would someone know that they were suffering from sinusitis? What’s the number one most common symptom? Dr. Zara Patel 16:41-17:21 The number one most common symptom of true sinusitis is facial pressure. So there’s also other cardinal signs like loss of smell and taste, really foul smelling, thick drainage, nasal drainage, and nasal obstruction or congestion. But a lot of symptoms can overlap in whether it’s just the nose that has that inflammation or the sinuses. And so facial pressure is really the most specific sign of sinusitis that you can sort of look for. Terry 17:22-17:47 You’re listening to Dr. Zara Patel, professor and director of endoscopic skull base surgery in the Department of Otolaryngology Head and Neck Surgery at Stanford School of Medicine. Dr. Patel is director of the Stanford Initiative to Cure Smell and Taste Loss. She’s also director of the Neurorhinology Advanced Sinus and Skull Base Surgery Fellowship. Joe 17:48-18:02 And Terry, it’s nice to know the key monitor is facial pressure, you know, in that area of the sinuses. Well, after the break, we’re going to find out what it’s like to have sinusitis. Terry 18:03-18:08 Does the congestion mean you have an infection, or, you know, could it be something else? Joe 18:08-18:20 What steps does Dr. Patel take to diagnose the cause of sinusitis? What are the different kinds of sinusitis? How does the microbiome of the nasal sinuses affect inflammation? Terry 18:21-18:25 What factors determine if the sinusitis is acute, recurrent, or chronic? Joe 18:25-18:31 Could old-fashioned treatments like a neti pot or inhaling steam vapor be helpful? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 20:18-20:21 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 20:21-20:39 And I’m Joe Graedon. Terry 20:39-20:49 Today, we’re talking about the holes in our heads. We call them sinuses, and they’re essential for good health. They play a critical role in our immune function. Joe 20:49-21:01 What happens when our sinuses become inflamed or infected? Pathogens like bacteria or fungi can take up residence in our sinuses and make us miserable. Terry 21:01-21:41 We’re talking with Dr. Zara Patel. Dr. Patel is professor and director of endoscopic skull base surgery. She’s also director of the Neurorhinology Advanced Sinus and Skull Base Surgery Fellowship in the Department of Otolaryngology Head and Neck Surgery at Stanford School of Medicine. Dr. Patel is director of the Stanford Initiative to Cure Smell and Taste Loss. We spoke with her about loss of smell and how to treat it back in March. You can find that interview as show number 1422 on our website, peoplespharmacy.com. Joe 21:42-21:59 Dr. Patel, what’s it like to have sinusitis? I’ve had it once or twice. And yes, I feel the pressure and I’ve lost the sense of smell and pretty much the sense of taste. And it’s awful. Dr. Zara Patel 21:59-21:59 Yeah. Joe 21:59-22:36 But you deal with people who get frequent sinus infections and sinusitis and they are miserable. I mean, when my friend comes down with it, he’s not fun to be around. He’s just in not just pain. He’s just awful. He just wants to go hang out in a cave someplace until it gets better. So tell us what the subjective feelings of sinusitis are like and then how to distinguish between an infectious type of sinusitis and then some of the other things that can trigger it. Dr. Zara Patel 22:37-25:14 Sure. So there’s actually quite a lot of variability in how people experience sinusitis and whether it’s an acute sinusitis, an acute flare of chronic sinusitis or chronic sinusitis actually changes the way that a person experiences that disease process. So what you’ve been even describing is acute sinusitis or flares of acute sinusitis, where you feel a lot of that really bad pressure in your face, a lot of this nasal drainage, the loss of smell, and people often just feel overall crummy. They feel like they’re just not functioning at their optimal best. People will often have sort of a sensation of brain fog or just not able to focus, low stamina, not able to work out the way they normally would, and just feeling not so great. That can happen with both acute sinusitis as well as the chronic sinusitis. There’s so many different forms of chronic sinusitis. There’s the infectious type that we’ve sort of touched on where infection can lead to this inflammation and people have a lot of pus draining out. But there’s also the much more inflammatory type where people develop polyps that fill their sinuses, completely block the sinuses, and then eventually if it goes on long enough can just block the nose self. Interestingly, those people, although when you look at their sinuses, it looks much worse, they often actually don’t have as extreme or severe of symptoms. Sometimes all they feel is nasal obstruction and loss of smell because it’s just developed over such a long period of time that they’ve kind of gotten used to it. And so there’s a lot of different ways that people experience the disease. What I can say sort of across the board for all patients with chronic rhinosinusitis is that we know that the amount of sort of suffering or how much it impacts their daily life, how well that they can work or have to miss work, how well that they can go about doing their normal daily activities is on par with some of the sort of most significant chronic diseases that we are familiar with, things like heart failure or diabetes, chronic rhinosinusitis factors up in those levels when you think about health utility scores. And so it is highly impactful on people’s quality of life. Terry 25:15-25:40 Dr. Patel, how does a specialist like yourself diagnose the cause of the sinusitis. So how can you tell if someone is having a sinus problem due to, oh, wildfire smoke in the area, or maybe they have an infection? And what type of infection? How do you make that diagnosis? Dr. Zara Patel 25:41-28:54 Yeah, it’s not always easy, I’ll say. A lot of the understanding of what has led to that end state of sinusitis has a lot to do with careful history taking more than anything else. That’s where the art of medicine comes in as opposed to science. Because often what people tend to use to try to prove or disprove infection are tools that are now our understanding of what those tools can do shows that they’re not very perfect or good. So for example, people have suggested culturing sinuses to decide if there’s a bacterial infection or a viral infection or whether it’s just inflammatory. And for a long time, that was pretty standard that if people came in with sinusitis, we’d just swab them and see what it was and make sure we knew what antibiotics to give them. But now that we have much better, more accurate tools of looking at the bacteria that are in our sinuses, we know that culturing and swabbing the nose and growing that culture on a Petri dish is not very exact at all. In fact, when we compare cultures to actual PCR analysis, which is kind of the best way of looking at the microbiome in the sinuses. We know that cultures do not show what the most prevalent bacteria is in the sinuses. They do not show what the most pathogenic bacteria is in that particular sinusitis. And they really don’t show us overall the entire picture. We have hundreds of bacteria and viruses and fungus particles in our sinus microbiome at baseline in a healthy sinus, we have these and they aren’t necessarily bad for us. It’s really only when we have an alteration in the diversity, when there’s some that overgrow or are underrepresented and we have decreased diversity of species, that’s what we can say is, okay, that matches an abnormal type of microbiome. And that’s what we see in people with chronic sinusitis. But to try to answer your question more succinctly, that just shows that, you know, culturing sinuses is just not really a great way of distinguishing whether people have infection or inflammation. And that’s why a careful history is really often the best way. Now, having said all that, I will say in particular patient populations where we know they’ve already been treated with a whole host of antibiotics, they’re not responding to the antibiotics. And we want to know if someone has grown a resistance to particular antibiotics, then culturing can be quite helpful because then we can test whether they are sensitive or resistant to particular antibiotics. So cystic fibrosis patients, for example, who have been on antibiotics since almost birth for all of their different complicated infections, those are people that we culture quite frequently and we do actually get good results and can tailor our treatment for them. But it’s not something that I honestly do for all of my patients with sinusitis. Joe 28:55-29:48 Now, Dr. Patel, you’ve just said something that I think is really provocative, and I’m not sure everyone who’s been listening picked up on it. You basically said there is a microbiome in the nasal sinuses, and there are hundreds, not dozens, not scores, hundreds of creepy crawlies in there. And some of them are probably healthy, sort of just like our digestive tracts where we have, well, probably trillions. So we have all kinds of different kinds of bacteria and viruses and fungi. And I think a lot of times people think, well, just give me a Z-Pak doctor and that’ll knock out my sinus infection. But if it’s a fungus that’s growing out of control, antibiotics aren’t going to do a thing. Dr. Zara Patel 29:49-31:48 Yeah. So what I would say to that is that’s correct. We have this microbiome. I think the understanding of the microbiome has been, a lot of people talk about the microbiome in an incorrect or inaccurate way. So yes, we have all these things to discuss. So for example, a lot of people come to me and say, oh, someone told me I might have fungal overgrowth or a fungal infection in my sinuses and that’s what’s causing this problem. We have disproven that so many times that fungus is the cause of any sort of acute or chronic sinus issue other than in immunocompromised patients. Immunocompromised or immunosuppressed patients are the only people that actually have to be concerned about a fungal infection. And in those patients, it can become very dangerous. It invasive type of fungal infection that can lead to death. But people with a functioning immune system, and this isn’t just people who think their immune system is like a little weak or something, this is people who are actually completely suppressed that that happens to. People with a normal immune system will not get fungal infections in their sinuses. Our immune system is very clear about not having that occur. We can get reactivity to fungal spores, And that is quite commonly what happens. We can get allergic fungal sinusitis where we’re all breathing in fungal spores every single day and people can react to that like a foreign body reaction, an allergic reaction, and that causes swelling of the lining. But I will say that there are a lot of alternative practitioners out there giving away, you know, having people do fungal tests and making a lot of money off of antifungal treatments that are completely not based in scientific fact. So I want to make that totally clear. Terry 31:49-32:09 Tell us about the different types of sinusitis that you have encountered. Acute sinusitis, you mentioned already, we hear that there’s recurrent sinusitis, chronic sinusitis. Why would someone go from acute sinusitis to chronic sinusitis? What are the factors? Dr. Zara Patel 32:10-33:55 Yeah, we actually are learning more and more about that because that’s something that happens quite often. People go their entire lives with no sinus problem at all. And then suddenly they have one big, big flare, a big event of sinusitis. And then suddenly they just cannot resolve. They cannot go back to their normal baseline and they come in and wonder, you know, why have I developed this chronic problem? Why couldn’t I just take a course of antibiotics like that and get back to normal like I always did in the past? What we are now learning through some really interesting research is that your basal stem cells, the cells that can differentiate into all the different types of cells in the lining of the sinuses, are actually impacted and affected in a long-term permanent sort of way by a big inflammatory event, whether it is an infectious event or an inflammatory just allergic type of event. And what happens is that those stem cells shift, they have memory. And instead of differentiating into all the normal types of cells they always have in the past, they instead start preferentially producing the inflammatory type of cells, things like goblet cells that produce more mucus, those cells that are able to respond to allergens or infectious pathogens much more readily. And so that is one of the reasons why people can have this sudden shift from just having acute sinusitis and being able to resolve to more of a chronic pattern, which sometimes, you know, medical therapy can resolve and sometimes it cannot. Sometimes people need in the end to undergo surgery to help with that type of problem. Joe 33:56-34:09 So let’s start talking about treatment. I want to go back to my friend who has what he has described as the humongous sinuses, even if that’s not really his problem. Terry 34:09-34:15 But what he does have is frequent sinus infections or sinusitis. Right. Joe 34:15-34:54 If he gets a cold, if he comes down with some other kind of infection, it often attacks his sinuses. And his number one go-to treatment is what he calls inhalation. So, you know, I think when he was a kid, his mother would have a pot of water on the stove and she would put some Vick’s vapor rub in there and he put a towel over his head and he would inhale the vapors. And he says it works. Maybe not every time and maybe not perfectly, but it is that steam inhalation that he seems to think is beneficial. Any truth to that? Dr. Zara Patel 34:56-36:42 Yeah. So, you know, we can start with why does he have these frequent sinus infections, right? And that goes to the underlying anatomy and the likely environmental reactivity or predisposition to swell if you get a virus or are exposed to an allergen. So there is some underlying anatomy that some people have, anatomic variants, that make your drainage pathways a little more crowded. And so you have less room for the mucosal surface to swell before it completely shuts off that drainage pathway. And so whether it’s an anatomic factor or more likely to swell, people who end up getting these sinus problems, when they do that inhalation or have that heated steam that they’re breathing in, what that does is it’s really just kind of loosening up any of that mucus that’s kind of getting stuck or plugged in those tiny little drainage pathways. And that can in turn allow for more drainage of the mucus behind it. And so certainly doing things like, you know, just standing in the shower for a long time and allowing that to hit your face or doing that steam inhalation, that can be helpful. But probably the most helpful thing that people can do is just rinsing their nose with salt water because that can really get in there and not only loosen up mucus, but through the mechanism of osmosis, when you put salt inside the water, it can draw out that excessive boggy moisture that’s in the tissues and naturally decongest the lining. And that also allows that mucus to come out. So that’s another way that you can really nicely open up the sinus pathways in some cases. Joe 36:43-36:54 Now, Dr. Patel, that sounds suspiciously like a neti pot, which goes back quite a long time in the Ayurvedic tradition. Dr. Zara Patel 36:55-37:49 That’s right. That’s exactly right. Neti pot has been used for hundreds, if not thousands of years. And the only difference now is kind of what we recommend around using boiled water or distilled water to make sure that people are using water that’s safe for their nose and sinuses. Because there have been some case reports out there of people getting bad amoebic infections from rinsing their nose. But those are all honestly related to people either rinsing with things like shallow well water where that stuff can grow or rinsing with water that’s gone through a filter that hasn’t been changed for 20 years or things like that. So really, if you boil the water that comes out of the tap or if you use distilled water, that’s really safe and effective. And yes, you’re right. It has many, many years of proof of principle that it can help people. Terry 37:51-38:18 You are listening to Dr. Zara Patel, professor and director of endoscopic skull base surgery. Dr. Patel is director of the Stanford Initiative to Cure Smell and Taste Loss. She’s also director of the Neurorhinology Advanced Sinus and Skull Base Surgery Fellowship in the Department of Otolaryngology, head and neck surgery at Stanford University School of Medicine. Joe 38:19-38:26 After the break, we’ll hear more about how neti pots can be helpful and how to find the right one. Terry 38:27-38:30 When do you move on to some other treatment beyond irrigation? Joe 38:31-38:35 What place do nasal sprays and topical steroids have? Terry 38:35-38:43 We’ll find out about ingredients that are not good for your nose, so you can avoid nasal sprays that contain them. Joe 38:43-38:50 Dr. Patel will also describe how people make the decision to have surgery for chronic sinusitis. Terry 39:05-39:09 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 39:17-39:20 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 39:21-39:39 And I’m Terry Graedon. Joe 39:40-39:50 We’re talking about sinusitis today and some strategies to prevent or treat this common disorder. Are there medications that can make matters worse? Terry 39:51-39:59 When is surgery appropriate for sinusitis? What factors should doctors and patients consider when contemplating that approach? Joe 40:00-40:05 What’s the best after-surgery care to prevent problems from coming back? Terry 40:05-40:35 Today’s guest is Dr. Zara Patel. She’s a professor in the Department of Otolaryngology, Head and Neck Surgery at Stanford School of Medicine. Dr. Patel is also Director of Endoscopic Skull Base Surgery and Director of the Neurorhinology Advanced Sinus and Skull Base Surgery Fellowship. Dr. Patel is director of the Stanford Initiative to Cure Smell and Taste Loss. Joe 40:36-40:59 Dr. Patel, we’ve been talking about the neti pot, and I wish you could describe that because some of our listeners may never have seen or heard about a neti pot. I describe it as Aladdin’s lamp, but that’s not a very good description. And are there any brands that you sometimes recommend that might be especially helpful. Dr. Zara Patel 41:00-43:27 Yeah, I think that’s actually a great description. It is a sort of small squat type of pot that has that sort of elongated spout coming off of it. And it can be ceramic. It can be made of plastic. It comes in all sort of shapes and sizes, honestly. But what that is, is a high volume, low pressure type of irrigation. Now we’ve studied a lot of different irrigation mechanisms. There’s no particular brand that I would recommend. But what I would say is the type of irrigation device that I recommend for my patients is actually not a low pressure, high volume, but a high pressure, high volume. It’s actually just a simple squeeze bottle. And you use it in the exact same way that you would use a neti pot. You’d put your head over the sink, turn it a bit to the side and a little head hanging forward. And then you’re just sort of slowly and gently squeezing the salt water through. And your active squeezing, that active sort of control over the flow of water is why the high pressure, high volume is a little bit more effective than low pressure, high volume at getting in and out of the sinus drainage pathways. So that simple squeeze bottle is the one that I recommend most. And a lot of patients will ask me, well, what about these motorized irrigators that they see advertised on TV? Can I use that? That seems a little more simple. I can just put it up to my nose and have it do the job for me. And what I sort of caution about is that any motorized device, that motor you’re not actually able to get to to really sterilize. And that can sometimes harbor bacteria or viruses or fungus that you then are jetting back into your nose and sinuses. And so, you know, if people insist on using those, I say, okay, maybe try using a really dilute bleach solution like 10% to rinse through that motor once a week. But then you really have to put a ton of water through that device to make sure you’re not putting bleach in your nose. So that becomes a little more cumbersome. And I think just the simple squeeze bottle and washing it with hot water and soap completely sterilizes the entire device in between uses. I think that’s a little bit more straightforward and is really helpful. Terry 43:28-43:49 We have seen such a squeeze bottle under the brand name NeilMed. Is that the sort of thing you have in mind? Dr. Zara Patel 43:34-43:35 That’s exactly right. Terry 43:36-43:49 Okay. Now, obviously, we want to start with irrigation, but what if that’s not quite enough? When do you move on to some other treatment and how do you know? Dr. Zara Patel 43:50-45:28 Yeah. So, you know, I would say people who have persistent symptoms, whether it’s nasal congestion or obstruction or facial pressure or that smell issue or drainage, if those things are not completely resolved by rinsing, then you probably need something more. And that something more can be as simple as just optimizing your topical regimen. So adding some sprays to your rinses can be really effective for a lot of people, especially if it’s just allergy that you’re dealing with. But if that’s not enough, and we can talk a little bit about the different types of sprays that can be helpful for people, but if sprays and rinses are not enough, then that’s when we start talking about medical therapy that you would take in pill form. So in the form of either antibiotics or steroids or a combination of that. And that sometimes is what people need to get rid of their sinusitis, whether it’s an acute episode or a chronic episode. And then even that sometimes for some patients is not enough. And if someone has failed all of that, good optimized topical therapy, good, appropriate medical therapy, that’s when we start talking about sinus surgery. And that can really be the most definitive final step for people. And I guess I shouldn’t say final, but the most definitive next step for people. And then often we want them to continue with an optimized topical regimen to keep them at that good new baseline that surgery can get them to. Terry 45:28-45:52 Now, you mentioned sprays and you said you’d tell us what kinds. I’m assuming that one of the types of sprays you might recommend would be, again, steroid. You mentioned that sometimes people need to take oral steroids, but I’m assuming that the topical steroids, which are so common, like Flonase, would be a first step rather than oral. Dr. Zara Patel 45:53-46:58 Yeah. So I’ve made a whole YouTube video about nasal sprays and also a whole different YouTube video about rinses. So if people want really good detail, they can go find me on YouTube and, and re and listen to those videos. But just in brief, the sprays that we tend to prescribe people can be nasal steroid sprays, like fluticasone or Flonase or Nasonex, Nasocort, those types of things, or antihistamine nasal sprays like Astapro or Astelin, Patanase, those types of things, or a particular type of spray that can just decrease the amount of mucus production in the nose, something called ipratropium or Atrovent nasal sprays. They all do slightly different things. And so we choose them for different types of diagnoses and different patients. And we can use them in combination also because they’re all doing different things. There are lots of nasal sprays out there that are sold over the counter that are actually really bad for your nose and should not be used on a regular basis. Joe 46:59-47:06 I assume you’re referring to the decongestant sprays. Can you go into a little more detail on those, please? Dr. Zara Patel 47:06-49:16 Sure. So that’s one form of the sprays that are bad for your nose. So decongestant sprays like Afrin or Sinex, there’s a lot of other brand names out there. What they’re doing is they’re constricting the blood vessels in the structures in your nose, most often the turbinate structures that tend to swell in response to things like allergens in the air. That’s why they can give a really great immediate relief and decongestant because there’s a lot of blood flow to those structures. And so constricting the blood vessels will immediately shrink down the size of those structures. The problem with that is that these vessels should be at a good resting tone. They should not be too constricted or too dilated all the time. They should be able to respond to whatever is going on in your environment to constrict or dilate in that response. If you continually apply a vasoconstrictor, the baseline resting tone becomes more and more and more dilated and needs that medication to constrict even back down to normal. And so what you get over time is what we call rebound congestion, you make yourself more and more congested. You feel worse and worse and worse by using the spray. And then people get addicted to these sprays because then that’s the only thing that can make them feel even a little better and able to get airflow through. So really the only time that I tell people to use a spray like that is if they’re having a very severe nosebleed, and that can help constricting the vessels, stopping the nosebleed in that moment. But really, these sprays should not be used other than that really specific instance. Now, there’s also other types of sprays that are sold over the counter that have all kinds of different ingredients that are not great for your nose. They contain things like menthol that might desensitize your receptors for airflow. They contain other ingredients that haven’t been studied and may be detrimental. We know that zinc nasal sprays were sold for a long time and caused irreversible smell loss. So I would really be cautious about putting really anything in the nose that is not being prescribed by your doctor. Joe 49:16-49:52 I do have one of my favorite nasal sprays. And these days, very few physicians recommend it. But it’s really been around a long time. And it was developed originally from a plant called Bishop’s weed. And the original inhaler was for asthma. It was called Intal. And now I think that’s unavailable, but you can still get nasal chrome, which contains the ingredient cromolyn sodium. Dr. Zara Patel 49:53-49:53 Yeah. Joe 49:54-50:18 And it stabilizes those mast cells in the nose that release not just histamine, but lots of other inflammatory compounds. Do you ever recommend Nasalcrom? I know that a lot of doctors say, well, you have to use it two, three, four times a day. Nobody will ever do that. It’s not worth your time. But what’s your thought? Dr. Zara Patel 50:19-50:56 Yeah, certainly that’s something that people still prescribe and still use. I think it’s good for a particular subset of patients. It’s not helpful for everyone. When we’ve done studies on it, you can see that there are very particular patients who respond really well. The majority of patients don’t find a lot of benefit from it. So you really have to, again, it goes back to that careful history taking as to what is causing the patient’s symptoms. And that really allows us to decide which specific spray is going to help which specific person. And so yes, for some patients, that is a great option. Terry 50:58-51:19 Now, Dr. Patel, a few minutes ago, we suggested that surgery might be a next step for people who have not responded adequately to some of these medical treatments. Tell us, if you would, please, what is the goal of surgery? How do you decide that it is time for surgery? Joe 51:20-51:26 And what is it you do when you perform surgery on someone with chronic sinusitis? Dr. Zara Patel 51:27-54:22 Yeah. So how we decide it’s time for surgery really, again, depends on how well patients have responded to any of those topical therapeutic regimens or medical therapy. And if they have not been able to resolve and we see not just based on their symptoms, but we see on a CT scan, that’s a really crucial component to have objective findings, either a CT scan or nasal endoscopy that we perform in the clinic. If we see on those types of images that patients do truly have sinusitis and that is the cause of the symptoms, because often people have these symptoms and not have sinusitis, which we can talk about in a moment. If that is proven, then surgery is the next step. And what surgery entails is what we call endoscopic sinus surgery. So using that small, tiny, thin camera that we look into patients’ noses in our clinic. And a lot of different instruments that have been developed over time to be very specific to these tiny little nooks and crannies that are within the sinus spaces and drainage pathways. So that we are very delicately and meticulously opening the sinuses, removing these tiny little septations, removing inflammatory tissue and any mucus that’s trapped in there. So that at the end of that surgery, you have one big confluent drainage pathway and aeration pathway for all of the sinuses on each side. And that can be really, really effective and helpful in just allowing patients to have their sinuses function again more normally. Now, what I will say is that for most patients with a chronic inflammatory process like this, they need to continue doing something like rinses and sprays to keep themselves at that good new baseline. And I often will see patients who have had six or seven sinus surgeries by other practitioners out in the community, and no one should have that many surgeries. You should have one good, complete, thorough surgery by an expert sinus surgeon, and then have the education about what you need to stay on to remain well, and that should be it. Now, the reason people fail sinus surgery include things like either they haven’t had a good surgery, they haven’t had the complete or thorough surgery, they’ve just had something like balloon sinuplasty, which is not surgery, and they needed something more than that, or they haven’t been educated on what their regimen should be after surgery. So there’s a lot of different reasons why people could fail. But if you go to an expert, someone who, you know, like me as a rhinologist or has done thousands of this type of surgery and treated a lot of patients like this, you should be able to get a really good result with just one good surgery. Terry 54:22-54:30 And so what is it that you’re telling your patients, after surgery, you need to do this and you need to be very conscientious about it. Dr. Zara Patel 54:30-55:47 Yeah. So again, that depends on the individual patient. So if a patient’s main problem leading up to the surgery was underlying anatomy changes or variants that were really, really crowding them, maybe they had a terrible septal deviation and that was leading to crowding of the sinus drainage pathway or really a lot of cells that were going into the drainage pathway of another sinus, things like that, then maybe they don’t need to continue doing long-term topical therapy. Maybe I’ll just have them doing rinses for a good six months to a year, and then they can just go about their life and be done with it. But most patients are not just having anatomic issues. They’re having either a combination of underlying anatomy and inflammatory patterns, or it’s really just much more of a reactive inflammatory issue. Now, surgery can do a lot of great things, but nothing about surgery is going to change your underlying reactivity to your environment. And so that’s why remaining on rinses and sprays and us optimizing that, changing the type of sprays or adding medication even to the rinses can be what really keeps you at that good new baseline after surgery. Joe 55:48-56:13 Dr. Patel, what can we do to keep our sinuses healthy so that we can avoid surgery, so that we can avoid infections or sinusitis or all of the things that we’ve been talking about today? Are there any steps that people can take in a kind of preventive methodology to keep that part of our anatomy healthy? Dr. Zara Patel 56:14-58:05 Sure. I think that just rinsing with salt water is a great idea for anyone that kind of feels predisposed to allergy or reactivity. Anyone who feels like, oh, I have a toddler at home and they come home and just bring illnesses back to me all the time so I keep getting sick. Just rinsing your nose on a regular basis can be really effective at sort of helping the underlying immune mechanism in your nose of just clearing away these inflammatory factors and pathogens before they’re able to really embed and enter into cells and cause that infectious inflammatory reaction. So just doing that. And then of course, just all the other things about staying healthy in general. I think that when people have overall physical health, mental health, emotional health. We’ve seen that patients can respond much better to our treatments for chronic sinusitis. There’s so much more research that can be done in exploring these connections and pathways. A lot of people ask, should I eat something in particular or should I not eat something in particular And really there hasn’t been any evidence showing that food changes sinusitis predisposition at all. But I will have patients sometimes coming in and saying, oh, well, I cut this out of my diet and I feel like my sinuses are less reactive than before. And in the end, we have a lot more research to do into the causes of inflammation, not just in the sinuses, but throughout our body. And so the more that we learn about that through science and good clinical trials, the more we’ll be able to really educate people about what those underlying factors may be. Terry 58:05-58:29 Dr. Patel, you suggested that imaging, CT scan, or nasal endoscopy is critical before considering sinus surgery because you want to make sure it really is sinusitis and not, that would respond to surgery and not something else. So I’m wondering if you can tell us what that something else might be. Dr. Zara Patel 58:29-01:00:20 Yeah, there’s actually so many different things that can masquerade as sinusitis. The most common missed diagnosis in patients that have been told all their lives by their primary care doctors or urgent care doctors that they have sinusitis is migraine. So people often think of migraine in a very classic form. They have aura, they have these terrible debilitating headaches, they have to lay down in a dark room, but that’s not always the way that migraine presents. There is something called atypical migraine and even a subset called atypical facial migraine. And so people can have pain and pressure in their facial region for a lot of different reasons. There’s a lot of primary headache syndromes that can masquerade as sinusitis. So migraine is one. There’s also tension headache, cluster headache, hemicrania continua. There’s all these different headache syndromes that people can think are really sinusitis. There’s temporomandibular joint dysfunction, so that when you have either inflammation or some misalignment of the joint, all of the muscles of our facial skeleton and our scalp and our jaw and our neck attach to that joint. And so if there’s any tension there, you might have this radiating pain and pressure right across your cheek, right across your forehead. And of course, people are going to think that’s their sinuses, but a CT scan is what allows us to differentiate that. So when people are having a lot of pain and pressure, we get a CT and it’s totally clear in there, we then know, okay, this is not your sinuses. And then we can point them down the correct pathway of investigation. So really getting that imaging and understanding what’s going on in there is crucial. Joe 01:00:21-01:01:18 Dr. Patel, we live in North Carolina and like a lot of states in the southeast, in the summer, it gets hot and humid. And what that often means is that in the crawl spaces of people’s homes, where sometimes they have air conditioning ducts, the hot, humid air comes in through the vents. It hits the cold air in the ducts. And of course, it turns into precipitation. And now in that area, the basement or the crawl space, there’s a lot of moisture and heat, and that leads to mold and mildew. And I’m just wondering how mold and mildew may affect some people, either in a sense of allergic reaction or ultimately leading to allergy and then sinus problems? Dr. Zara Patel 01:01:19-01:04:45 Yeah, it’s a great question. And it goes back to what I had touched on earlier that, you know, definitely a lot of people react to fungal spores in their environment in an allergic manner. So we see a lot of allergy, especially in the Southeast region of the United States, but definitely everywhere, especially with climate change, you know, more and more places are becoming warmer than they were before. And as winters are less cold and we see less complete killing off of all of these different sort of allergens, we are seeing more and more allergy throughout the US. So people can have allergy, which is separate actually from chronic sinusitis. Often we see allergic rhinitis and chronic sinusitis in the same patient, but we’ve actually done a lot of studies trying to show causation and we have not been able to identify that. And so it’s just that both of those things can happen in the same person, but not always in the same person all the time. So you can have allergy from fungus and you can go to an allergist, get tested and potentially get desensitized through allergy shots or drops. That’s a great way of trying to deal with that type of thing. And again, rinses, sprays that deal with that. Those are great ways of treating allergic rhinitis. And then you can also get an entity that we call allergic fungal sinusitis. And remember, this is not a fungal infection. You do not treat this with antifungal medication or therapy. You do treat this with, again, allergy desensitization and often surgery. Because what happens with allergic fungal sinusitis is, and this is also the sort of mechanism by which people can develop what’s called a ball or mysotoma in their sinuses. The lining of your sinuses recognize these fungal spores as either a foreign body and they produce a bunch of mucus and wall it off. That’s what causes a fungal ball. Or they can recognize it and they react to it in an allergic manner. And that causes this huge inflammatory reaction in some patients where there’s a huge number of polyps that are produced. And you also develop all this mucus, this inflammatory mucus that walls off around all of these fungal spores in there. And some patients get so bad of allergic fungal sinusitis that the bone within the sinuses actually starts getting eroded from this chronic constant pressure of all of these polyps growing within their sinuses. And before I came to Stanford, I actually worked at Emory University in Atlanta, Georgia for four years right after training. And I saw a lot of allergic fungal sinusitis in the Southeast. And sometimes patients will come in and you can actually see that their eyes have been pushed apart. The nasal bridge has been flattened because of all of this pressure coming from the inside of their sinuses and almost trying to break through a road through the bone. And we get erosion of the bone that separates the sinuses from the above. And so these are patients that really need surgery to clear out all of the polyp and inflammatory mucus and then stay on a really strict regimen of anti-inflammatory rinses to keep them from regrowing that type of polyp formation. Joe 01:04:45-01:04:58 Of course, I would argue that if you are in an environment where there are a lot of fungal spores, Maybe you should do something about that crawl space. Terry 01:04:59-01:04:59 Like move. Joe 01:04:59-01:05:19 Well, either move or have it dried out and sealed up and make sure that you’re not hosting a lot of mold, mildew, fungal, and bacterial stuff that should not be in your home and in your duct work. Dr. Zara Patel 01:05:19-01:05:35 Yeah. So I would say I tell a lot of patients, you know, they’ll ask me, oh, should I get this remediated? And certainly if you have the ability to do that, yes, definitely try to get that fixed. Unfortunately, there’s a lot of people that live in environments that they don’t have complete control over. Joe 01:05:35-01:05:35 Right. Dr. Zara Patel 01:05:35-01:05:56 So a lot of renters, right? They ask their landlord to take care of things, and they’ve been asking them for years, and it just doesn’t get taken care of. And so, you know, certainly if you have control over your own living environment and you have the funds available to take care of something like that, then yes, you should try. But unfortunately, that’s not the reality for a lot of people. Terry 01:05:56-01:05:58 Right. And it is pricey. Dr. Zara Patel 01:05:58-01:05:58 Yeah. Joe 01:05:59-01:06:19 The idea that sinusitis and rheumatic diseases can go together, can you help us understand that a little bit better? There apparently is some research suggesting that people who have chronic sinusitis may also have rheumatic disease. Dr. Zara Patel 01:06:21-01:08:17 Yeah. So the study that you’re referencing showed that patients with chronic sinusitis may develop rheumatoid arthritis or other autoimmune type of diseases later on, like five to 10 years later. And what I want to be clear about is that the study does not show causation. When you read media publications about it, often it’ll say, oh, chronic sinusitis is a risk factor for developing rheumatoid arthritis. That’s not actually what the study shows. What it shows is that there is an association. So when you look back and look back to see, oh, these patients with rheumatoid arthritis, what did they have before in their health record? Well, some had chronic sinusitis. And an association, it’s one of the most important things actually in scientific research and literature is to make that distinction. So yes, it totally makes sense that someone who has developed an inflammatory condition is likely to develop other inflammatory conditions, whether that has to do with their specific environment or their specific genetic underlying predisposing factors, or most likely a combination of both. Yes, it makes sense that people who develop one inflammatory disease are more likely to develop other inflammatory diseases. Now, what may also be true is that when you develop an inflammatory disease and that kicks your immune system into kind of this overdrive of dealing with chronic inflammation on a regular basis, especially if it goes untreated or unchecked, could that potentially lead to a predisposition of developing others? Maybe. That’s the part that we don’t know. It hasn’t been studied or proven, but could potentially be true and I think is a really interesting line of research for some people to focus on. Joe 01:08:18-01:08:59 Dr. Patel, you deal with hundreds, if not thousands, of patients with sinusitis over the years. And I fear that friends and family of people who are suffering from sinusitis are not as sympathetic as they need to be. You know, when someone has sinusitis, they don’t look different. They don’t, you know, they don’t have a crutch. They don’t clutch their chest. They just look normal and yet they’re miserable. Can you help us better understand what’s going on for someone with sinusitis and perhaps have a little more sympathy for them? Dr. Zara Patel 01:09:00-01:10:50 Yeah. Well, I think that what I had mentioned before that the sort of health utility or cost of having chronic sinusitis is right up there with someone that has heart failure, right? That’s a really big deal, the amount that their quality of life is impacted by this underlying disease process. And it can be those really apparent things like drainage and loss of smell taste and pressure or headache. But also we’ve shown that people maybe are not really feeling like they can process as well as they normally would when they have this chronic sinus issue going on. They feel like they’re not at their best. They can’t perform well at work. They can’t connect well with their family and friends. They’re sort of always suffering and feel like they can’t go outside because as soon as they go outside, they’re going to react to something more. Sometimes people will avoid social events because people are worried they have some infectious or contractible disease process because they’re constantly blowing their nose or coughing because of the post-nasal drainage. So it really is highly impactful on patients’ quality of life. And I just encourage all patients who are suffering from sinus issues to really see a highly specialized, well-trained ENT doctor because you don’t have to suffer like that. And I will say a lot of my patients who I’ve done sinus surgery for will often say, gosh, I just cannot believe I waited this long to feel this good. I can’t believe I just let myself suffer for that many years when I could have been feeling like this. So that’s my final sort of word of advice. Terry 01:10:50-01:10:55 Dr. Zara Patel, thank you so much for talking with us on The People’s Pharmacy today. Dr. Zara Patel 01:10:56-01:10:58 My pleasure. Thank you for having me. Terry 01:10:59-01:11:54 Dr. Zara Patel, thank you so much for talking with us on The People’s Pharmacy this week. Dr. Zara Patel 1:11:04-1:11:08 It’s been a pleasure being here. Thank you so much for having me. Terry 1:11:08-01:11:53 You’ve been listening to Dr. Zara Patel. Dr. Patel is professor and director of Endoscopic Skull Base Surgery. She’s also director of the Neurorhinology Advanced Sinus and Skull Base Surgery Fellowship in the Department of Otolaryngology Head and Neck Surgery at Stanford School of Medicine. Dr. Patel is director of the Stanford Initiative to Cure Smell and Taste Loss. We spoke with her about loss of the sense of smell and how it can be treated back in March. You can find that interview as show number 1422 on our website, peoplespharmacy.com. Joe 01:11:54-01:12:03 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Liederman composed our theme music. Terry 01:12:03-01:12:11 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 01:12:11-01:12:35 Today’s show is number 1,448. You can find it online at peoplespharmacy.com. The show notes now include a written transcript of this conversation. At peoplespharmacy.com, you can also share your comments about today’s show. You can also reach us through email, radio, at peoplespharmacy.com. Terry 01:12:36-01:13:10 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, you’ll learn what we can do to help keep our sinuses healthy and prevent problems. What else might be masquerading as sinusitis? What role do mold and mildew in warm, humid crawl spaces play? You may be surprised to learn that rheumatic disease may also go hand-in-hand with sinusitis. Joe 01:13:10-01:13:30 At peoplespharmacy.com, you can 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. And we’d be grateful if you’d write a review for the podcast. In Durham, North Carolina, I’m Joe Graedon. Terry 01:13:30-01:14:05 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 01:14:05-01:14:15 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. 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Transcribed - Published: 10 October 2025

This week, we start the show with an interview with epidemiologist Thomas Farley, MD, MPH. His essay in JAMA Health Forum (Aug. 8, 2025) describes why older Americans are dying of falls at an alarming rate.  Once you have a chance to hear why this problem is worse in the US than in comparable countries, we will welcome your calls and stories. Prescriptions for medicines that make people drowsy or unsteady play a major role. Are you taking any? You can call in between 7 and 8 am EDT on Saturday, October 4, 2025, at 888-472-3366. 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 EDT on 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 October 6, 2025. The Epidemic of Deaths from Falls: Dr. Thomas Farley wrote in JAMA Health Forum that falls kill more Americans over 65 than breast or prostate cancer. If you add up deaths due to car crashes, overdoses and other unintentional injuries in older people, the total is still below the number of deaths from falls. That toll was more than 41,000 in 2023. It has tripled over the past three decades. Why are elderly Americans (particularly those 85 and older) so much more vulnerable to dying because of a fall? Perhaps older people everywhere suffer the same fate. Dr. Farley considered that as a possible explanation. But in other high-income countries that might serve for comparison, the rate of deaths from falls has actually dropped over the past 30 years. One difference that might help us understand what is going on is the rate of prescriptions. After all, older people have always contended with vision problems, physical frailty, cognitive impairment or clutter that is a trip hazard. Those things probably haven’t changed much since the year 2000. Today, though, older people are taking more medications. Older Americans take far more than those living elsewhere. Which Drugs Increase the Risk of Falls? Not all drugs increase the risk for falls. From 2017 to 2020, Dr. Farley points out, 90% of seniors were taking prescription meds, and 45% were taking drugs considered “potentially inappropriate.” Many of those could be termed Fall-Risk Increasing Drugs, or FRIDs. Are you taking any? Any medicine that interferes with balance or causes drowsiness is probably a FRID. Dr. Farley points to four categories in particular: opioids to treat pain, benzodiazepines for anxiety, antidepressants and gabapentinoids used off label to treat pain. (These are gabapentin, aka Neurontin, and pregabalin, known by the brand name Lyrica.) Other medicines, such as beta-blockers for heart conditions or anticholinergic drugs like diphenhydramine, can also cause problems. The overwhelming majority of older folks injured during a fall were taking one or more FRID at the time. Some of the medicines we are discussing are also covered by the American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults.  Any prescriber caring for people over 65 should be able to check whether the drug they are contemplating is on the Beers list. They may also want to consider whether there might be a less risky alternative. If you are accompanying an older relative, you could ask about that. Occasionally older patients are reticent about asking questions for fear of offending the prescriber. Beyond the Usual Suspects: It is hardly surprising that opioids would be related to a risk of falls. There are, however, other medicines that might be a problem in some circumstances. Blood pressure pills may cause dizziness, especially when a person first stands up. Certainly high blood pressure needs to be treated, but perhaps patients should consider trade-offs in terms of how aggressively to pursue perfect blood pressure numbers. Another medication that has been associated with falls, surprisingly, is the combination of atorvastatin to lower cholesterol and insulin for diabetes (Gerontology, Sep. 2, 2025). Call in Your Questions About FRIDs: Listen to Dr. Farley describe the problem. Then we welcome your calls. Have you taken a medicine that makes you drowsy or unsteady? Have you or an older relative taken a tumble you suspect was related to a medication? We want to hear about it. We spoke earlier with Dr. Farley. After we listen to his interview, Joe and Terry will try to answer your questions about medicines that might increase the risk for falls. Are there alternatives? What can you do? The show airs live from 7 to 8 am EDT on Saturday, Oct. 4, 2025. Give us a call to ask a question or share a story: 888-472-3366 This Week’s Guest: Thomas A. Farley, MD, MPH, has been a public health educator, researcher, and practitioner for more than three decades. Dr. Farley is a Professor of community health at Tulane University and has held positions in health agencies at the federal, state, and big city level. He is the author of Prescription for a Healthy Nation, Saving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives, and Prevention of Diseases in Populations: From Biology to Policy. Dr. Farley writes a newsletter on Substack called Healthscaping. https://medium.com/@DrTomFarley/about 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). Thomas A. Farley, MD, MPH Listen to the Podcast: The podcast of this program will be available Monday, Oct. 6, 2025, after broadcast on Oct. 4. 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 for Show 1447: 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 00:05-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Falls send a lot of people to the ER. In fact, more older Americans die from falls than from breast or prostate cancer. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:35-00:44 The number of deaths from falls in the U.S. has been increasing dramatically in recent decades. That’s not true of other developed countries. What makes us so vulnerable? Joe 00:45-00:53 Our guest today blames overuse of prescription drugs. Many of the pills Americans take make them unsteady on their feet. Terry 00:53-01:01 Has your medicine ever made you dizzy? Our lines are open for your stories and questions at 888-472-3366. Joe 01:01-01:07 Coming up on The People’s Pharmacy, the surprising risks in your medicine cabinet. Terry 01:15-02:26 In The People’s Pharmacy health headlines. When COVID first appeared, one of the novel symptoms that people reported was a loss of the ability to smell. Now research indicates that this problem can last for years. The study, called RECOVER, included 1,393 people who said they had trouble detecting odors. In addition, 1,563 were included who did not report that problem. Nearly all of the volunteers had a documented COVID-19 infection. The researchers tested participants’ ability to smell. 80% of those reporting olfactory difficulties had tests confirming the problem. Somewhat surprisingly, 66% of those who did not report trouble smelling also had some abnormalities in their sense of smell. Of those, 8% were severely impaired. Not being able to smell is bad enough. The investigators also report a link between an impaired sense of smell and cognitive difficulties or brain fog. Scientists suggest that these deficits could have a profound impact on people’s well-being. Joe 02:26-03:23 The FDA first approved the anticoagulant heparin in 1939. It was originally used to prevent blood clots. A new study of COVID patients demonstrates that heparin can prevent severe complications from SARS-CoV-2. 238 patients with COVID were assigned to receive inhaled heparin. Another 215 received standard of care and 25 got placebo. In-hospital death was far higher in the control group. Heparin is not just an anticoagulant. It also has antiviral and anti-inflammatory activity. Administering it in inhaled form can prevent lung injury and blood clots in the lungs. The researchers suspect that heparin could be beneficial against other serious lung infections, such as pneumonia or influenza. Terry 03:24-04:59 It may sometimes seem that people who have heart attacks or strokes are struck down out of the blue. A new study suggests that instead, nearly everyone who experiences a cardiovascular event had at least one suboptimal risk factor beforehand. The research included more than 9 million adults in Korea. A routine screening in 2009 recorded blood pressure, cholesterol, blood glucose, and smoking history. The scientists also checked prescription records for medicines used to treat these problems. When researchers checked participants’ health records after 13 years, they were able to see who had developed cardiovascular complications and who had not. They also studied nearly 7,000 American adults participating in the multi-ethnic study of atherosclerosis. These middle-aged to older individuals did not have heart disease when the study began. They, too, had their blood sugar, blood pressure, and cholesterol measured, and they reported if they were smokers. Nearly 18 years later, the investigators determined who suffered heart attacks, strokes, heart failure, or cardiovascular death. In both Korea and America, 96% of those who experienced complications had blood pressure above 120 in the initial screening. Even though this wasn’t technically hypertension, it was considered non-optimal. High cholesterol and high blood sugar were also common. Most people had multiple risk factors. Joe 05:00-05:35 The CDC is reporting an alarming rise in drug-resistant bacteria called NDM-CRE. This group of germs has surged in recent years and can cause pneumonia, urinary tract infections, sepsis, and wound infections. These bacteria are highly resistant to existing antibiotics. That makes treatment very challenging. Experts recommend testing and preventive strategies such as adherence to disposable gowns, gloves, and masks when interacting with patients. Terry 05:36-06:20 People at high risk for cardiovascular disease are sometimes encouraged to take aspirin as a preventive. A new study investigated whether the PREVENT risk calculator can determine who might benefit from aspirin for prevention. The vast majority of those who reported taking aspirin to prevent heart attacks did not qualify based on the PREVENT Risk Calculator. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. I’m a medical anthropologist. Joe 06:20-06:42 And I’m Joe Graedon. I’m a pharmacologist. Today, our lines are open for your calls and questions. Have you had a bad fall while taking a medicine that made you dizzy or drowsy? We want to hear your story. Our lines are open at 888-472-3366. Terry 06:42-06:49 Today’s topic is about avoiding falls and becoming aware of which drugs might increase the risk of falls. Joe 06:49-07:07 To start off, we’re talking with Dr. Thomas Farley, professor of community health at Tulane University. Dr. Farley wrote an alarming analysis in JAMA Health Forum in August titled, Risky Prescribing and the Epidemic of Deaths from Falls. Terry 07:08-07:12 Welcome to the People’s Pharmacy, Dr. Thomas Farley. Dr. Thomas Farley 07:12-07:13 Thank you. It’s good to be here. Joe 07:14-07:34 Dr. Farley, we saw your opinion piece in JAMA Health Forum a little while ago, and it really got our attention. It was titled Risky Prescribing and the Epidemic of Deaths from Falls. Tell us a little bit about what prompted this really important article. Dr. Thomas Farley 07:35-08:20 Well, so I’m an epidemiologist and a doctor who works in public health and was writing a textbook for public health students on the roughly 30 leading causes of death in America. And one of those is falls in older adults. And as part of my routine research for the textbook, I looked at trends in falls. And I was shocked to see that over roughly the past 30 years that the mortality rate from falls in the United States has roughly tripled. We now have about 45,000 people dying per year from falls over the age of 65. And I found that that increase had not been seen in other countries around the world. The U.S. is an outlier of this. So I said this is an important problem that people need to understand what’s behind it and also to take seriously. Terry 08:22-08:53 And, Dr. Farley, we want to ask you what the reasons might be. What you wrote was, in 2023, more than 41,000 individuals older than 65 years died from falls. Among older adults, the number of deaths from falls is more than from breast or prostate cancer and is more than from car crashes, drug overdoses, and all other unintentional injuries combined. What the heck is going on? Dr. Thomas Farley 08:54-09:43 That was exactly the question I had. What the heck is going on? Why are we seeing this tripling of falls to where now this is really an important cause of death in America today? You know, older adults have always fallen. They’ve always been at risk for the falls. But we’re seeing, why would we be seeing this increase? And so the next thing I did was to say, well, what are the things that put people at greater risk for having a serious fatal fall? And there are things like having a physical disability, having vision problems, maybe having cognitive problems like early dementia, living alone, having a cluttered household, using alcohol. But none of those things have any reason to think that they would have tripled in the past 30 years. On the other hand, there have been big changes in prescribing a prescription drug to older adults. So that’s what led me to really look into what has happened with the prescription drugs in the past 30 years. Joe 09:44-10:54 So let’s drill down on the medications, if you don’t mind. You know, there are some drugs that are highly sedating, you know, the anti-anxiety agents, what we call the psychotropics, the drugs for schizophrenia, for example, or severe depression. But there are lots of other medications that can make people feel dizzy. And I think that a lot of doctors just sort of pass over that pretty quickly without really asking people, “is this medicine making you feel dizzy?” And I’m particularly thinking about high blood pressure because the guidelines now say 120 over 80. Doctor, you’ve got to get everybody. I don’t care how old they are. Everybody needs to be under 120 over 80. And yet that may take three, four, or five different blood pressure medications to achieve that goal. And that can lead to something called orthostatic hypotension and dizziness. So if you could drill down a little deeper on the blood pressure problem. Dr. Thomas Farley 10:54-12:01 If I could, first I’ll talk about the drugs that affect the brain in other ways that you mentioned. Really, any drug that makes you drowsy or clumsy, sedating, is going to increase your risk of falls. Those are things that the drugs that I worry about the most. But then, as you say, there are other drugs that affect your heart and cardiovascular system, which may cause people to just have less blood flow to the brain over a very short period of time, and they can have a fall from that. As I look at the data, I have to say I’m more concerned about the first category, the central nervous system active drugs, than I am about the blood pressure drugs. Blood pressure absolutely is a serious problem, increases your risk of heart disease and stroke and kidney failure. People with hypertension need to be on medications, but there are safer high blood pressure drugs than there are less safe high blood pressure drugs. And so it is fair for people who are older adults who are on a high blood pressure medication to talk to their doctor, say, is this one of those high blood pressure meds that’s going to increase my risk of falls? Is this one that is safer? Terry 12:02-12:38 Now, Dr. Farley, in the article in JAMA Health Forum, you do talk about categories of medications that might make people drowsy or woozy. Benzodiazepines, for example. And when we write about benzodiazepines, which we do from time to time, we usually say this category of drugs is generally considered inappropriate for older adults. Are doctors paying attention or are they still prescribing benzos for older people? Dr. Thomas Farley 12:39-13:22 They’re still prescribing benzos for older people. From what I could find, there’s not as much research on this as I would like to see. But I found one study that looked at people over the age of 85 who were seen in an outpatient setting, 20% of them were giving prescriptions for benzos. That’s absolutely a very high-risk drug for them, and that’s not appropriate. I mean, overall, there was a study done, published in JAMA Internal Medicine, that showed more than 90% of older adults are taking prescription drugs, and 45% are taking prescription drugs that are considered to be potentially inappropriate. So there’s an awful lot of prescribing going on out there on drugs that are potentially quite risky, benzos being one of them that make me worry a lot, but others as well. Joe 13:23-14:16 We’re talking about diazepam, Valium, alprazolam, Xanax. These are drugs that a lot of people take for anxiety. But there are also problems for some people with antidepressants that can make them feel dizzy as well. And millions of people are taking antidepressants on a regular basis. I’m also wondering about antihistamines because, you know, people, if they have stuffy nose or allergies, are likely to take over-the-counter drugs. And some of them, like diphenhydramine, Benadryl, can make people very woozy. And now all the PM pain meds, you know, the Aleve PM and the Advil PM and the Tylenol PM, they all contain diphenhydramine. And for some people, they may have a little wooziness if they have to get up in the middle of the night. Dr. Thomas Farley 14:18-14:39 Yeah. So I think of antihistamines in two categories. There’s kind of the older ones, as you mentioned, diphenhydramine, that absolutely make people that are sedating and make people clumsy so they could increase the risk of falls. The newer ones are probably less likely to do that. And I don’t have data out there as to which ones are prescribed more these days or whether there’s an increase in one category or the other. But that’s absolutely something that I would be concerned about. Joe 14:41-15:40 I have a letter that we received from one of our readers. She says, a few years ago, my cardiologist put me on spironolactone to lower my blood pressure from 140 over 80. Shortly thereafter, I got up from bed for the bathroom. I blacked out in the bathroom, fell, and fractured two vertebrae. I was given a walker and kept on spironolactone. Later, I was using the walker to get to the bathroom in the middle of the night. I blacked out again, fell onto the walker and cut both knees. That resulted in a three-week stay in a rehab facility. My cardiologist never mentioned that spironolactone might make me faint or fall. I’m no longer on any blood pressure medication, but due to the fractures, I am four inches shorter and my life has been changed forever. I think we sometimes forget that, you know, dizziness sounds like such a mild side effect, but it can have devastating consequences. Dr. Thomas Farley 15:41-16:05 Yeah. You know, for women in particular, a fall, even a small fall can lead to a hip fracture and hip fractures absolutely can be fatal on older adults. And so, you know, I, I, there definitely are some antihypertensives that are going to increase the risk of falls more than others. And so, again, I’m a big believer that we should treat people with hypertension. I don’t want anybody to get that impression. Joe 16:06-16:07 Right. Dr. Thomas Farley 16:06-16:15 But I do think that older adults need to be having a serious conversation with their physician about, are they on an antihypertensive that is going to be safe from a false perspective? Joe 16:15-16:42 We just have a minute left, but it seems like very rarely do health professionals, especially family practice doctors or interns, actually check people for their potential for dizziness. It might happen at physical therapy. It might happen at health coaches. But shouldn’t doctors be checking for dizziness every time an older person comes in who’s taking many medications? Dr. Thomas Farley 16:43-17:31 They should be assessing the risk of falls more broadly. And dizziness would be part of that, but also the other things, are they particularly physically frail, do they have vision problems? And look, there’s a falls risk checklist that they can use. And they ought to be far more careful with patients that are at risk of falls than those that have a lower risk of falls. I think more generally, this data says to me that not just individual doctors, but health systems as a group ought to be looking at this in the same way that they looked at opioids in the past and say, you know, we need to be pulling data on our providers and see who’s prescribing these fall risk increasing drugs or FRIDs a lot. And if so, have some conversations with them about how to get patients onto either drugs that are safer or to see whether they need to be on the drugs at all. Terry 17:32-17:37 Dr. Thomas Farley, thank you very much for talking with us on The People’s Pharmacy today. Dr. Thomas Farley 17:38-39 Thanks for having me. Terry 17:39-17:47 You’ve been listening to epidemiologist and health educator, Dr. Thomas Farley of Tulane University. You can find a link to his paper on our website. Joe 17:48-17:59 Our phone lines are open for your stories, comments, and questions. That number, 888-472-3366. Terry 18:00-18:03 You could also put a comment on Facebook or at People’s Pharmacy. Joe 18:04-18:15 Again, that number, 888-472-3366. We invite your questions about medications that might increase the risk for falls. Terry 18:16-18:54 Again, that phone number for you, 888-472-3366. 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 18:54-19:12 And I’m Joe Graedon. Terry 19:12-19:23 Today, we’re talking about FRIDs, F-R-I-D. Is that acronym new to you? It was for us. It means fall-risk-increasing-drugs. Joe 19:24-19:48 We invite you to share your story about a medicine that might have made you feel, you know, woozy or unsteady. Our number, 888-472-3366. Again, if you’d like to join our conversation. We are live in the studio, 888-472-3366. Terry 19:49-20:38 And Joe, we have a comment from Jeannie. She says, I’m 80 plus years old. And at this point, I’m taking no prescription drugs because every one of them has side effects. I have high blood pressure, 142 over 70. And my doctor wanted me to take losartan. After reading the side effects, I decided the answer would be no, because it can cause dizziness. It can also lower your heart rate, and mine’s already low. I average 40 beats a minute, and when I’m asleep, sometimes it’s 30 beats a minute. Taking Losartan means I could fall and maybe break a hip. Some seniors who break their hips have died within a year because of the stress on their bodies. Why would I want to trade one problem for another problem? Very good point. We do need to point out, you have to do the balancing act, right? Joe 20:38-21:25 You do have to do the balancing act. It is critical to keep your blood pressure under control. We don’t want anybody allowing blood pressure to skyrocket. But sometimes trying to get everybody down to below 120 over 80 can lead to dizziness, especially something called orthostatic hypotension. It’s when you stand up suddenly and then all of a sudden you get dizzy and then you may fall. And that’s because of the blood pressure medication. So as Dr. Farley said, you want to make sure you talk to your doctor about drugs that don’t make you feel dizzy. Again, our phone lines are open. 888-472-3366 is the number to call if you have a story to share. Terry 21:26-21:30 And we go to Arlington, Texas to talk to Ann. Ann, your question, please. Caller 21:33-21:48 Hi, this is Ann. I was wondering if I only take Synthroid in the morning before I eat, but I’m dizzy right when I get up, and then I’m kind of dizzy until I eat more during the day. How do I figure out what’s making me dizzy? Joe 21:50-21:58 Good question, Ann. Well, first, are you taking any other medications besides Synthroid, which is a thyroid medication, right, Ann? Caller 21:59-22:09 Yes. Just later in the day, I take hydroxychloroquine and some supplements, calcium and that kind of thing. Terry 22:10-22:26 Usually, we don’t think of supplements as causing dizziness. And generally speaking, Ann, I wouldn’t expect Synthroid to cause much dizziness either. This sounds like you may need to have a more in-depth conversation with your doctor. Joe 22:26-23:16 You know, I’d have to look up hydroxychloroquine, Terry, because, you know, it is a drug that is prescribed. It’s an old-fashioned medication. It’s sometimes used for arthritis symptoms, for example, or other autoimmune conditions. And so it’s not clear to me if that could be a contributor. But you definitely want to be very careful when you get up in the morning and so that you don’t, you know, on your way to the bathroom, for example, have a fall. So that’s a critical issue to bring up to your doctor whenever you get a chance. Okay. Thank you so much for your call. Bye bye. Terry, it looks like you’ve got Bert in Clearwater, Florida. Terry 23:16-23:19 Let’s go to Bert and find out what’s on his mind. Joe 23:21-23:21 Hi, Bert. Terry 23:21-23:22 Hey, Bert. Joe 23:22-23:22 Are you there? Caller 23:24-23:25 Hello, yes. Joe 23:26-23:26 Go ahead, please. Caller 23:27-23:50 I’m here. What’s your question? I was just calling in to say that with respect to dizziness, I’ve had some problems with taking Flomax and drugs for a similar kind of problem. And that I find that, you know, like I’m sitting on a couch or something like that, I’ll get up and I’ll be busy and have to put a hand out and steady myself. Terry 23:51-23:52 That’s, yes. Caller 23:52-23:58 For a few seconds or whatever until that goes away. And then it’ll go away and then I go ahead with what I’m doing. Joe 23:59-24:26 Bert, you’re describing a classic case of orthostatic hypotension. That’s the doctor’s term for stand up, oops, feeling dizzy. And what that means, quite honestly, is that you’re going to have to get up from the couch cautiously. So don’t ever stand up suddenly and start walking because you might end up on the floor. Terry 24:27-24:30 Bert, did we interrupt you before you were finished with your story? Caller 24:31-24:34 No, no. I think I got everything out. Joe 24:35-24:56 Okay. Well, excellent. Be careful. And we do understand that sometimes Flowmax is essential to help you not have to get up three, four, five times in the middle of the night to go to the bathroom. That’s when it’s especially important to be careful if you do get up to go. So thanks for the call. Let’s just give the phone number again, Tara. Terry 24:57-25:13 Absolutely. 888-472-3366. That’s our number. We’d love to talk with you and hear about your experience. And let’s talk to Janet in Pittsboro, North Carolina. Janet, tell us your story, please. Caller 25:13-25:14 How are you? Joe 25:14-25:15 We’re doing well. Caller 25:15-25:40 I am with uh, prescribed [muffled], which is also called sertraline, to help me sleep. I have a problem with insomnia. And the prescription is 50-milligram tablets. And it says take three to four tablets by mouth at bedtime as needed. I cannot. That’s an overdose to me. Terry 25:40-25:40 Yeah. Caller 25:41-26:14 But not too long ago, I took two. And right before that, I took one 5-milligram diazepam. And I fell. And I had fallen last October a year ago, almost exactly a year ago. And formaldehyde dust left in my house by a contractor, and I broke my femur. And that was a disaster. I mean, I was in ICU for 10 days, but that didn’t involve a drug. That involved me trying to clean up this dust. Terry 26:14-26:14 Uh-huh. Caller 26:15-26:23 But now, just the other day, well, September the 9th, I think, I fell again, but I was dizzy when I got up. Terry 26:24-26:52 I understand, Janet. We actually would like to make some comments on what you’ve told us. And we’d like to remind everybody that when you want to talk to us on the show, you need to turn off your radio because otherwise it will be distracting for everyone. So, Janet, I’m going to hang up here and we’re going to make some comments about the diphenhydramine and the sertraline that you have been taking. Joe 26:52-26:56 I thought I also heard her say something about diazepam. Terry 26:57-26:59 I didn’t catch that, but it might have been there. Joe 27:00-27:04 I thought I heard that. And that would be, of course, a benzodiazepine. Terry 27:05-27:14 Sertraline is one of the medications that Dr. Farley was talking about that put older people, and it sounds like Janet might be an older person. Joe 27:14-27:15 It does sound that way. Terry 27:15-27:34 Put older people at risk for falls. And, Joe, we were talking about drugs that are prescribed. Sertraline is a prescribed antidepressant. Obviously, Janet’s doctor is prescribing it for her sleep. That’s an off-label indication. Joe 27:34-27:41 I’m having a hard time understanding that. And she said three or four pills, and I’m thinking, what? Oh, whoa, whoa, whoa, whoa. Terry 27:42-27:45 Yeah, that doesn’t sound like a good idea. Joe 27:45-27:46 Well, first of all. Terry 27:46-27:53 But diphenhydramine, Joe, in combination with sertraline or even by itself, tell me about diphenhydramine. Joe 27:53-27:59 Well, of course, we’re talking about Benadryl. We’re talking about the PM in Tylenol PM. Terry 27:59-28:12 And a lot of people who have trouble sleeping will take this medication, which is over the counter. You can take it every day without even telling your doctor. But we’d like to suggest you need to tell your doctor. Joe 28:12-28:28 And we’d also like to suggest that if you have to get up in the middle of the night to go to the bathroom, it would not be a good idea to take any of those PM pain medicines because they could make you woozy, you know, at three in the morning when you get up. Terry 28:28-28:39 And sertraline as a sleeping pill, if you’re susceptible to falls, is a bad idea. Get your doctor to give you something better. Joe 28:39-28:45 Let’s talk about the “Beers” list. And we’re not talking about drinking beer. Terry 28:46-28:54 No, we’re not. We’re talking about a gentleman whose last name was Beers who was concerned about this type of problem. Joe 28:54-29:01 It was spelled B-E-E-R-S, Dr. Beers. And before we do that, Terry, what’s the phone number? Terry 29:02-29:12 The number is 888-472-3366. And Joe, tell me more about Dr. Beers and his list. Joe 29:12-29:26 Well, he created a list many decades ago, and he said to his colleagues, doctors, don’t prescribe drugs on my Beers list because it will make them vulnerable to lots of problems. Terry 29:27-29:48 So the drugs that Dr. Beers put on his list are drugs that are potentially inappropriate for older people. And sometimes referred to as PIP, Potentially Inappropriate Prescriptions. But basically, we’re talking about older people because they’re more vulnerable to problems with certain drugs. Joe 29:48-29:55 Well, what’s become very popular these days is a category of drugs called gabapentinoids. Terry 29:55-30:01 And we’ve got a comment on that, Joe, from Facebook. Would you like to hear it first? And then you can launch into your… Joe 30:01-30:02 I would like to hear it. Terry 30:02-30:28 Okay. Mary Jo wrote, I’m a paramedic. I have a question about Neurontin. People are prescribed this all the time for their peripheral neuropathy, which makes them a fall risk anyway. But when elderly people consume it, they have a bigger risk of falling. And I can’t read the rest of Mary Jo’s comment, sorry to say. So now you get to carry on about Neurontin. Joe 30:28-30:34 Mary Jo is a paramedic. So she is likely to be in that emergency. Terry 30:34-30:37 She gets called. When somebody falls. Joe 30:37-31:17 When the ambulance comes, that’s Mary Jo. And, you know, the gabapentinoids, and that’s gabapentin, it’s pregabalin, Lyrica. She mentioned Neurontin. And these drugs are now being prescribed so widely for pain, especially for nerve pain. So gabapentin is the number five most prescribed drugs in America today. You know, so many people are in pain and they can’t take opioids because their doctors are afraid of them or they’re afraid of them. And as a result, they’re put on gabapentin. And it can make people vulnerable to falls. Terry 31:17-31:19 It can definitely do that. Joe 31:19-31:43 That number again, 888-472-3366. If you’d like to join our conversation, are you taking one, two, three, maybe four blood pressure medications simultaneously? How does that affect your level of dizziness? We’d love to hear from you. Again, that number, 888-472-3366. Terry 31:44-31:49 And we go to Peggy in Auburn. Peggy is, where is Auburn exactly? Caller 31:50-31:53 It’s in the southeast corner of Nebraska. Terry 31:53-31:54 Wonderful. Joe 31:54-31:56 Right next to Iowa and Kansas. Terry 31:56-31:57 Okay. Joe 31:58-31:59 Terry, where did your mom grow up? Terry 31:59-32:07 In the western corner of Nebraska. We’re not going to get into geography. We don’t have time for geography, but I appreciate that. Caller 32:07-32:28 Now, your story, please. I am taking two blood pressure medications. And at the time, amlodipine and my doctor prescribed hydrochlorothiazide. And that made me dizzy. And I passed out. I walked outside. It was sunny. It was warm. Went to the ground. Joe 32:29-32:29 Oh, my. Caller 32:29-32:37 Fell to the ground. I called him and told him he changed the medication to metoprolol. Okay. Joe 32:38-32:40 Metoprolol, right. A beta blocker. Caller 32:40-32:40 Metoprolol, yes. Joe 32:41-32:46 And were you able to get up and manage to not break any bones on that fall? Caller 32:47-32:51 I did not break any bones. I’m 59 years old. Okay. Terry 32:52-33:16 So the people who are most likely to break bones are the really older people, you know, 80 and older. So we’re glad you didn’t break anything, and we’re glad that you realized that the drugs causing your problem were your blood pressure medicines, and you got your doctor to change the prescription. Good work, Peggy. Thanks for calling. Joe 33:18-33:19 We appreciate it. Terry 33:20-33:22 And, Joe, we’re getting close to our break, aren’t we? Joe 33:22-33:40 Oh, we got lots of time. Okay. I think it’s been so long since we’ve done a live show, we kind of have forgotten the time cues. Al, we’re still good, right? Yeah, we still have two minutes. Okay. So shall we go to Herb? Terry 33:40-33:41 Sure. Joe 33:41-33:46 In Research Triangle Park, North Carolina. We can just squeeze Herb in. Terry 33:46-33:48 I think we have enough time to talk to Herb. Joe 33:48-33:49 Herb, what’s the story? Caller 33:51-33:52 Hi. Terry 33:52-33:52 Hi. Caller 33:52-35:19 Terry and Joe. Good conversation. I don’t know what to say. Here it is. I have a 97-year-old mother who has no issues other than she is not 120 over 80. Oh, my. So she has been prescribed amlodipine, the sort of those kind of things. I have been fighting this battle for some time. So what I would like to say is that your audience, don’t give up the fight. Don’t give up the fight. What I did was I said, look, when she goes into to see the doctor, she’s excited because she gets the white coat syndrome. So what I do is I have her and me to take her blood pressure in an ambulatory way throughout the week, not just there. So that would be my suggestion to people. At 97, she does use a walker. I will say that. But I think sometimes trying to do good does not always end up being good for a 97-year-old mother. And I thank you all so much every week for what you do, and I also do your subscription as well. Herb, thank you so much for that call. Terry 35:20-35:38 And thank you for watching out for your 97-year-old mother. The fact that she uses a walker is very smart. And the fact that you are taking her blood pressure, making a record of it so that you can show the doctor what her blood pressure is like at home, that makes a lot of sense. Joe 35:38-37:00 Well, you know, this idea of white coat hypertension is something that I think a lot of people have to struggle with because, you know, they have to drive to get to the doctor’s office. If there’s traffic, it can be very anxiety producing. And then the question becomes one of how well is your blood pressure taken at the doctor’s office? When we come back after the break, we’re going to ask you to give us a call about how your blood pressure has been taken. So there are some guidelines from the American Heart Association. You’re supposed to, number one, be allowed to rest quietly for about five or 10 minutes when you get to the doctor’s office. You’re encouraged to go to the bathroom and pee. And then when you get into the office, they need to make sure that they take it correctly, that you’re not sitting on the exam table with your arm dangling down, that you’re in a chair with your arm supported. Has that happened to you? I’m curious. Have you been encouraged to follow those guidelines or did they just take your blood pressure as soon as you walk in the door? Give us a call. Tell us about your experience with white coat hypertension. Our lines are open at 888-472-3366. You can send us something through Facebook. Terry 37:00-37:14 That’s right. Facebook or at People’s Pharmacy. And that’s how we got Mary Jo’s comment. And, you know, when we come back from our short break, we will talk more about drugs that increase the risk of falls, but we’ll especially get to the blood pressure. Joe 37:15-37:20 888-472-3366 is the number to call. Terry 37:38-37:41 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:51-37:53 Welcome back to the people’s pharmacy I’m Joe Graedon. Terry 37:54-38:12 And I’m Terry Graedon. Joe 38:13-38:23 Have you ever been warned about drug-induced falls? Has your doctor evaluated you for such a risk, and how would they even do that? Terry 38:24-38:40 I’m not sure how they would do that, but there are some tests that they use to see how people can get up out of a chair and that sort of thing. So there may be assessments. Joe 38:36-38:38 Well, you know, physical therapists do this all the time. Terry 38:39-38:41 That’s true. They check your balance. Joe 38:41-39:03 And doctors should be trained so that they do know how to test a, not just an older person, anybody for a fall risk, especially if they’re taking more than one or two medications. And I suspect that if you were to ask a lot of nurses these days, when a patient comes in, How many drugs are they taking? I bet the average is more than two. Terry 39:04-39:21 Especially if someone is struggling with high blood pressure. Now, I love the idea that Herb suggested a few minutes ago that you should take your blood pressure at home and keep a record of it. So you know what it’s like throughout the day and you can share that with your doctor. That’s important. Joe 39:21-39:31 And, you know, does a 97-year-old woman need a whole bunch of medications to get her blood pressure under 120 over 80? Terry 39:32-39:43 The idea is that you’re going to increase longevity. But once you get to 97, I don’t know that you’re aiming for greatly increased longevity. She’s already there. Joe 39:43-39:45 The risk of a fall. Terry 39:45-39:47 Is significant. Joe 39:47-40:11 And worrisome. I remember my mom went in to see Dr. Bob Gutman, who was an internist, and he said, Helen, I could get your blood pressure down to 120 over 80, but you’ll feel bad. And are you willing to take the risk for a stroke and let it be a little higher? And she said, yes, Dr. Gutman, I’m willing. And she lived to 92 and died from a medical mistake. Terry 40:12-40:18 But she chose not to have a fall because the idea of a fall frightened her. Joe 40:18-40:21 It sure did. You have a story from Jane. Terry 40:22-41:32 I do have a story from Jane, and then we’ll go to the calls. Jane said, I worry about how often doctors put people on blood pressure drugs based on one reading at the clinic. Way too often that reading was gotten by totally incorrect methodology. Like many people, I have white coat hypertension. And Joe, when we’re done with Jane, we’ll ask you to explain that. I now take a chart of at-home readings covering the last 10 days to two weeks of several readings a day. Even though these are perfectly fine numbers, I still have to fend off the doctor wanting to start me on meds based on the somewhat high reading at the office. Also, in the last 20 years, my pressure has been taken correctly only two or three times. I wonder how many people are dutifully taking their medication every day based on a single reading done improperly at the doctor’s office and therefore are perpetually experiencing low blood pressure or maybe dizziness at home. I suspect a fair number of falls, appearances of cognitive decline, etc. are the result of this unfortunate dogma. So we appreciate Jane’s comments. Joe 41:32-42:04 We surely do. And this idea of white coat hypertension has been controversial for decades. There are some people who say, oh, that’s all nonsense. If somebody has 130 over 90 in the doctor’s office, they have to be treated, even if their blood pressure is 120 over 80 at home. I think that thinking is starting to disappear. I hope it is, because a lot of times these days, people are not getting their blood pressure taken correctly. Terry 42:04-42:11 Let’s talk to Patricia in Wilmington. She’s got a story about a drug we haven’t mentioned yet. Patricia, welcome to the People’s Pharmacy. Caller 42:13-43:04 Thank you. Hi. Yes, first time caller. My husband is 86 and he takes many drugs for a variety of issues. But one of the drugs that he’s been prescribed over the years is Viagra. And I’m not sure why 86, you still need to be taking Viagra, but that’s a whole nother story. Sometimes he’ll take more than what’s prescribed because he’s not getting the effects that he wants. So he’ll take two or three. And that’s caused him to get dizzy and lightheaded. And so I plan to go to his doctor with him the next visit to have a discussion about does he really need to continue to have the Viagra and also the importance of taking just the prescribed amount Terry 43:04-43:24 and not what you think you need. Such a great comment. And I don’t think people actually appreciate that Viagra can make you dizzy, especially in combination with other medications or if you take more than the prescribed amount. So, Patricia, we really appreciate this comment. Joe 43:25-43:39 That voluntary dose increase of two or three Viagras would definitely be problematic. The dose is 100 milligrams. So if he were taking 200 or 300 milligrams, whoa. Terry 43:39-43:44 And, of course, falling would be the least romantic thing you can possibly think of. Joe 43:45-43:50 Exactly. So, yes, definitely discuss with his doctor this potential problem. Terry 43:51-43:56 And we’ve got a call from Ken in Medville or Meadville, Pennsylvania. Joe 43:57-43:58 I bet it’s Meadville. Terry 43:59-43:59 Is that right, Ken? Caller 44:01-44:03 Yes, yes, you are, Joe. Meadville. Joe 44:04-44:11 I grew up in Pennsylvania. I went to Penn State, and there were a bunch of kids there from Meadville, Pennsylvania. What’s the story? Caller 44:12-45:07 Well, I’m 79, and I’m on a medication called nadolol, 20 milligrams. I guess that’s a beta blocker, but it can be used for blood pressure, too. I missed the first few minutes of the show. I was wondering if that was one of the ones on the Beers list. And I’m having severe balance issues. I wouldn’t call it dizziness, but I can’t seem to walk down the sidewalk when I’m out walking straight. I kind of wander back and forth. I can’t stand on one foot. I’ve always been athletic. I still can play table tennis quite actively. Joe 45:09-46:24 Well, let’s start at the beginning. You’re taking a beta blocker, as you have pointed out, nadolol. And to be honest with you, physicians have generally moved away from beta blockers for high blood pressure as the first line approach. In fact, I can’t say off the top of my head if nadolol is on the Beers list, but I can say quite confidently that most physicians would not start with a drug like nadolol to control blood pressure. And so even if you’re not quote unquote dizzy, if you’re unsteady on your feet, it is absolutely time to be in touch with your doctor and say, let’s try something else. And that something else might be a drug like a diuretic. It might be a medication like an ACE inhibitor. But you definitely need to talk to your doctor because if you’re feeling unsteady, if the possibility is when you’re walking on the sidewalk or someplace else and you fall, it could be a disaster. So Ken, thank you so much for calling and please do follow up with your physician as soon Terry 46:24-46:32 as possible. Shall we go to Richmond, Virginia and talk to Ann? Absolutely. And our numbers are Joe 46:32-47:08 888-472-3366. We just have a few minutes before we have to sign off. We’d love to hear from you, especially about how your blood pressure has been taken in the doctor’s office. Has it been done correctly? Has it been taken by a nurse, a doctor, or a technician? Did your arm get supported at chest or heart height? Because a lot of times your arm will be dangling or it’s not supported that can affect your blood pressure reading. But where are we going to? Richmond, did you say, Terry? Terry 47:08-47:14 Yes, we’re talking to Ann. She’s been waiting to make her comment or ask her question. Go ahead, please, Ann. Caller 47:16-47:38 Hi. I have eye issues. I have glaucoma and other eye issues and have been treated with lots of different meds. But the longest one is Latanoprost and also dorzolamide, timolol. I wonder if there are any eye meds that I should be careful of for dizziness because I’m dizzy. Joe 47:38-47:55 You know, and that’s a brilliant question. And thank you so much for asking about eye meds. Because I think a lot of times people assume, oh, well, if I just put a drop in my eye, it’s just going to stay in my eye. It won’t have an impact on the rest of my body. Terry 47:55-48:03 But timolol, for example, we know for sure that it can have an impact. And it’s possible that Latanoprost also does. Joe 48:03-48:24 Well, timolol is a beta blocker, and we just ended up talking about beta blockers. And so you should definitely talk to your doctor about this if you are feeling somewhat dizzy as a result of your eye drops. So, you know, when you put eye drops in your eyes, they don’t just stay there. They circulate through the rest of your body. Terry 48:24-48:28 Now, of course, you do need to treat your glaucoma. Joe 48:28-48:28 Absolutely. Terry 48:28-48:46 So you and your doctor are going to have to come up with a regimen that will work for the glaucoma and not put you at risk of a fall. So good luck with that, Ann. We sure hope you come up with something helpful. And Joe, did you want to talk to Eric in Charleston, West Virginia? Joe 48:46-48:54 Absolutely. Eric, welcome to the People’s Pharmacy. What’s this about blood pressure cuffs? Well, good morning. Caller 48:55-49:37 Yes. I have two items, actually. The cuff was interesting because at one point I went to my GP and the nurse came out and took my blood pressure and it was way up, way too high. And then the doctor came in and said, hmm, we used the wrong cuff. Your arm happens to be a little larger than usual and therefore we need to give you a big cuff. And so we took it and it came back 10 points lower than when it was. So it seemed to be very important to pick the right cuff, especially if your arm is larger than normal. Terry 49:38-50:16 Absolutely, Eric. And the same thing holds true. If your arm is extra small, you need the right size cuff. Because if your arm is extra small and they use an ordinary cuff, your blood pressure reading is going to be a little bit too low. And Joe, we got a Facebook comment from Karen who says, I think something needs to be said about the devices being used to check blood pressure nowadays. I’m 65. I’ve had great blood pressure around 120 over 70 my whole life. But about 15 years ago, I noticed that my blood pressure registers higher in the doctor’s office. And it probably has something to do with the cuff. Joe 50:16-50:55 Well, the cuff is one of those things that is often not even considered. I mean, because if you’re the patient and you walk into the doctor’s office, they slap the cuff on your arm. They never measure your arm. So if you have a very small arm or a very large arm, I mean, imagine a guy six feet, four inches tall, weighs 250 pounds, lifts weights. He’s going to have a gigantic bicep. And if they use a standard cuff on him, it will be an inaccurate reading. When’s the last time you ever had your arm measured before you had your blood pressure taken? Terry 50:55-51:01 Well, let’s talk to Phil in Clearwater, Florida, because he’s got some stories to tell. Hey, Phil. Joe 51:03-51:05 Hello. How are you today? We’re doing well. What’s up? Caller 51:06-52:03 Well, I just want to give comments. I concur with you that a lot of physicians or their staff do not let you take time. And like sometimes I go to the doctor’s office and, you know, I’ve showered and got ready and I ran in there. And, you know, then they take you back and boom, they take your blood pressure right away and it’s elevated. And then they say, well, I’ll take it again. The doctor takes it like at the end of the exam and it’s back to normal. Same thing happened to my wife. She went there and I swear they want to put a diagnosis of hypertension in your chart so that they can charge more to the insurance company. But I don’t know if that’s true or not. That’s my hypothesis. But I just think you need to take control of your own body, your own medication, and tell them, no, I want you to wait five or ten minutes. Let me relax here a second. So it’s stressful enough going to the physicians anyway. But on top of that, I think they’re not always doing it correctly. So I concur with what you said. Joe 52:03-52:22 And there’s one other thing, Phil. You should never talk when you’re having your blood pressure taken. Because if the technician or the nurse starts to ask you questions like, how are you doing? Or what’s going on in your life? Or some other medical question, talking will raise your blood pressure. Terry 52:23-52:47 Joe, in fact, we got a Facebook comment from Renee who says, for white coat hypertension syndrome, show the nurse a note that says, no talking until after I weigh, relax, and they take my blood pressure. They rush you and they want to ask you all kinds of questions and show their incompetence before taking my vitals. Thanks for that, Renee. Yes. Joe 52:47-52:53 And always go to the bathroom. You’re supposed to urinate before you have your blood pressure taken. Terry 52:53-52:58 I don’t believe I have ever been asked if I needed to use the facilities. Joe 52:59-53:01 I’ve never had that happen to me either. Terry 53:01-53:04 Do we have time to talk to Johnny in Fort Worth or? Joe 53:04-53:07 Very briefly, Johnny. Terry 53:07-53:08 We’re almost out of time. Joe 53:08-53:11 We have just a minute or two left. Go ahead, quickly. Caller 53:12-53:43 Hi. Hi. I take a hormone drug. I have prostate cancer. And I also take four pills a day. I’ve lost four pills a day, but I’ve noticed that when I’m driving, sometimes I have an urge. I get anxious. And I’m just trying to figure out what’s going on. I don’t. My blood pressure usually runs by 140 over something. But that’s my issue. And I’m trying to think. I’ve been trying to work with my oncologist, trying to figure out what’s going on. Thank you. Joe 53:43-54:07 You will need to work with your oncologist because, obviously, it’s critical that you keep your prostate cancer under control with your meds. But you don’t want to be dizzy while you’re driving. So that’s a critical point to bring up to your doctor. Well, Terry, we are just about out of time. I am so grateful for all of the calls we’ve had from all over the country. Terry 54:07-54:54 And, Joe, we have one more comment. I think we have time for it. Jan says she’s a nurse in the emergency department. A woman brought her mother in because she was dizzy and nearly falling. Her doctor had prescribed a benzodiazepine, Librium, the day before her visit to the ED. Remember, Jan’s a nurse. She says, I informed the ED physician that her symptoms started right after she took the first dose. And the physician said it couldn’t be the medication because the dose was too low. He told her to call her doctor the next business day, which was two days from when we saw her. Her daughter was afraid to leave the patient alone at home, of course. Providers need to improve the medication reviews when patients’ experience falls. Joe 54:55-55:08 Absolutely. And that is very good advice from a nurse. Thank you so much for that, Jan. Well, that is all the time we have today. Thank you so much for listening and sharing your stories today on The People’s Pharmacy. Terry 55:09-55:20 Absolutely. And The People’s Pharmacy is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 55:20-55:35 Lynn Siegel produced today’s show. Pamela Alberta provided technical assistance. Al Wodarski, the great Al Wodarski, engineered. Dave Graedon edits our interviews. And the People’s Pharmacy theme music is by B.J. Liederman. Terry 55:35-55:53 We would like to thank today’s guest, Dr. Thomas Farley, who is professor of community health at Tulane University. You can find a link to his article in our show notes. It’s the article titled Risky Prescribing and the Epidemic of Deaths from Falls. Terry 56:08-56:31 Today’s show is number 1,447. You can find it online at peoplespharmacy.com. You can subscribe to our podcast through your favorite podcast provider. We post the show on our website on Monday morning. That’s where you can share your thoughts about this show. And you can email us your comments, radio at peoplespharmacy.com. Joe 56:31-57:07 If you go to peoplespharmacy.com, you can sign up for our free online newsletter. It’s an easy way to stay on top of the breaking health news. By subscribing to our newsletter, you’ll also have regular access to our weekly podcast and find out ahead of time which topics we’ll be covering. And speaking of the podcast, Terry, we would be so grateful if our listeners would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. And when you go to the YouTube channel, in about a week or two, you can see Dr. Farley and The People’s Pharmacy. In Durham, North Carolina, I’m Joe Graedon. Terry 57:07-57:24 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 57:29 – 57:37 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 57:38 – 57:45 All you have to do is go to peoplespharmacy.com/donate. Joe 57:45-57:56 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.

Transcribed - Published: 2 October 2025

Are you concerned about your bone health? Do you worry about osteoporosis? According to the CDC, more than 10 million Americans have low bone density that makes them more vulnerable to fractures. For many older people, a fracture can be devastating, reducing mobility and possibly even leading to death. What does the latest medical science tell us about how you can maintain strong bones? 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 on Saturday, Sept. 27, 2025, at 7 am EDT on 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 Sept. 29, 2025. Strong Bones: You may have seen Halloween skeletons or even chewed the meat off a bone that you then dropped on a plate with a clatter. No wonder we usually think of bones as hard, unchanging objects. Dead bones are. But living bones are quite different. Strong bones are constantly undergoing change. Scientists call it remodeling. One set of specialized cells, osteoclasts, breaks bone tissue down and recycles it. Another set, the osteoblasts, builds bone back. Ideally, their activities are in balance. But if the osteoclasts start to get ahead, as they tend to do while we age, that can weaken bone. The result is low bone mass, known as osteopenia, or even serious bone loss called osteoporosis. This puts a person at risk for fractures. Who Gets Osteoporosis? Osteoporosis may have been less common a hundred years ago or more, when many people had to do manual labor that put stress on their bones. That helps for strong bones, so today’s sedentary lifestyles can undermine bone health. Although we think of osteoporosis as typically affecting postmenopausal women, men can lose bone mass too. Medications may contribute to the risk for bone loss. Steroids such as prednisone or methylprednisolone are especially risky if taken for a long period of time. Androgen deprivation therapy for prostate cancer is a risk factor specifically for men. Diagnosing Osteoporosis: Doctors assess bone mineral density with imaging called dual-energy X-ray absorptiometry, or DEXA for short. Then they compare the results on the scan to the results they would expect from a 30-year-old person. Results more than 2.5 standard deviations from that could result in a diagnosis of osteoporosis. A person who experiences a fracture without trauma, such as falling from standing height, is also suspected and often diagnosed with osteoporosis. Non-Drug Approaches to Strong Bones: People who want to keep strong bones need to focus on exercise. High intensity exercise can be helpful, but brisk walking may be enough. Tai chi and yoga are also popular. If you have been diagnosed with osteoporosis, be sure to check in with your doctor before you start a new exercise program. Building balance and core strength without increasing your risk of a fall (and thus a fracture) would be ideal. Our guest expert, Dr. Kendall Moseley, says the jury is still out on technology such as vibrating platforms, weighted vests or vibrating belts. More studies should show how valuable these could be. Following a diet that supplies adequate protein, vitamin D and calcium is also crucial. If you must take a calcium supplement, calcium citrate may be well tolerated and absorbed. How Do Doctors Treat Osteoporosis? Physicians prescribe several different types of medications to help curb bone less and perhaps even build it back. Some of the oldest and least expensive are the bisphosphonates such as alendronate (Fosamax). These slow bone break down and give the osteoblasts a chance to catch up. They can be hard on the digestive tract, though, and they have been associated with a few rare but alarming side effects: jawbone deterioration and atypical thigh bone fracture. Most people seem to do well on them. Doctors generally prescribe them for up to five years. Did You Forget Evista? Another type of osteoporosis medicine is called raloxifene (Evista). It is appropriate only for women, because it is an estrogen modulator. It acts like estrogen in the bones and reduces bone loss. In the breast and uterus, it opposes estrogen activity. Raloxifene does double duty in reducing the risk of breast cancer as well as osteoporosis. Like all drugs, though, it has some worrisome side effects. It can increase the risk of blood clots that cause deep vein thromboses and strokes. What About Prolia? Denosumab (Prolia) is a monoclonal antibody that also interferes with osteoclasts. That is how it improves bone density. One thing to keep in mind about Prolia is that stopping it requires careful planning and backup medication. Otherwise, a patient can lose all the bone that was built rather quickly and may suffer debilitating fracture. This Week’s Guest: Kendall Moseley, MD, is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. In addition, Dr. Moseley is Medical Director of the Johns Hopkins Metabolic Bone & Osteoporosis Center. Kendall Moseley, MD, is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Listen to the Podcast: The podcast of this program will be available Monday, Sept. 29, 2025, after broadcast on Sept. 27. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, we discuss the pros and cons of estrogen for strong bones. You’ll also learn about a drug that builds bone, teriparatide (Forteo). And you’ll hear about the importance of preventing falls and how to do that. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript for Show 1446: 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 00:06-00:13 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Joe 00:14-00:27 Hypertension is often called the silent killer, but osteoporosis might be considered a silent and deadly disorder. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:41 If an older person breaks a hip, the consequences can be disastrous. They often lose mobility and they may even die. Joe 00:42-00:50 The focus for osteoporosis is usually on older women, but we should remember that men can also lose bone and become vulnerable. Terry 00:51-00:57 There are drugs that hurt bone health as well as help build it back. What about supplements or exercise? Joe 00:57-01:06 Coming up on The People’s Pharmacy, the science of strong bones, lifestyle, medication, and movement. Terry 01:14-02:32 In The People’s Pharmacy health headlines, semaglutide has gotten a lot of attention over the past few years. If you don’t recognize this generic drug name, you probably do recognize the brand names. Ozempic for type 2 diabetes and Wegovy for weight loss. Both these medications are self-administered injections, but not everyone is enthusiastic about needles. There’s also an oral form of semaglutide called Rybelsus. The FDA has approved it for treating type 2 diabetes six years ago, and so far it has mostly gone under the radar. A new study published in the New England Journal of Medicine demonstrated that oral semaglutide at 25 mg a day helped people without diabetes lose significantly more weight than placebo. The randomized trial included more than 300 volunteers and lasted approximately a year and a half. This could be good news for people who have trouble accessing injectable semaglutide or keeping it cold. People taking semaglutide reported improved quality of life. They were also more likely to report side effects, especially digestive distress. Joe 02:34-04:17 Aspirin has been available for well over 100 years, but the active ingredient has been used by native healers for thousands of years. In 1991, a research article in the New England Journal of Medicine reported that regular aspirin users were 40 to 50 percent less likely to die of colon cancer. Now, 34 years later, another research paper in the New England Journal of Medicine reports that people taking aspirin had a significantly lower chance of colorectal cancer recurrence. Swedish scientists recruited patients after they’d had their tumors removed. The particular hotspot mutation called PIK3CA. The aspirin dose was 160 milligrams, or roughly half a standard strength tablet daily, for three years. 626 patients were randomly assigned to receive either aspirin or placebo. 7.7% of people taking aspirin experienced a recurrence of their colorectal cancer, whereas 14.1% of those on placebo had a recurrence. That was about a 50% relative risk reduction. 43% of the participants taking aspirin experienced a non-severe side effect compared to 35% of those on placebo. Serious adverse events occurred in 17% of aspirin takers compared to 12% of placebo recipients. The authors conclude that low-dose aspirin represents an effective, low-cost treatment approach to prevent colorectal cancer recurrence in high-risk, genetically selected patients. Terry 04:17-04:58 Nutrition experts have praised the Mediterranean diet as a way to reduce cardiovascular risk. It’s also been considered as a way to lower the likelihood of developing dementia and a natural approach to calming inflammation. Now, dermatologists have announced the results of a study showing that four months on a Mediterranean diet can reduce the severity of psoriasis symptoms. Almost half of the participants following a Mediterranean diet reduced their psoriasis score by 75 percent, and none of those on the control diet did so. The researchers conclude that this dietary strategy could be helpful along with medical treatment. Joe 04:59-05:41 A new study of acupuncture for chronic low back pain called Back in Action produced positive results. 800 patients were randomized to receive either standard acupuncture of 8 to 15 treatment sessions, enhanced acupuncture, which included 4 to 6 maintenance sessions beyond the standard, or usual medical care alone. Those in the acupuncture groups had significantly greater reductions in their pain-related disability than those in the usual care group. The authors conclude that, quote, these findings support acupuncture needling as an effective and safe treatment option for older adults with chronic low back pain. Terry 05:42-06:05 Do cocoa flavanols normalize blood pressure? In the COSMOS study, people with systolic blood pressure under 120 were significantly less likely to develop hypertension if they were taking cocoa flavanols than if they took placebo pills. People whose blood pressure started higher did not get the same benefit. 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 06:17-06:29 And I’m Joe Graedon. According to the CDC, over 10 million Americans over 50 have osteoporosis. That means their bones have become fragile and more vulnerable to fracture. Terry 06:30-06:40 More than 40 million Americans have low bone mass or osteopenia. What can be done to prevent fractures, disability, and death from weakened bones? Joe 06:41-07:00 To find out, we’re talking with Dr. Kendall Moseley. She is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She also serves as medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 07:01-07:04 Welcome to the People’s Pharmacy, Dr. Kendall Moseley. Dr. Kendall Moseley 07:05-07:10 Thank you so much for having me today. I’m very excited to chat with you both about a topic that’s near and dear to my heart. Joe 07:11-07:48 Well, it’s near and dear to our hearts as well, Dr. Moseley, but I suspect that there’s a tremendous amount of confusion when it comes to bones because we’ve all seen skeletons. We’ve all had interactions with bones, perhaps in food. And it just always seems as if bones are so solid. And yet, in reality, bones are constantly breaking down and building up. It’s a very dynamic process. Could you just give us a quick overview on bone physiology? Dr. Kendall Moseley 07:49-09:21 Absolutely. And I think you’ve highlighted something I always try to stress when I talk to groups of people is that bones are not these inanimate objects. I mean, we’re not these walking, kind of lumbering rocks moving down the street. In fact, we have this very important scaffold underneath our skin that enables us to walk and roll and twist and bend. And without a very strong scaffold, we’re kind of in trouble. So you’re right. Bones are dynamic. Our bones are always building up and they’re always breaking down. And it’s that process of kind of building up and breaking down that allows us to be flexible, right? If we didn’t have remodeling of our bones, we’d be very stiff and brittle. But it’s that balance, that key balance of how our bones build up and how they break down that really dictates how strong our bones can be. Clearly, you would prefer a lot more building up than breaking down. And at different parts in our life cycle or different times in our life cycle, we have different balances in that building up and breaking down. If you really want to get into the nitty gritty of the pathophysiology, which I think is important to understand because there are two very different types of cells that treatments for bone disease sometimes impact, we really boils down to these cells, one of which is called the osteoclast. It’s kind of like a little Pac-Man cell that’s responsible for breaking down our bone if it’s an area of injury or a little micro fracture. So that osteoclast will come in and kind of carve out a pit of bone so that the osteoblast, B as in build, can come in and fill in new bone. Again, to rejuvenate that area and to keep your bones flexible. Terry 09:22-09:34 And I’m assuming that as we get older, there are more osteoclasts or they’re moving faster than the osteoblasts building our bones back. Am I wrong? Dr. Kendall Moseley 09:35-10:58 No, I think that that’s a wonderful way to think about it. You know, the life cycle is complicated. You know, when I meet patients for the first time, and again, I’m in a metabolic bone clinic, so I see patients who generally come already with a diagnosis of osteoporosis or low bone density. And when we’re sitting there talking to one another, we say, gosh, why aren’t your bones perfect? And believe it or not, what we do is we go all the way back to childhood because changes happen throughout the life cycle to bones. We build or gain bone. We’re building more bone than we’re breaking down until about the third decade of life. So those osteoblasts are overtaking the osteoclast to give us nice, strong skeletons. So you might imagine how early childhood insults could impact the bones. In midlife, we have kind of a steady state where the blasts in the clasps are kind of remodeling at a usual rate, generally in balance with one another. At around the time of menopause that women go through, there is a steep decline in bone density, which is driven primarily by those osteoclasts, those Pac-Man cells that break down bone at a much more rapid rate than the osteoblasts are able to keep up with. And men have an inflection point later on in life. They don’t go through a menopause per se, but about the time, about 70 years of age or so, again, that imbalance starts to shift, which favors the osteoclast or bone breakdown, where again, it’s kind of like a tortoise and the hare story that the tortoise is no longer keeping up with the hare and the bones will break down. Joe 10:59-11:46 Dr. Moseley, I’m curious as to how things have changed, because I suspect that our ancestors, and when I say our ancestors, I’m not talking about Neanderthals. I’m talking more about our grandparents and our great-grandparents. they were probably spending a lot more time outdoors. You know, farmers and just workers and, you know, both men and women were just physically more active than we are today. Today, I think we spend a lot of time sitting. And I’m curious as to how our lifestyles have affected bone health over the last, let us say, 50 to 100 years. Dr. Kendall Moseley 11:47-13:01 Now, I think that that is a fair assessment. We know that activity movement is critical for bone health. You know, in fact, when we talk about the tenets of therapy for osteoporosis and low bone density, one of the things we always have to discuss in clinic is how can we get you more active? What kinds of exercises should you be doing? Because movement really stimulates those bones to kind of rebuild, grow, remodel. And so absolutely, you know, back in the days when we were out and about, you know, in the farms or, you know, pushing things, you know, down the street. I think we did have a lot more activity related to our bones. I will also counter, though, you know, we didn’t live as long back in the day. And so that graph that I just kind of talked about with this aging process kind of inevitably causing slow and steady bone loss as we get older, a lot of the implications for weakened bone really don’t occur until that later stage in life where women are postmenopausal or men are older. And so did we really see the full effects of osteoporosis and bone loss, you know, in prior generations when perhaps they didn’t live to be the older ages where the fracture started to manifest or people passed earlier from other conditions that we didn’t have treatments for? Terry 13:01-13:19 Dr. Moseley, I want to just revisit something you said a few minutes ago and really bring it back up because a lot of people think of osteoporosis as a women’s problem. And you mentioned men get osteoporosis too. Tell us a bit more about that. Dr. Kendall Moseley 13:20-14:28 Terry, thank you for bringing that up. It is a very important point. And oftentimes, you know, my practice is a lot of women in my practice, and oftentimes women will bring their significant others or their spouses and they listen to my spiel and they kind of turn to their spouse or significant other and they say, well, gosh, Maybe that means we need to screen you as well. And it’s true. So men do get osteoporosis. It is a misconception that this is a woman’s disease. Statistically speaking, about 10 million Americans in the United States have osteoporosis greater than the age of 50. About 8 million of those individuals being women, 2 million being men, although even that statistic I counter. One big point is that we really under-diagnose osteoporosis. We don’t name it when we see it, and secondly it relies upon screening for osteoporosis and as we’ve just said men really we don’t see this as a man’s disease so are we screening men to even be able to make the diagnosis in that portion of the population so absolutely bones thin at different times in our lives but there are still other factors other disease states other medications that can threaten a man’s Joe 14:28-14:56 skeleton just as easily as it can a woman’s well you mentioned medications and of course a lot of men who are diagnosed with prostate cancer are given hormone suppressing drugs, what we call antiandrogens. And I suspect that has a profound impact on bone strength and not just in men, in women too, because testosterone people think, oh, that’s a man’s hormone, but it’s responsible for bone strength in both men and women. Dr. Kendall Moseley 14:57-16:11 Right, right. No, absolutely. So one of the biggest offenders and we, you know, the term is iatrogenic, meaning sadly, we as doctors do this to patients, I mean, deliberately, because oftentimes we’re treating another disease state and we have no choice, but we do give patients oftentimes medications that have side effects that directly hurt the bone. One of those medications, in fact, is androgen deprivation therapy. So on prostate cancer with a goal to get testosterone levels to zero, we give them these hormone blockers. And it’s kind of like a menopause for men that they go through when we have that low testosterone. We know testosterone is converted into estrogen. So that causes low estrogen in men, which can hurt the bones. Women, there’s a corollary with breast cancer. So our breast cancer survivors, we treat with drugs such as aromatase inhibitors, where again, we render estrogen levels to zero. And we see oftentimes a significant amount of bone loss associated with those medications as well. Probably the worst drug that we use, but oftentimes very, very necessary for patients with chronic inflammation or autoimmune disease would be things like steroids. So steroids, I always refer to as somewhat dirty drugs. You know, if you need them, you need them, just like anti-cancer therapies. But those medications as well can really thin bones through a number of different mechanisms. Joe 16:12-16:36 So the anti-estrogens for breast cancer, the anti-androgens for prostate cancer, and the corticosteroids that are used for so many different conditions, including autoimmune disease and asthma and COPD, all of those medications can have a profound effect. Should everybody who’s taking one of those medications get a bone scan? Dr. Kendall Moseley 16:37-18:07 In my humble opinion, absolutely. And I think most guidelines would agree. I, you know, it depends on timing. So the low hanging fruit, the easy answer would be with your anti-estrogen medications and your anti-testosterone medications. And certainly if you know an individual is going to be treated with those drugs, it’s usually for a longer period of time. So anti-estrogen medications upwards of five to 10 years in many breast cancer survivors. Anti-androgen medications oftentimes not as long, but sometimes two years or more. And in those patients, you absolutely do want to get a screening bone density test and anticipate that in fact those medications are going to thin the bones and ideally jump ahead of that problem. And again, we have interventions we can use pharmacologically and lifestyle-wise to anticipate the bone loss and obviously treat it before it becomes a problem. Steroids are a little bit trickier. Steroids in general, we say that if a patient is going to be on a dose of prednisone or an equivalent of 5 milligrams or more for 3 months or more continuously, that would be a dose at which you certainly would want to get a screening bone mineral density test, potentially treat to prevent bone loss, depending on what that screening bone mineral density test shows, and then follow the patient more closely. We’re not as worried about the inhaled steroids. We’re not as worried about steroid injections that patients oftentimes will get for joint pains and arthritis. It really is the systemic steroids that cause the most problems. Terry 18:08-18:15 You’re listening to Dr. Kendall Moseley, Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 18:16-18:21 After the break, we’ll learn the difference between osteopenia and osteoporosis. Terry 18:21-18:24 If you break a bone, does that mean you have osteoporosis? Joe 18:25-18:27 What are the options for treating osteoporosis? Terry 18:28-18:30 Exercise might be helpful. Which ones are best? Joe 18:31-18:33 Should you be wearing a weighted vest? 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 18:55-19:13 And I’m Terry Graedon. Joe 19:13-19:21 Today, we are talking about bones. How would you know if your bones are strong or vulnerable to breakage? Terry 19:21-19:27 What options are available to maintain bone health? Are some exercises better than others? Joe 19:27-19:52 We’re talking with Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins. She’s also Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 19:53-20:17 Dr. Moseley, I think there are a lot of kind of long, complicated words that we need to deal with in this interview that people may have heard or maybe not have heard, but are not completely certain what does it mean. So let’s start with the difference between osteopenia and osteoporosis. Dr. Kendall Moseley 20:18-24:09 Right. I think that’s a great question. There’s a lot of big words in the bone field, and those would be the big ones that patients bring to the office. So we have to think about bone density and bone health and bone strength along a spectrum. So, you know, spectrums are uncomfortable for a lot of people. We like to have our bins, our diagnoses. And so in the bone world, we divide things into normal. We say osteopenia, although we are getting away from that term. We more so use low bone density and then frank osteoporosis. And the World Health Organization would define those three terms based on a T-score. And what is a T-score? So To make a diagnosis, to screen for osteoporosis, we use a very specialized scan called a DEXA scan. It’s a dual energy X-ray absorptiometry scan. You can see why we call it DEXA. And it’s basically a fancy X-ray. And it’s a 2D interpretation of bone quantity, usually looking at the spine, looking at the hip. And it’s two different locations in the hip. It’s the total hip and the femoral neck. And sometimes we even look at a forearm in certain circumstances and disease states. And it’s that fancy x-ray, again, that we use to follow osteoporosis, but more importantly, to diagnose it in those in whom we’re worried that they have thinner bones. That T-score is really just a standard deviation. And the standard deviation is that individual’s bone compared to that of a 30-year-old, which seems very unfair. But as I said earlier in the segment, we really gain bone until about the age of 30. So we’re kind of comparing that patient to what their ideal should have been back in the day. A T-score, anything between 0 and negative 1 is considered normal, so normal bone density. Anything between negative 1 and negative 2.5 or 2.4, excuse me, is considered low bone density or osteopenia. And anything less than or equal to a negative 2.5, again, negative 2.5 standard deviations from normal is considered osteoporosis. And that’s what spits out on the reports, and that’s oftentimes what patients bring to the clinic. Although it’s very, very important to insert a big caveat here. People with low bone density or osteopenia can still fracture. In fact, the majority of fractures, which is the take-home message, we’re trying to prevent broken bones, the majority of people who fracture actually are in the osteopenia or low bone density range as compared to the osteoporosis range bone density. So if someone comes to clinic and maybe that DEXA scan says the T-score is a negative 1.5 or it’s a negative 1.8, which technically, again, is osteopenia or low bone density. If that same patient has also had a fracture, a fragility fracture, that patient has osteoporosis. So it doesn’t matter to me what this screening scan shows. If that bone has broken in a fragility manner, and gosh, I get that question all the time, too, so I’m going to beat you to it. What is a fragility fracture? This is a fracture of the spine, hip, pelvis, wrist, upper arm from standing height or less. So slipping outside on an icy street and bracing your fall with your wrist, if you break that wrist, that is a fragility fracture. Stepping out of the bathtub and maybe the floor is a little bit slippery and you come down hard on your hip and you have a hip fracture, that is osteoporosis. Falling out of a two-story building or a motor vehicle accident and you break your pelvis, that’s just lucky, you know, walked away with just one broken bone. So, again, fragility fractures, no matter what that bone density test is showing, whatever that score says, if you have a fragility fracture, you have a diagnosis of osteoporosis, that should be treated. It’s akin to having a heart attack, right? I don’t need a cath if you’ve had a heart attack to tell me you have cardiovascular disease and we have to take that seriously. Joe 24:09-24:51 I’ve got a question for you because our grandson, who’s seven, was running the other day at camp and he tripped and he fell and he broke his arm. That happens a lot to kids. You know, they fall off the jungle gym or they fall off their bicycle and they land and out goes their arm and boom, they’ve broken it. Now, they don’t have osteoporosis. Why would a woman who falls in a similar situation, maybe while riding a bicycle, why would she be automatically defined as osteoporotic? Dr. Kendall Moseley 24:53-26:07 Well, a woman who falls off a bicycle, that’s considered traumatic, right? So maybe it’s less than standing height because she’s sitting down on a bicycle, but she’s fallen off of a moving object going presumably at a fairly rapid speed and you get entangled in the wheels, etc. So I would probably talk through the logistics of that particular fall, and I would probably walk away saying that was more traumatic than atraumatic. Getting back to kiddos, they’re a different bird. So again, falling off of a jungle gym, that’s from a height higher than standing height. Kiddos also have just very different bones. So their bones are kind of built to be a little bit more flexible. They’re a little bit more rubbery. They remodel at a faster rate. And so they do oftentimes get these fractures, you know, tripping, falling, bonking their heads. We had that a couple of weeks ago in our household. We know those fractures heal very rapidly. Where we start to worry in kiddos, and this is probably beyond even the scope of our discussion today, is when there are multiple fractures, low trauma fractures, you know, situations in which it doesn’t make sense that that arm or that leg breaks. And then there’s a whole host of genetic conditions that oftentimes we will screen for to make sure that, in fact, that child doesn’t have a metabolic disease. Terry 26:07-26:42 Well, I think it’s important for parents to realize that a situation like that requires extra attention. But we’re not going to follow through on that any further. What I’d like to do is go back to your idea that a fracture might institute treatment. And what I mostly hear from people my age, women my age, is that they have been told by their doctor that they have to take a drug because of the osteoporosis. Joe 26:42-26:47 And a lot of them don’t want to take a drug. Or the osteopenia in some cases. Terry 26:47-27:08 Or the osteopenia. And the most popular drugs are the bisphosphonates like alendronate, which used to be called Fosamax. So what options are there for treating osteoporosis? Is bisphosphonates where you start? Or are there other things people can do? Dr. Kendall Moseley 27:10-29:57 Now, when I talk to patients, I always break it down into, gosh, what are things that you can leave here with? What is your to-do list going to look like? And that can be things like calcium, vitamin D, exercise, protein, other healthy lifestyle interventions, and we can get into that absolutely. And then there’s things that maybe I need to do, you know, when the prescription pad may need to come out. When we think about osteoporosis and how we treat osteoporosis, again, we love our bins in medicine. It helps to organize our thoughts and kind of talk to people about how we’re thinking about their disease state. And osteoporosis is no different. We think about it on a spectrum. So is the osteoporosis mild? You know, in a mild case of osteoporosis, maybe just low bone density, no prior fractures. We sometimes use a tool called a FRAX calculator that comes up in the guidelines. If we’re seeing signals that things are generally fairly positive, we might just recommend lifestyle interventions, calcium, vitamin D, some good exercise, protein, et cetera. As we move further down into the different bins, we get into different categories. So moderate osteoporosis or low bone density, where again, the DEXA scan is giving us data, we don’t like to see the numbers are decreasing. There’s maybe an increased falls happening at home. The FRAX calculations are more elevated. That might be a category in which, in addition to lifestyle interventions, we might recommend medical therapy, usually something more mild. You know, if we think about it as a swimming pool, we start in the shallow end and get a little bit deeper. That might be an oral bisphosphonate. For women, we use things called selective estrogen receptor modulators, which act on the estrogen receptors within the bone. As we wade deeper into the pool, we get into the more, you know, severe osteoporosis or, excuse me, high-risk osteoporosis or severe osteoporosis. In those categories, that’s when we start using, again, in addition to lifestyle interventions, the calcium, the vitamin D, and the exercise, that might be a place at which we do start to recommend more intense pharmacotherapy. That might still just be an oral but it may be an infusion, it may be an injection, depending on the case. What I think, though, doesn’t always matter. I think everything comes down to forming a relationship with a patient and talking through what the patient’s concerns are about their bones, what their concerns are about the logistics of a medication. Because if I think you need a daily injection, but you don’t want to do anything, there’s no point in us kind of not reaching any sort of conclusion in terms of treatment. If you’re in a very high-risk fracture category, we might want to start with a bone-building drug. But if you tell me all you’re willing to do is an oral pill once a week, I’d rather not let perfect be the enemy of good. And we might start with something milder, despite what I think. Joe 29:57-30:24 Dr. Moseley, you’ve mentioned exercise a couple of times, and we’ve gotten all kinds of recommendations with regard to exercise. You know, it has to be bouncy exercise. You have to jump up and down. You have to stress your bones. And then we’ve heard from other experts who say, you know, if you do Tai Chi, it’ll actually be good for your bones. Terry 30:24-30:24 Or yoga. Joe 30:25-30:37 Or yoga will be helpful. And so there’s just a lot of confusion around the best kind of exercise or it’s just exercise in general. Walking, will that be helpful? Dr. Kendall Moseley 30:39-32:45 Yes, yes, and yes. So my take home with patients is always just keep moving. Just keep moving. We all have physical limitations, right? There are patients who can’t, you know, run. They can barely walk. Oftentimes they’ll come in in a wheelchair and a walker, but it’s important that they move their bodies. Walking counts in terms of exercise. There are two, you know, big picture issues when we think about exercise and bone or movement and bone. And the first is, yes, is there a way that we can kind of physically tax or stress bone in a way that promotes healthy bone remodeling and bone building. And there are data in individuals who use high-intensity exercise. There was a trial called the LIFTMORE trial looking at women and men, older women and men, with supervised high-intensity exercise about three times per week and showing, in fact, there was benefit to the bone. And this is heavy weights. This isn’t just your little two or three pounders that you’re using, but in fact, supervise, you know, high weight, high intensity exercise, and they gained bone. Is that possible for all patients, to all patients have access to that sort of exercise and gyms and equipment, et cetera? Not necessarily. So the second thing we need to think about with exercise and the importance of exercise is, gosh, how do we keep you upright and fracture free by virtue of the fact you’re not falling? So if we can strengthen individuals, lower body strength, core strength, and you can get that just through walking or through yoga or through Pilates, you know, really making sure that you have a sense of self in space, keeping you from falling, that’s a victory in and of itself as well when it comes to bone strength. So, yes, I mean, would we love everybody out there lifting, you know, 30-pound weights and a supervised setting and potentially gaining some bone? That would be lovely. But I think realistically speaking, we all bring different limitations to a clinical setting. And just moving, again, just getting those legs working, just getting a sense of balance, sending people to physical therapy for balance training and core and posture, that can be just as important as getting them into a gym. Terry 32:45-33:30 Dr. Moseley, there’s something else I’d like to ask you about while we’re on this topic of physically stimulating our bones. Something that’s gotten some buzz is vibration. And there are people who have purchased pads that they stand on that vibrate to try to help their osteoporosis. there is also a device that I saw, I think it has been cleared or approved, I’m not sure which, by the FDA. You wear it like a fanny pack. It’s a belt called an Osteoboost and it vibrates for half an hour a day, provided you wear it that long. Are these devices of any use? Dr. Kendall Moseley 33:32-35:28 I think the jury’s still out. I get those questions all the time in clinic because, Again, I’m very encouraged that patients want to feel empowered with their health and they want to do things other than just take a pill or do an injection. I think it’s important. It’s a partnership that way. What can you do? What do I need to do to strengthen your bones? So vibration plates and these vibratory belts that are out there now, I think they’re trying to get at the pathophysiology of bone remodeling, which is, again, stressing bone, targeting mechanoreceptors that live in the bone that cause release or non-release of hormones that could be detrimental to bone remodeling and bone strength. And I think there’s promise there in the idea that it’s targeting, again, these mechanoreceptors in the bone. What we don’t have with either the vibratory plates or the belt are fracture data. So there are some data potentially showing stability of bone density with the use of these different devices. There are some data potentially showing some improvement in bone density. With the belt, it was only tested in individuals with low bone density or osteopenia. We don’t know in an osteoporosis population. The vibratory plate data is kind of all over the place. But what we don’t have with those devices is fracture prevention data. And that’s always hard to get. Even in the drug trials, you need thousands and thousands of study subjects to determine if that intervention is going to reduce fracture risk. So we may never have that information. So what I tell patients when they bring those, you know, pamphlets to the office or that printout or that clipping from a newspaper article is they say, I don’t think that these devices are going to hurt you at all. I think, in fact, they potentially could be beneficial to you. And how can we work those devices into our treatment plan so that, Again, you are doing things at home that may be beneficial to your bone, but I’m also keeping tabs on your bone density. And we, again, can decide together if we need to ratchet up your treatment plan to the point where we need pharmacotherapy. Joe 35:28-35:38 Dr. Moseley, I’ve been seeing a lot lately about weighted vests or sort of backpacks that are supposed to be good for you. Any thoughts about that? Dr. Kendall Moseley 35:39-36:37 Weighted vests are going to fall into the vibratory plate category and even these belts. And it’s the idea that you want to put deliberate strain on your bones to encourage them to remodel more actively. And again, this is a space where we maybe have some data showing stability of bone density, maybe a little bit of improvement in bone density. We do not have fracture data showing that weighted vests are beneficial to bone health. My challenge I have with them is depending on the vest, and there’s so many different types out there, they sometimes can cause low back pain. They can cause posture problems. We certainly don’t want anyone falling over from their weighted vest. So if there’s any hint that the vest might cause instability in the patient, I tend to be against them. But gosh, if it’s one more tool hanging by the front door that encourages someone to go outside and take a walk with their weighted vest on, by all means, I’m very optimistic that this could be something, again, to motivate people to take their bones into their own hands. Terry 36:38-37:03 You’re listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 37:04-37:08 After the break, we’ll learn about raloxifene as a treatment for osteoporosis. Terry 37:09-37:12 It might reduce the risk of breast cancer as well as of bone fractures. Joe 37:13-37:20 What other drugs do doctors prescribe for osteoporosis? And what are their pros and cons? Terry 37:20-37:24 Are there problems in stopping certain bone-building drugs? Joe 37:24-37:27 Dr. Moseley will share her pillars of treatment. Terry 37:40-37:43 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:53-37:56 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:56-38:13 And I’m Terry Graedon. Joe 38:13-38:23 There are now numerous medications to improve bone health, but they all have some side effects. Which are the safest and most effective? Terry 38:23-38:41 The FDA first approved a drug called raloxifene in 1997 to prevent postmenopausal osteoporosis. The brand name was Evista. Although other osteoporosis medications approved around the same time are still in wide use, raloxifene has almost disappeared. Joe 38:42-38:52 Why don’t doctors consider raloxifene for osteoporosis? This medication has another important benefit that has seemingly been forgotten. Terry 38:52-39:18 Today’s guest is Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 39:20-40:00 Dr. Moseley, we’d like to talk about treatment first and some of the medications that you do prescribe. And I’m just curious about a drug that seems to have been forgotten. I mean, it never really gained much popularity, but it’s, I think, kind of an interesting medication called raloxifene because it has both, I’ll call it pro-estrogen and anti-estrogen activity, which seems like an oxymoron. Like, how could that possibly be? But could you just give us a quick overview of a drug that seems to have gotten kind of dusty in the dustbin of history? Dr. Kendall Moseley 40:02-43:08 Sure. I don’t think of it that way as a dusty drug. We actually use a fair amount of it in our clinics because it has a role in osteoporosis care. So raloxifene is what we call a SERM. It’s a selective estrogen receptor modulator. And as you indicated, it has stimulatory properties at the level of the bone and actually inhibitory properties to tissue such as the breast and the uterus. So raloxifene is actually similar to a drug called tamoxifen that many women and men have heard of it that’s used as an anti-breast cancer medication in that patient population. So raloxifene, for starters, because it’s a selective estrogen receptor modulator, is not to be used in men. It is solely to be used in women. And we generally, as I was talking about those bins of risk, the low, the moderate, the high risk, and very high risk, we generally reserve that medication for individuals in a low to moderate risk category. And that’s because we have data showing that raloxifene, in fact, does reduce the risk of vertebral compression fractures. And again, we look at different types of bones and different fractures. We don’t have as much data demonstrating that raloxifene actually reduces the risk of hip fracture. And so when we have patients who maybe have low risk or moderate risk osteoporosis, it’s spine predominant, we see that that’s the lowest site. Oftentimes we will use raloxifene. It’s a daily pill. It’s easy to take. It’s easy to stop. It has a relatively low side effect profile. So probably the first thing I warn women is beware, your hot flashes may come back once you start this medication. Some run for the hills when I bring that up. Others say no problem. It doesn’t typically last forever, but certainly for the first few weeks or so, those hot flashes can come back. The other side effect that’s certainly more serious than the hot flashes would be that it can increase the risk of blood clots and stroke as a result. So if there’s a patient who has a history of blood clots or a clotting disorder or pulmonary embolus, again, that would not be a medication of choice. The reason it is appealing to a lot of women and certainly even our use in clinic is it doesn’t necessarily come with the more scary side effect profile that some of the other drugs have. So, again, you can start it and stop it at any time without any ramifications, no rebound bone loss. You can take it indefinitely as long as the patient is tolerating it without concern for jaw necrosis or atypical femur fractures that, again, come up with some of our other drugs. So it’s fairly easy to use. It’s inexpensive. We don’t typically have to fight the insurance companies too terribly hard to get it prescribed. So that’s helpful. And we actually wind up using raloxifene a fair amount for, again, those patients who come in and they acknowledge that their bones are less than perfect. They’re concerned about their bone health, but perhaps they’re similarly concerned about medication side effects. And again, in the interest of not letting perfect be the enemy of good, if what we decide upon is raloxifene, this daily pill that may not have that hip fracture prevention data, it’s certainly better than nothing. So again, in our bone clinics, we do use it. Joe 43:08-43:51 And the thing that I think a lot of women find very attractive about raloxifene is that it It has a breast cancer prevention piece as well as, as you pointed out, a vertebral fracture prevention piece. So it’s sort of a double benefit. But let’s move on, Terry, to some of the other medications because, as you’ve already mentioned, there are some pretty serious side effects. And you mentioned atypical femur fracture. We want to talk about the tooth problem. And we want to talk about some of the newer drugs that are injectable that once you get them, it may be in your body for six months or longer. Terry 43:51-44:04 But let’s take that one at a time. So let’s start with those bisphosphonates that Joe was alluding to. What drugs are we talking about? When do you use them? What do people need to know about them? Dr. Kendall Moseley 44:06-47:19 Right. So we can start, I guess, with the bisphosphonate category. And bisphosphonates are probably the old guard of the osteoporosis regimen. I mean, they started, you know, greater than two decades ago with use of these. And probably the one most people have heard about is alendronate. Alendronate is a once-a-week pill that’s a little bit challenging to take. You take it first thing in the morning, full glass of water, nothing else to eat or drink for an hour, no going back to bed. And these medications, the way that they work in the bisphosphonate category is they are drugs that effectively get incorporated into the bone, into the hydroxyapatite matrix of the skeleton. And once these drugs are incorporated into the bone and they come in proximity of those Pac-Man cells, see here those cells come back again. When those Pac-Man cells come along and encounter these bisphosphonates, they effectively render the Pac-Man cells, the osteoclast, useless. So they can’t break down bone anymore. they’re incorporated into the skeleton, so they do have a lasting effect. And when I talk to patients about these, we kind of think about it like coats of paint, right? So with each year that you’re on these drugs, you kind of paint the wall once again and once again and once again, and the paint can accumulate, which is why there can be concern about long-term use of these medications. And I’m going to throw five years out there, but there’s no rule that five years is a maximum amount of use you can do these. But after about five years of use, we do start to consider a pause in therapy in the appropriate patient because of these layers of pain and this, you know, potential paralysis of the Pac-Man cell and paralysis of a bone remodeling process can cause adynamic and potentially more brittle bone. You know, if your bones are frozen and they can’t rebuild and remodel themselves, we worry that that’s not healthy either for the skeleton because we do start to encounter very rarely atypical femur fractures where kind of there’s a hip fracture that happens below the, you know, kind of along the thigh, which is not anticipated, or we can see jaw complications with jaw erosion, that things can get infected, all stemming from this idea that brittle old bone can’t rebuild, remodel, and heal itself as easier as, you know, refreshed bone. There’s an IV formulation of that pill now called zoledronic acid. It’s administered once a year. So in patients who really aren’t good at swallowing pills, patients who have esophageal disorders, history of ulcers, which can be a side effect of the alendronate therapy or the oral bisphosphonates, this once a year drug can be quite helpful. It’s given through the vein over about 30 minutes. That one, typically three to five, although again, with an asterisk in the appropriate patient, sometimes we go shorter versus longer. But that drug two, similar side effect profile with rare risk, again, of these atypical femur fractures and jaw necrosis. But I always like to pause there and say, you know, these are rare side effects and we have to always consider the alternative, which are what are our real concerns about you breaking your hip or breaking your spine or losing bone in the context of that new steroid that you’ve been prescribed. So it’s always a balance talking about side effects of medicine, which they all have, and the benefit of the drug at the end of the day and reducing fracture risk. Oftentimes we have to 50 to 60 percent. Terry 47:19-47:32 And I’m supposing that there’s no really good way to predict ahead of time who might be at higher risk for one of those really awful side effects like an atypical femur fracture. Dr. Kendall Moseley 47:33-49:37 Yes, I mean, I wish I had a crystal ball. I mean, we do know that there are certain individuals at higher risk for the more rare but real side effects. So jaw necrosis, in general, the risk will be higher in, let’s say, cancer patients. So they get bisphosphonates at much higher doses, much more frequent doses. But even in osteoporosis patients, and it would typically be in the setting of what we consider to be invasive dental work. So this is if you are having an extraction, you’re having an implant, you’re having a bone graft where there’s kind of deliberate invasion of the jaw bone itself that can become subsequently infected. and the concern is that bone once infected can’t heal itself well and can, you know, erode over time. We get questions a lot about things like root canals or what about, you know, braces. Sometimes our orthodontists are worried about braces or bridges, caps. Those are not invasive. We’re not getting into the jaw in those contexts. So again, we’re less worried about that and the jaw necrosis complication. Atypical femur fracture is something that typically we have observed, and it’s been really since the onset of alendronate. Women used to get a prescription for alendronate in one hand and hormones in the other hand, and it was see “see you again never.” So we’ve learned now that with longstanding bisphosphonate use, we can see these atypical femur fractures. And that’s why I gave that five-year number a little bit ago, which is where after about five years of use, We don’t see a precipitous increase in atypical femur fractures, but we certainly start to consider, is this medication actually necessary? Because that long-term use can be a problem. We see increased risk in individuals on bisphosphonates who’ve also been treated with long-term steroids. Both conditions can cause this adynamic or frozen bone. And we know that Asian women are at higher risk for atypical femur fractures. So that’s something that we always want to consider when meeting with the patient, again, on that yearly basis to decide whether or not it’s appropriate to continue therapy versus discontinue the therapy. Terry 49:38-50:12 Now, Dr. Moseley, let’s assume that your patient has been on a bisphosphonate for five years, has stopped, comes back to you in a year or two, and you say, that osteoporosis, it’s still a problem. We’re going to move on to the next category of drugs. You have those bone-building drugs, but there’s a problem with them as well. You mentioned before that raloxifene, the SERM, is easy to stop, but some of these bone-building drugs, they could be hard to stop. Dr. Kendall Moseley 50:13-50:25 Well, I want to kind of push back a little bit on the bone-building. I think the drug you may be referring to is denosumab, which actually is a drug, which is an anti-breakdown drug, first and foremost. Joe 50:26-50:42 And Dr. Moseley, a lot of people are not familiar with generic names like Alendronate or Denosumab. So we’re talking about Fosamax in the case of the bisphosphonates, and Prolia is the brand name for Denosumab. Terry 50:42-50:46 Or is it pronounced Prolia [pro-LEE-ya]? I’m never sure exactly how, and I’ve heard it both ways. Dr. Kendall Moseley 50:47-52:44 I’ve heard it in both scenarios as well. You could probably use them interchangeably. And I’m glad you said that too. The academician in me has been taught never to use the trade names. But no, the denosumab, the prolia, or prolia, however you’d like to inflect that, that’s the one that’s an anti-breakdown drug that has more anabolic properties. So if you want to gain bone, oftentimes we do see more improvements statistically at the spine and the hip with that every six-month injection. But indeed, and I’m glad you brought this up, Terry, because it’s important, that drug, once you start it, it can be challenging to stop. That drug works very differently from the bisphosphonates. It is what’s called a RANK ligand inhibitor, which basically interferes with how the osteoclast and the osteoblast communicate with one another. But it’s a monoclonal antibody, meaning it doesn’t get permanently incorporated into the skeleton. Rather, it’s given every six months because it’s almost as though the clock strikes midnight when you stop it. And all of these cells, all of these osteoclasts that have been kind of paused for the duration of the use of the medication, if you stop it abruptly, they wake up and have a party and can actually break down your bone at a very rapid rate to the point at which we’ve even seen spontaneous vertebral compression fractures in patients who stop their medication without talking with their doctor first. So that drug gets every six months. It is not impossible to stop. In fact, we’re looking as a society at different transition mechanisms, usually, and almost, actually, I’ll say almost always with the use of a bisphosphonate to try to prevent this rebound effect of the drugs to see if patients can stop the medication. but it can be very challenging. So that drug is not for those who come to see me and don’t want to take anything or those who oftentimes have a difficult time making it to their clinic appointments. That is a drug for individuals highly committed to their bone health and very dedicated to a treatment course of 5, 10 or even beyond that years. Joe 52:45-53:28 Dr. Moseley, what about estrogen? I mean, estrogen, it seems like a roller coaster ride. Back in the, oh, I’d say 1970s, 1980s, Premarin was the number one most prescribed drug in America. Just about every woman who was going through menopause was put on Premarin. It’ll take away your hot flashes. It’ll build your bones. It’ll make you feel sexy. I mean, it’s the greatest. And then of course along came the women’s health initiative and then oh my goodness no estrogen it’s too dangerous and now it seems like estrogen is coming back again tell us a little bit about estrogen and bones. Dr. Kendall Moseley 53:29-55:08 Yes, well I mean, that’s uh, you’re right it’s a very very hot topic now and I think we’re all kind of re-evaluating how we think about estrogen not just for bone health but also women as they’re going through the perimenopause, you know, did we kind of throw the baby out with the bathwater, so to speak? We love estrogen for bones. You know, as I described earlier, women lose a tremendous amount of bone density through their perimenopause due almost entirely to this decline in estrogen. It’s like we take the brake off of the osteoclasts and they wake up and they break down a lot of bones. So we absolutely like estrogen for bones. What’s happened though, is that estrogen is really not first-line treatment for osteoporosis or low bone density, in part due to the fact that we do have these data potentially in older women showing increased cardiovascular risk, increased cancer risk. So we don’t typically use it as a first-line drug to treat osteoporosis or prevent bone loss. But if we do see women who are on estrogen for other purposes, maybe they’re on it for vasomotor symptomatology or mood or difficulty with sleeping, We certainly will keep those women off on their hormones, excuse me, and potentially add additional therapy down the road for bone health if we feel that it’s warranted. So we’re probably going to see that pendulum continue to swing back. There is a committee being formed as we speak to reevaluate this exact question about the role of menopause hormone therapy and osteoporosis treatment to see, again, if maybe we got a little bit ahead of ourselves and underestimated the importance of estrogen and bone health, particularly in younger women. as they go through the early stages of their menopause. Terry 55:09-55:21 Dr. Moseley, unfortunately, I don’t have these generic names on the tip of my tongue, but drugs like Forteo, for example, now, is that a drug that is meant to build back bone? Dr. Kendall Moseley 55:22-57:04 Absolutely. I’m glad we’re spending some time on this because it’s a very important category of medications, these anabolic or bone-building drugs that we use in these high-risk fracture individuals. So very low bone density, multiple fractures, oftentimes failing other drugs, where we have to turn to this category of bone building drugs. And there’s a few, luckily, in that category now. So starting with your self-injection medications for up until about two years, we’ve got abaloparatide and teriparatide, also known as Tymlos and Forteo. And these are subcutaneous injections that patients, in fact, give themselves. And sometimes we see those eyebrows shoot straight up when that seems to be a tall ask for the patient. But it’s a self-injection for up to two years. It’s actually parathyroid hormone, interestingly enough. So we’re harnessing the body’s own hormone, giving it back to patients in a pulsatile fashion, which can increase bone density. And then the other drug that’s slightly newer approved in 2019 called romosozumab or Evenity, which are subcutaneous injections administered monthly in a healthcare setting for up to one year, so 12 sets of injections. It should be noted that all of the bone-building drugs, the abalaparatide, the teriparatide, and the romosozumab, after that one- to two-year treatment duration have to be followed by an anti-breakdown drug. If they’re not followed by an anti-breakdown drug, either an oral bisphosphonate, an IV bisphosphonate, or denosumab, in fact, those patients very sadly can lose whatever bone they’ve gained while on treatment back down to baseline, which is always a very, very sad day when we see those patients in clinic because it’s a wasted opportunity to build good bone. Joe 57:05-57:40 Dr. Moseley, there’s one important area that we have not talked about, and that is fall prevention. You know, we talk a lot about exercise. We talk about other lifestyle changes, but avoiding a fall may be the most important thing of all in preventing a fracture of the hip or even a fracture of arms or legs or goodness knows what else. So how can not just women, but older men avoid a fall that could lead to a fracture? Dr. Kendall Moseley 57:41-59:36 Right. No, I think that’s a tremendous question. In fact, every clinic visit, when I see patients, we go through, have you had any falls this year? The first step is assessing the home. And I think the majority of falls happen in the home and it might be a throw rug. It may be furniture that’s too close together. It may be, you know, plastic toys from the grandchildren underfoot, pets. I’m not saying get rid of the grandchildren or the pets, but we do have to be conscientious about our home environment to make sure there’s grab bars on the shower. Make sure that the impediments to just walking aren’t challenging. Some people choose to move to single-story homes, you know, if stairs become too difficult. I think that’s also something to consider. But then there’s also the strengthening itself, the balance and the posture. So oftentimes we fall when we become unstable. Sometimes we don’t have a choice. There’s neuropathy, excuse me, that sets in due to nerve conditions, diabetes, et cetera. Sometimes there’s low vision that we have very little control over. But those things that we can modify, lower body strengthening, posture, core strength, which certainly over time become weaker, people become more stooped. all of those things lead to increased risk of falls. And then finally, we have to really, as clinicians especially, reevaluate those medication lists. I think geriatricians or, you know, boneheads, people across the board agree that a lot of times falls happen because of the medicines we put people on. And this can be anything from anti-diabetes medications, which can cause dips in blood sugar and cause some dizziness, to different types of nerve medications that may cause dizziness over treatment of blood pressure, where blood pressure is quite low. I see many, many falls in the context of maybe overly aggressive medication regimens, or maybe patients just aren’t talking about how they feel dizzy every single time they stand up after that new blood pressure medicine was added. But we really owe it to our patients to make sure that every drug on that medication list needs to be there, particularly as it pertains to fall safety. Terry 59:37-59:51 Dr. Moseley, we have only two minutes left of time. So I am going to ask you to summarize, please, your pillars of treatment, the things that we all need to take away from our conversation today? Dr. Kendall Moseley 59:52-01:00:03 Oh, so many pillars and so little time. So we started with lifestyle. It absolutely is important that patients really follow as healthy a lifestyle as possible. Calcium is important for bone… Terry 01:00:03-01:00:04 How much? Dr. Kendall Moseley 01:00:03-01:00:09 I know there’s a lot of debate. So calcium, the recommendation… Joe 01:00:07-01:00:09 How much and what kind? Dr. Kendall Moseley 01:00:09-01:01:27 So exactly. So the boneheads and even the cardiologists agree that calcium for those with established bone disease, again, this is not a healthy community dwelling population, but those who make it into a bone clinic who are at risk for fracture, 1200 milligrams a day, ideally through diet, ideally, but there are dietary restrictions. So if you have to take a supplement, calcium citrate is the supplement of choice. It’s better absorbed. You don’t have to take it with a meal. And in fact, it does not require an acidic environment for absorption. Vitamin D, very important. Ideally, we’re shooting for a blood level anywhere between 20 to 30 nanograms per milliliter, depending on what guidelines you look at. And for some patients, that might mean 1,000 units a day. For others, 5,000 units a day. For others, prescription strength. So that’s something to work on with their physician. Exercise so resistance training and walking counts about 150 minutes per week as high intensity is tolerated and then finally protein we really protein is having its moment so we want to aim for 0.5 grams of protein at least per pound of body weight because we know we lose muscle as we get older and that’s critical for bone health so lifestyle factors and then obviously the pharmacologic strategies as we discussed earlier if absolutely necessary. Terry 01:01:28-01:01:33 Dr. Kendall Moseley, thank you so much for talking with us on The People’s Pharmacy today. Dr. Kendall Moseley 01:01:34-01:01:42 Thank you so much for having me. And it’s always a joy to talk to people who are interested in bones. And hopefully people walk away with a few little lessons themselves today. Terry 01:01:43-01:02:08 You’ve been listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is clinical director of the Division of Diabetes Endocrinology and Metabolism. She’s also medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 01:02:09-01:02:18 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:02:18-01:02:25 This show is a co-production of North Carolina Public Radio, WUNC with the People’s Pharmacy. Joe 01:02:26-01:02:55 Today’s show is number 1446. You can find it online at peoplespharmacy.com. The show notes now include a written transcript of this conversation. At peoplespharmacy.com, you can also share your comments about today’s interview and let us know what you do to keep your bones strong. You can also reach us through email. We’re radio at peoplespharmacy.com. Terry 01:02:56-01:03:19 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, you can hear how estrogen might be used to make bones stronger. What about other drugs that build bone? What practical steps could you take to prevent falls and avoid breaks? Joe 01:03:19-01:03:43 At peoplespharmacy.com, you can 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 would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:03:43-01:04:21 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 01:04:22-01:04:31 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 01:04:32-01:04:36 All you have to do is go to peoplespharmacy.com/donate. Joe 01:04:37-01:04:50 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.

Transcribed - Published: 26 September 2025

The statistics are shocking. At any given time, nearly one fourth of American adults are experiencing low back pain. Even worse, roughly one-third of the population will have to deal with chronic pain at some point in their lives. How does the brain react to pain? What can people with chronic pain do to alleviate their suffering? Our guest is a nationally recognized pain expert with a number of suggestions. 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 on Saturday, Sept. 20, 2025, at 7 am EDT on 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 Sept. 22, 2025. Chronic Pain: We are all familiar with the instantaneous pain of having your hand contact a hot pan. In that case, pain serves its most important function, warning us not to do that again! Many people have known the pain of a sprained ankle or a twisted knee. In most cases, we recover from such mishaps in time, and the pain becomes a memory. But sometimes, the brain circuits get stuck, so to speak, and we end up with ongoing chronic pain. That can last and cause suffering well after the original stimulus has disappeared. There is no evidence that suffering is good for the soul. The Experience of Pain Is Personal: It is critical to remember that pain is subjective. The nerves may carry a sensation of “heat” from that hot pan or “pressure” if you slam your thumb in the door. It isn’t pain until the brain interprets it. And brain interpretations can and do vary from one person to the next. Past experience and levels of social support as well as expectations of relief influence the ways that people feel pain in response to injury. Personalizing Treatment of Chronic Pain: If the experience of pain, especially chronic pain, is highly individual, shouldn’t treatments be individualized as well? Every pain patient deserves an individualized assessment, with particular attention to red flags that might be warning of an imminent medical emergency. Ruling that out must not invalidate the patient’s experience. Then the patient and provider can proceed to work on a multi-modal approach to pain control. How Will the New FDA Opioid Guidelines Affect Patient Care? The FDA recently issued new guidelines on the use of opioid (narcotic) pain relievers.  The agency will require much clearer warnings about the risks of such medications, especially when used for longer periods of time. Prescribers will be reminded to use the lowest effective dose for the shortest time needed. They will also be reminded that these drugs should never be stopped suddenly, because that could trigger withdrawal symptoms. Should people be avoiding opioids? Dr. Mackey thinks the new guidelines are in line with precautions that responsible prescribers are already observing. What Non-Drug Approaches Can Help Chronic Pain? We asked Dr. Mackey when non-pharmacologic approaches are appropriate, and he responded that they are always appropriate, sometimes in conjunction with rather than instead of medication. There are at least six categories of tools for pain, including medical interventions (surgery, for example), mind-body approaches such as mindfulness-based stress reduction (MBSR), physical therapy, nutraceuticals, complementary and alternative therapies (such as acupuncture) and medications. Each of these categories might have only a small effect by itself but taken together they can provide substantial relief. What About Drugs? There are probably a couple of hundred drugs that could be helpful, only a handful of which are opioids. So even for people who don’t tolerate opioids, there are plenty of tools to help alleviate pain. Dr. Mackey does prescribe opioids, but he also prescribes medicines such as topiramate, duloxetine, ketamine and low-dose naltrexone, among other medications. Keeping in mind that everyone is different, these will be used in a variety of methods and combinations, depending on patient response. How Can Patients Find a Pain Doctor? In some parts of the country, especially rural areas, it may be difficult to find a healthcare provider skilled at treating chronic pain. Dr. Mackey suggests utilizing the resources of the American Academy of Pain Medicine. Another resource, possibly more for providers than patients is Doximity. This Week’s Guest: Sean Mackey, MD, PhD, is a pain management specialist and anesthesiologist. He holds the titles of Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine (Adult Pain) and, by courtesy, of Neurology and Neurological Sciences, all at the Stanford University Medical School. Dr. Mackey is Chief of Stanford’s Division of Pain Medicine and a past President of the American Academy of Pain Medicine. His website is https://seanmackey.people.stanford.edu/research Sean Mackey, MD, PhD, Stanford University Division of Pain Medicine Listen to the Podcast: The podcast of this program will be available Monday, Sept. 22, 2025, after broadcast on Sept. 20. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, you’ll learn what is happening in the brain when we feel pain. We also discuss the anger and depression that so often accompanies chronic pain (and may unwittingly exacerbate it). You’ll also hear about two drugs often used to treat pain. The gabapentinoids gabapentin and pregabalin can be helpful in some situations. What side effects should patients be warned about? Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Watch the Video: Here is a clip from our interview with Dr. Mackey.   Transcript for Show 1445: 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. 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. The CDC estimates that almost one in four American adults suffers chronic pain. Are there successful treatment strategies? This is The People’s Pharmacy with Terry and Joe Graedon.   Terry 00:34-00:43 The experience of pain is deeply personal. Shouldn’t treatment strategies be personalized as well? What works for one person might not help someone else.   Joe 00:44-00:53 We’re honored to be speaking with one of the country’s leading pain experts. Dr. Sean Mackey is Chief of Stanford’s Division of Pain Medicine.   Terry 00:54-00:59 Dr. Mackey will offer insights into the multimodal approaches his patients have found helpful.   Joe 00:59-01:07 Coming up on The People’s Pharmacy, your brain on pain. Why chronic pain changes everything.   Terry 01:14-02:01 In The People’s Pharmacy health headlines, daylight savings time will come to an end on November 2nd, But scientists don’t agree on the health implications of turning the clocks back an hour. A Stanford University study published in the Proceedings of the National Academy of Sciences suggests that going back and forth between standard time and daylight savings time disrupts circadian rhythms. The researchers found evidence that this increases the risk for obesity and stroke. They calculated that sticking with standard time year-round would prevent 300,000 strokes each year and cut down on obesity. People who usually stay up late suffer greater biological consequences from shifts in time regimens.   Joe 02:02-02:59 Previous research blamed changing clocks for higher rates of car crashes and heart attacks. That may have inspired the Stanford scientists. However, researchers at Duke University have just published their analysis of data from 168,870 patients over the course of a decade. The study in JAMA Network Open found no differences in heart attack rates in the weeks before and after changes to daylight savings time. In addition, they found no increase in stroke or mortality. These dueling findings could leave policymakers in a quandary. Should we stop switching times twice a year because of the possible risks involved? Or is it actually relatively safe to switch into and out of daylight savings time? Clearly, the answer is the common and extremely unsatisfying conclusion. More research is needed.   Terry 03:00-04:10 Another topic that has been controversial for decades is hormone replacement therapy to relieve menopausal symptoms. HRT is unquestionably effective, but the Women’s Health Initiative raised serious doubts about its safety over 20 years ago. Instead of reducing the risk of coronary heart disease, as expected, HRT actually appeared to increase heart risks. A new analysis of these data, published in JAMA Internal Medicine, found that women in their 50s did well on hormone replacement therapy, But women in their 70s appeared to have an increased risk of atherosclerotic coronary vascular disease if they were taking estrogen, alone or with progestin. The authors conclude, the findings support guideline recommendations for treatment of vasomotor symptoms with hormone therapy in women aged 50 to 59 years. caution if initiating hormone therapy in women aged 60 to 69 years, and avoidance of hormone therapy in women 70 years and over.   Joe 04:11-05:05 The FDA has announced that it will be cracking down on direct-to-consumer prescription drug advertising. The Commissioner of the Food and Drug Administration, Dr. Marty McCary, offered a viewpoint in JAMA outlining the new approach. The agency will be rolling back a 1997 loophole that allowed pharmaceutical manufacturers to shorten the length of cautions and side effects in ads or commercials. The FDA will now require much more complete disclosures of risks. That could make advertising prohibitively expensive and less appealing. Commissioner McCary concluded, quote, we will no longer tolerate deceptive practices that distort the patient-doctor relationship and waste billions of dollars in health care resources that could be better spent lowering drug prices for Americans.   Terry 05:06-06:17 Israeli scientists have been studying a green Mediterranean diet for years. This eating pattern follows the Mediterranean approach of lots of vegetables, fruits, and whole grains, and very little meat, sugar, or processed foods. In addition, a green Mediterranean diet includes green tea and a green smoothie containing the water plant mankai every day. The study examined the status of approximately 90 proteins found in the blood. Two, in particular, were lower in people whose brains were functioning well. They’re called galactin-9 and decorin. Following a green Mediterranean diet seems to lower the levels of these proteins and might help slow cognitive aging. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon.   Joe 06:17-06:28 And I’m Joe Graedon. Have you ever burned yourself on a hot frying pan or hurt your back lifting something too heavy? Describing your pain level to someone else can be difficult.   Terry 06:28-06:36 Acute pain like that is something almost everyone has to deal with. Chronic pain, on the other hand, can be far more challenging.   Joe 06:36-06:55 To help us better understand the nature of pain and how to treat it, we turn to Dr. Sean Mackey, a pain management specialist. He holds the title of Redlich Professor at Stanford University Medical School, where he’s also Professor of Anesthesiology, Perioperative, and Pain Medicine, and by courtesy, of Neurology and Neurological Sciences.   Terry 06:56-07:02 Welcome back to The People’s Pharmacy, Dr. Sean Mackey.   Dr. Sean Mackey 07:03-07:22 Hey, it’s great to be back. I heard a lot of wonderful comments about the last show, and it always makes me feel good when the information that you folks are putting out there related to pain is making an impact in everyone’s lives. So thanks for all you’re doing and appreciate the opportunity to come back.   Joe 07:22-07:52 And thank you for your work, Dr. Mackey. We are so grateful to be able to speak with you again about pain. And, you know, pain, it’s such a personal thing. And it’s so hard to measure. So many times, you know, if a doctor is asking you, well, what’s your pain level on a scale of one to 10? And of course, that’s somewhat qualitative. And it’s hard for one person’s pain to compare to another person’s pain. It’s totally qualitative.   Terry 07:53-07:59 And it also depends on what your experience of pain may have been in the past.   Joe 07:59-08:49 Yeah, I do have a quick story to tell you about a dear friend of mine who recently had to undergo a medical procedure. And it was supposed to be, you know, kind of a minor procedure, no surgery involved, a little lidocaine, no big deal. He said it was the most excruciating pain of his life. This is a big guy. He’s like 6’4″, probably weighs about 230 pounds, lifts weights, does all kinds of stuff. And it was like, I couldn’t bear it. I was screaming inside. And some of those screams came out. So tell us about this thing about personal pain and how variable it is from one person to another.   Dr. Sean Mackey 08:49-11:24 Yeah, I think you hit it. You hit it perfectly. And therein lies the challenge we have with understanding, getting our heads wrapped around this concept of pain, because we all believe we know what it is because we base it on our own personal experiences. But the problem is that our personal experiences don’t translate to anybody else. And it’s getting back to what you said, this nature that pain is an individual and subjective experience. And that’s counter to everything that our beliefs are, our eyes see, and what we understand, meaning we all expect that there to be this direct one-to-one link between the amount of tissue damage and the amount of pain that somebody experiences. And that model, that mechanistic model was put forward by Rene Descartes back in the 17th century. And while he is a really smart guy. He gave us Cartesian geometry. He gave us some modern philosophical beliefs. He was completely wrong when it came to pain.   You have to think about pain in the context of how you would think about love. Like, how much do you love your child on a scale of zero to 10? How much do you love your dog? And then, you know, but it’s such a silly thing. Nobody, how many times have you ever been ask, hey, how much love do you feel? Nobody would ever ask that. But that is the same concept that we have to do when we’re talking about pain.   And the message that I would give people is pain is individual. And it is encapsulating all our prior life experiences, all of our thoughts, our moods, our emotions, everything we’re bringing into that experience right now. And whatever that person is experiencing, just accept it. We put a pain scale to it, which is probably more to get a sense of how much impact the pain is having, how much distress they’re having, than it meaning something really objective. And that is one of the key messages also, that this individual variability, we have to take care and not putting it onto others, particularly when making policy decisions and making broad statements about what somebody should be taking or not taking, what treatment they should be getting or not taking. Use it as a guide, no more or less.   Terry 11:26-11:47 Dr. Mackey, maybe we could ask a very simple question that may have a really complex answer, And that is, how do we feel pain? How do the sensors in our skin or elsewhere in our bodies send signals to our brain that become our pain experience?   Dr. Sean Mackey 11:48-14:05 Yeah. And that’s such an important foundational question because you’ve got to start there before you can really understand the nature of pain. So pain all starts typically with something happening out in your periphery, your periphery meaning in your body, your fingers, your hands, your legs, your arms, your abdomen, what have you. And in that, we have these little tiny sensors called nociceptors, technical term, but they’re just simply acting like a transducer.   Now, a transducer is defined as something that converts one form of energy into another form of energy. It just, this microphone is a transducer. It converts sound energy into electrical energy. Those nociceptors are converting pressure, temperature in the form of heat or cold into a little electrical signal that transmits up nerves. And we have special nerve fibers that transmit what will be the perception of pain. But it’s not pain yet, still in the body. It’s what we refer to as nociception.   Those signals go to our spinal cord. Back here, this long set of nerve fibers and nerve cells that are in our spine. And there’s some processing. There’s some little computers back there that are processing the signals, altering them, changing them, and then they’re sent up to the brain. And this is the key point. Until it hits your brain and it becomes the perception of pain, before then it’s all still nociception. But once it hits the brain, that’s where this experience, this wonderful and terrible experience of pain occurs. Wonderful. Because this experience of pain keeps us out of danger. We only had to touch a hot stove once to learn not to do it again. It keeps us away from injury, from harm. And back in the cave people days, it kept us away from being eaten and being prey.   Joe 14:06-14:21 Well, you know, Dr. Mackey, there are people who don’t have pain. And they are in terrible trouble because they do burn their fingers and hurt themselves because they don’t know how to avoid that hot stove.   Dr. Sean Mackey 14:22-15:25 You’re right. The problem that we’ve had is that those people are typically the protagonists in a TV show or a movie. And they’re made to look like supermen or women, where they can jump off buildings and land without getting hurt. Well, they don’t feel pain when they jump off the building or when they get stabbed, but they are getting injured. They leave that part out of the movie or the TV show.   It is a tragic, tragic situation to be born with this thing called congenital insensitivity to pain. These unfortunate children have to be continually protected from themselves because they can’t tell when they’re injured. And they typically die at an early age unless the parents go to extreme efforts to keep them safe. So you don’t under any circumstances, despite the movies and the TV shows, ever want to have that condition.   Terry 15:26-15:27 I’m assuming it’s very rare.   Dr. Sean Mackey 15:28-15:35 Very, very rare. I can’t even quote you how many zeros are before the final digit and the percentile. Very rare.   Joe 15:37-16:09 So pain is protective, but it also causes incredible agony and affects tens of millions of people. What worries me is that there are people who believe that suffering is good for the soul. If it didn’t kill me, it’ll make me stronger. And for those people, I think that is a real misnomer. It’s like, oh, no, pain is not good for the soul. Yeah, I’ve heard that one.   Dr. Sean Mackey 16:10-17:32 First of all, if you’ll allow me to gently add a zero to your numbers, it actually affects probably hundreds of millions. And I’ll even take it bigger if you want to go global and say billions. You know, you’re probably looking at a prevalence rate of around 30% or so. So, you know, close to one in three people on this planet probably have some level of chronic pain.   Now, people will listen to that and some will be skeptical and they’ll say one in three. I don’t see one in three suffering from chronic pain. And what you have to do is add some context to that. Meaning you have people with chronic pain that are self-managing at home. These are people like my father who, you know, had from all the sports injuries and everything else, a lot of back pain, a lot of arthritis, and wouldn’t see a doctor about it, wouldn’t even listen to me. And he just kind of sucked it up and dealt with it until it got too much.   And then you have people that end up in our clinic at Stanford, a tertiary referral center who have terrible high-impact chronic pain, who are seeking medical care, and everybody in between.   But pain is with us in society. It takes a terrible toll. In the United States alone, over half a trillion dollars we spend in chronic pain.   Joe 17:33-17:47 Dr. Mackey, we’re going to take a short break, but when we come back, we need to talk about what people can do for that chronic pain. One in three, that’s an astronomical number.   Terry 17:47-18:13 You’re listening to Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey is a past president of the American Academy of Pain Medicine.   After the break, we’ll reconsider the idea that suffering is good for you. The FDA is changing its recommendations on opioids again.   Joe 18:13-18:25 Should patients avoid opioids? How have the new guidelines affected doctors and patients? You’ll hear about alternatives to opioids. When are non-drug approaches to chronic pain most appropriate?   Terry 18:39-18:42 You’re listening to the People’s Pharmacy with Joe and Terry Graedon   Terry 20:42-20:35 Welcome back to The People’s Pharmacy. I’m Terry Graedon.   Joe 20:45-21:08 And I’m Joe Graedon. Chronic pain, it’s debilitating. It can take over your life and make it hard to focus on anything else. There was a time when opioids were among the most prescribed drugs in the country. But now, most health care professionals are very cautious about prescribing medications such as hydrocodone, oxycodone, or fentanyl.   Terry 21:09-21:22 What other options are there for people in pain? Are there non-drug approaches that can be helpful in alleviating pain? Our guest today has a six-point strategy for pain relief that involves a number of different disciplines.   Joe 21:23-21:53 We’re talking with Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. He’s chief of Stanford’s Division of Pain Medicine. His research aims to translate scientific discoveries into real-world pain relief. Dr. Mackey is a past president of the American Academy of Pain Medicine.   Terry 21:55-22:17 Dr. Mackey, we have just floated the idea that seems to be popular in some quarters, probably not among the one in three people who are suffering chronic pain, that suffering itself is good for the soul in some way. Why is that such a questionable premise?   Dr. Sean Mackey 22:20-23:48 You know, I think where it’s come from, or at least the camps that I’ve seen it from in particular, are those who want to deny or restrict certain treatments from patients. And the problem is that once you cut those off, those people aren’t left with anything, anything else.   And so then the narrative turns to, well, it’s good for the soul. Back in the day when things were better, people would just suffer and it made them stronger. Well, it makes for a nice story, but the reality is it’s far from true. What you end up with is just increases in disability, further drags on the individual, society as a whole. There is zero evidence that suffering is good for the soul.   Now, is it true that some level of stress can help make people stronger? Yeah, but the data on stress is rather clear. You know, it’s when stress is controllable. It’s when it’s time limited. When you’re talking about chronic pain, this persistent type of stress, every study to date has shown that it is bad for the individual, bad for their family, and bad for our society.   So this is one of those comments, those premises that I think is rather easy to dismiss.   Joe 23:50-25:19 Dr. Mackey, the Food and Drug Administration has just recently changed its opioid regulations again, and it’s going to be making it harder for people to get opioid pain medicine. And I think a lot of Americans think, oh, that’s a good idea. We have problems with addiction in this country.   We went back and we looked at 2010, and the number one most prescribed drug in 2010 in the United States was hydrocodone with acetaminophen. 122 million prescriptions were dispensed that year, and oxycodone was another 29 million. By the year 2017, it was down to $40 million for hydrocodone.   And in 2022, it was half that, roughly $23 million. So from 122 million prescriptions dispensed down to $23 million because I think people are so afraid of opioids. Even people who go in for surgery, you know, like knee replacement surgery, they come back and they say, well, I didn’t take any opioids. I was tough. It hurt, but I was tough. I managed to survive without opioids.   Is that a good idea? And has this whole FDA and CDC initiative to dramatically cut back on opioids affected both physicians and patients?   Dr. Sean Mackey 25:21-31:20 Wow, there’s a lot to unpack there. These are great questions. So let’s try and take on a few of these. In answering this question, for people who don’t know me, it’s helpful for me to put my position forward. My usual mantra is that I’m not pro-opioid. I’m not anti-opioid. I’m pro-patient.   I come from personal experiences with a family history deep in addiction. I’ve lost close family members to opioid overdose, to alcoholism, and to other substances. And at the same time, I prescribe opioids for people with chronic pain, cancer pain, and acute pain. And I’ve helped people come down on those agents voluntarily.   So you can hold these concepts both in your head, and both can be true. They can be terribly damaging, and they can be incredibly helpful for patients. And that’s why I said, I’m not pro, I’m not anti, I’m pro-patient. They’re a tool. They’re a tool that physicians, clinicians need to learn how to use responsibly.   We were prescribing far too many opioids in the years that you mentioned. There’s no question about it. I think the data is rather clear there was too much being prescribed. And there were a lot of people that were getting prescription opioid addiction and opioid use disorder back then. Most of that wave, a large part, not entirely, a large part of that wave has moved into illicit opioids now, as I know you’re well aware. the question i think for all of us is has the pendulum swung too far from this very permissive state which was going on back in the late 90s the 2000s into this rather extreme now anti-opioid state that in in many cases exists now personally I think it has and I think we need to come back to the center.   This occurred in the state of California. I was a senior editor for the California Medical Guide for prescribing controlled substances that we just released this last year. And in that, we recognized that things had moved too far into the other extreme and that we needed to put forward guidance on how to use opioids as an effective tool for the right patient in the right context.   Opioids should never be a first-line drug for chronic non-cancer pain. I think everybody would generally agree with that, and it’s probably not a second line. It’s probably not a third line. It is to be used when there has been failure to all of the more conservative therapies that are available to that patient. And what I mean by available to that patient is the narrative sometimes from groups that want to severely restrict all opioids is, well, you know, they can go get cognitive behavioral therapy or they can go get acupuncture or they can go get this.   And the problem is people have to realize that a lot of those resources aren’t available to people with chronic pain. Most of the multidisciplinary, interdisciplinary, comprehensive resources are all consolidated in large centers in the big cities, but we have huge swaths of America that are rural, where people have very little access to healthcare. And we have to recognize those people and what they have available. And in some circumstances, opioids are indicated.   Now, getting to your point, I saw the FDA, you know, new guidance. Candidly, I didn’t see anything in there that caused me real concern. I thought what they did was they’ve updated the language and they’ve included in some contemporary data that has come about from two post-marketing studies where they followed people over time who were taking opioids. One in which they followed prospectively, that means forward in time, and one in which they looked retrospectively back in time. And they were able to put real numbers to the incidence of people misusing or abusing opioids over time and people having an overdose risk. In the past, they gave warnings that there are risks of misuse and abuse and overdose, but they didn’t have real hard numbers, and now they’re able to put those forward.   We’ve also been able to see language where they’re recognizing more and more that there is a dose-related increase in adverse events. Well, that’s kind of common sense. The higher the dose, the higher the risk you are. I don’t think many people would disagree with that notion either. So there are some languaging changes. I haven’t seen anything, and I’d love to hear your perspectives, by the way, if you think otherwise. But most of this is to clarify what we’ve already known and add in that additional language. What are your thoughts about it? You mentioned that it’s going to be more restrictive.   Joe 31:21-32:30 Yeah. Just briefly, Dr. Mackey, and then Terry has a question about other alternatives. But what worries me is that they have really come down hard against long-acting opioids. And for people who are in excruciating pain, who cannot function, who otherwise are bed-bound and unable to work, taking away or making it restrictive for people to have access to the longer-acting opioids that would otherwise allow them to work, allow them to engage in activities that allow them to, you know, be, you know, I won’t say normal, but allow them to function in society.   That’s what I think concerns me because we’ve heard from so many people who have been able to take longer acting opioids and just function pretty, pretty well in society. Your thoughts? Well, you’re right. So I get your concerns and they’re real.   Dr. Sean Mackey 32:33-33:33 Here’s the thing to be clear. The FDA guidance simply says that you should start and focus on intermediate, excuse me, immediate release opioids first. And they make a clarification that you shouldn’t be jumping right to extended release opioids and that start with the short acting and then if needed, move into the extended release.   Now there’s all this language. I read that language, I’m not that concerned about it. However, the problem is how that language is spun and how it’s interpreted by others. And we saw that with the original CDC guidelines on opioids in 2016. Because it’s really easy to take that language and weaponize it or misinterpret it and come out with the messages that you just suggested, which is to restrict, restrict,   Joe 33:33-33:45 restrict. That would be sad. Well, it’s time now to, Dr. Mackey, it’s time now to, I think, shift over to alternatives, because as important as opioids are for some people, many people, in fact, Terry, there are alternatives.   Terry 33:46-34:08 There are, but one thing we haven’t yet clarified is how do people end up in chronic pain? I’m assuming that most chronic pain starts as acute pain. What’s the transformation process like?   Dr. Sean Mackey 34:09-34:58 Yeah, we’re still trying to figure that out. We know that, as you said, most chronic pain almost all starts with an acute pain episode, an injury, an infection, some episode that the normal healing processes may have healed up the tissues, but the abnormal signaling that is related to pain still persists. And over time, that persistence transforms what was a symptom of an acute situation into a disease in and of its own right, much like diabetes, which initially starts as impaired glucose tolerance to eating a donut, becomes pre-diabetes and then moves into the frank disease of diabetes. We’re still trying to identify the vulnerabilities and the mechanisms of that so that we can have treatments that will prevent it.   Terry 35:01-35:15 Well, let me follow up then with this question of treatment. Especially non-pharmacologic approaches to pain relief, can you tell us what some of them are and when they might be appropriate?   Dr. Sean Mackey 35:17-36:32 Sure. I would suggest that non-pharmacologic approaches are always appropriate. That doesn’t mean that people should be excluded from pharmacologic approaches. It means that the best way to treat chronic pain is when you approach it from, we call it a multimodal standpoint. It simply means use all the tools at your disposal.   And we have at least six categories of tools for pain. Only one of categories are medications, interventional procedures. These are typically your nerve blocks to minimally invasive surgeries. Mind-body therapies are behavioral interventions. options, physical and rehabilitative options. We have complementary alternative medicine options, which is a little bit of a dated term, but we’ll probably get to it. And then the last one, the sixth one is self-empowerment, which is broad strokes. It’s getting educated and empowering yourself with that education.   Hopefully the people that are listening to your show being an example in that sixth category. So of those six categories, we recommend dipping into all six of them and not relying on just one.   Terry 36:33-36:56 Give us an example, if you would, please, of how somebody who has consulted you for a chronic pain problem, tell us a little bit about their situation and how each of these categories might contribute to them being able to cope with their chronic pain.   Joe 36:56-37:06 And we just have about a minute before the break. So when we come back, we’ll ask you to kind of extend that six categories in a little more detail.   Dr. Sean Mackey 37:07-37:54 Yeah. First, it all starts with an assessment. So it has to be individualized. This gets back to the earlier part of pain being an individual experience. And so, you know, you’ve got to take the person for whom they are and what they bring into it. Some people may benefit from more of a rehabilitative approach as a frontline.   Some may be from a more pain psychology behavioral approach. Some, there may be some simple interventional procedures to knock out that nociception, those electrical signals. And that may be an appropriate approach. It’s all about the initial comprehensive assessment of that person and putting together a tailored treatment plan for them. And I think that’s where things start.   Joe 37:55-38:07 When we come back from this break, we’re going to ask you to give us maybe a story, an example, so that people can understand how you come up with that tailored treatment approach.   Terry 38:08-38:42 You’re listening to Dr. Sean Mackey. He is Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. He’s Chief of Stanford’s Division of Pain Medicine. Dr. Mackey’s research strives to translate scientific discoveries into real-world pain relief. He is a past president of the American Academy of Pain Medicine.   Joe 38:43-38:50 And Terry, you know, this idea of cookie-cutter medicine just doesn’t work when it comes to pain. It has to be tailored or personalized.   Terry 38:50-38:51 Exactly right.   Joe 38:51-38:55 After the break, we’ll hear what can be done for lower back pain.   Terry 38:56-39:01 Dr. Mackey describes how a patient used a multimodal approach and how that worked.   Joe 39:02-39:09 What are the top five medications for chronic pain, not counting non-steroidal anti-inflammatory drugs or opioids?   Terry 39:10-39:15 You may have heard of low-dose naltrexone. Dr. Mackey shares his experience.   Joe 39:15-39:18 Which alternative therapies might be helpful?   Terry 39:30-39:33 You’re listening to The People’s Pharmacy. with Joe and Terry Graedon.   Joe 39:42-39:45 Welcome back to The People’s Pharmacy. I’m Joe Graedon.   Terry 39:45-40:03 And I’m Terry Graedon.   Joe 40:03-40:22 Have you ever experienced back pain? If not, you’re a rarity. It’s estimated that 80% of Americans will experience low back pain at some point in their lives. As we speak, about one-fourth of the population may be experiencing some discomfort in their lower back.   Terry 40:22-40:36 Coming up, we’ll learn what people do for back pain and other chronic pain problems. Our guest will discuss low-dose naltrexone, acupuncture, alpha-lipoic acid, cannabidiol, and self-hypnosis, among other things.   Joe 40:36-41:00 We’re talking with Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. His goal is to develop precision pain care. Dr. Mackey is past president of the American Academy of Pain Medicine.   Terry 41:01-41:38 Dr. Mackey, I know that in your clinic you see people with chronic lower back pain. They’ve probably, if they’re in your clinic, they’ve probably seen a lot of other doctors and maybe some other types of practitioners. Can you tell us about an individual who came to you, used some of these multimodal options that we’ve just been discussing, and what options did they use, and what was the outcome?   Dr. Sean Mackey 41:39-44:34 Delighted. So why don’t we take Bob as a patient? Bob’s a guy in his 40s. He’s working hard. He’s got a couple young kids. and Bob has chronic low back pain. And so Bob comes into the clinic and he, Bob represents America. Like Bob represents, he’s everybody’s person with low back pain.   Everybody’s situation is going to be a little bit different, but you’ll get the, you get the point. Bob injured his back. It kind of laid him up for a while, but the pain persisted and he comes in to see. And part of Bob’s problem is that nobody believes he’s got back pain. So one of the first things that we do is we make sure that we believe that Bob has real pain because Bob’s been typically invalidated everywhere he’s gone. So first rules are to assess Bob for any, what we refer to as red flags. And these are causes of his pain that represent a potentially severe issue, infection, tumor, nerve impingement, things that need an immediate medical response.   But let’s assume that we eliminate all those. And by the way, those only represent a small percentage of people with back pain, but you got to do the first principles. So what you’re left with is Bob has his chronic mechanical low back pain, and we’re not going to break it down into the different components that could be contributing to that because we don’t have the time for this show.   But let’s just say that Bob is also expressing a lot of fear of movement because every time he moves, he gets increases in pain. And the problem is that that develops into this fear avoidance approach where over a period of time, Bob doesn’t want to move around. So he walks around like he’s got a stick up his butt. He’s real rigid because he’s heard that his discs are exuding these chemicals that are causing irritation on his nerves.   So we want to look at Bob from a holistic standpoint. And typically that involved having to see a pain physician, a physical therapist that specialized in taking care of people with pain, and a pain psychologist. And then we typically would all come together for a team conference. Let’s assume we’ve done all that. And what we’re doing is an interdisciplinary type of treatment plan for Bob that would include maybe some options around medications. And we have over 200 medications that have shown analgesic benefit now for pain, only 20 or so of which are opioids.   Joe 44:35-44:59 And could you give me your top five, if we were to look at your prescription pad for someone like Bob, what would be your top five non-opioid pain relievers? and let’s get rid of the NSAIDs if you don’t mind because of the stomach damage and some of the other problems that go with NSAIDs. But they might be on that list, Joe. They might be on your list, but give us your top five.   Dr. Sean Mackey 45:00-45:46 Yeah, NSAIDs wouldn’t be on my list, but there’s a selection bias because by the time people have come to see me, everybody’s already tried NSAIDs, right? Of course. Yeah, that’s the easy stuff. So you wouldn’t see NSAIDs high on my list because everybody’s gone through them with some exceptions. You’d probably see duloxetine high on that list just because it’s an FDA-approved medication for musculoskeletal pain. You’d probably see a desipramine on that list, which is a tricyclic antidepressant but effective for pain. You’d probably see one of the gabapentinoids on the list. Gabapentin or pregabalin is on the list. In my hands, You frequently would see me prescribing low-dose naltrexone that maybe we’ll get to.   Joe 45:47-46:05 Whoa, whoa, whoa. You stop right there. Low-dose naltrexone is one of the more controversial treatments. Please, as quickly as you can, explain why it’s such an interesting drug and how some people are benefiting from this amazingly small dose.   Dr. Sean Mackey 46:06-47:27 Yeah, yeah. Naltrexone’s got its perhaps controversy because at the regular dose, it’s used to treat addiction. opioid and alcohol addiction. At lower doses, it works in a completely different mechanism. It blocks some of the neuroimmune systems that are playing a role in pain.   And so it doses like four and a half milligrams or so. We’ve seen in some people rather miraculous benefits for their pain, particularly in conditions like fibromyalgia, complex regional pain syndrome, and some other pain conditions. Why I prescribe it so much is because it is probably the safest medication that I can prescribe. There’s almost no side effects to it. It’s also dirt cheap. It’s been generic for decades. Insurance typically doesn’t cover it, but its cost from a pharmacy is usually very reasonable.   I have no financial relationship with any medication or devices, by the way. But I love its safety profile, and I love the wins in patients when they get them. And not only do they win on pain, but it frequently will improve their sleep, their fatigue, and their mood. So you get this triple or quadruple whammy. What are your thoughts about it? What are you hearing? You said controversial.   Terry 47:27-47:40 Well, I’m assuming that if you are able to improve patients’ sleep and their mood, that also all by itself would improve their pain, wouldn’t it?   Dr. Sean Mackey 47:40-48:29 It does. But, you know, we did some of the initial studies on this. I have to credit Jared Younger, who was with our group at the time with, you know, the initial studies. And we looked at daily assessments of people over time taking this medication. And what we found is the first thing that was improving was typically people’s sleep, followed by their mood, then followed by their pain.   Now, we didn’t publish that data, and it needs to be replicated. And we also know there’s this bidirectional relationship between sleep and pain. Bad sleep worsens next day pain. Increased pain worsens next day sleep. So we have to disentangle all of that. But what I can tell you is all of these seem to get better in some people.   Joe 48:29-48:36 So the controversy, Dr. Mackey, is that we hear from some people who describe what you’re talking about.   Dr. Sean Mackey 48:36-48:36 Yeah.   Joe 48:36-49:02 Wow. Tiny dose, great relief. And other people say, eh, didn’t do much, didn’t do anything, big waste of time. Yeah. And I think what it reminds me is that what for one person is excruciating pain, for another maybe, you know, no big deal. And so we’re all different. I guess that’s the take-home message.   Dr. Sean Mackey 49:02-50:16 Isn’t that wonderful? Yeah. We have to embrace that differences and stop thinking that we’re all, you know, wired the same way. This differences is what leads to the biggest challenge that we have in pain medicine and medicine writ large, and that is on average, the effect sizes, the impact of any treatment we have on pain is rather small. It’s typically on the range on average of about one point out of 10 on a 10 point scale. That’s pretty poor. But within that average, you typically have people that got hit the ball out of the park, amazing wins. And you probably also have people that got worse on that medication.   So this is where in our world, this is what my research is all about. And others is working to develop this field of precision pain medicine, which is to understand those individual differences, take the information and then tailor treatments so that we can be better at choosing the right treatment for the right person in the right context.   Joe 50:16-50:29 Now, you were about, I’d say, three to four medications into your top five or six. What else do you prescribe besides the low-dose naltrexone that for some might be a home run and for others might be barely a bunt?   Dr. Sean Mackey 50:29-51:00 Yeah. So, you know, I will sometimes reach into the sodium channel blocking medications, sometimes like the topiramate. to the, sometimes mexiletine. It depends on the clinical condition that I’m treating, but we try to use medications from different categories that impact pain processing pathways.   Joe 51:01-51:02 You haven’t mentioned ketamine.   Dr. Sean Mackey 51:03-51:19 I occasionally send people over for a ketamine infusion that we do. These days, we do those in a hospital environment. We’re doing those in the clinic. But ketamine can be effective for some people.   Joe 51:20-51:27 And it’s now being tested orally. Terry, you wanted to talk about some of the other non-pharmacological approaches.   Terry 51:28-51:58 Dr. Mackey, you mentioned complementary and alternative therapies. And I did want to ask about acupuncture or cognitive behavioral therapy. Are there any complementary and alternative? As you say, it’s a slightly dated or maybe a really dated term. But we have a general idea what we’re talking about. Are there any of those therapies that are right at the top of your list?   Dr. Sean Mackey 52:00-52:50 Yeah. And candidly, I frequently don’t even think in terms of complementary alternative medicine, but I need a category there that fits outside of the, I don’t want to say the mainstream allopathic or otherwise medical area. And cognitive behavioral therapy would tend to fit more in pain psychology. Acupuncture is more in that CAM focus. I use a lot of acupuncture, and we do acupuncture in our clinic. Mindfulness-based stress reduction, MBSR, has historically been in that camp, although it’s now so mainstream that I’m not even sure it belongs there.   And some have used more of the term integrative medicine as a way to characterize these. But then one other big category that maybe what you’re getting at is nutraceuticals or over-the-counter agents.   Terry 52:50-52:50 Yes.   Dr. Sean Mackey 52:51-53:20 And these are agents that are not part of the FDA regulatory pathway, as you well know. some of these agents have shown in randomized controlled trials to have nice impacts on pain. Such as? Such as acetyl-L-carnitine, alpha-lipoic acid. And some of these agents are actually prescribed medications in Europe. But here- What about CBD?   Joe 53:20-53:29 What about this controversial non, shall we say, psychoactive part of marijuana?   Dr. Sean Mackey 53:30-54:08 Yeah, I think the verdict is still out on that. We need, we’re right at the still early stages of clinical trials in that. These days, they’re still on the small scale. We’re still trying to figure out dosing, delivery, frequency. There are some mechanistic reasons why there may be some value to CBD. I think the story remains to be written on it. Now, with that said, you’re going to find people in the audience that will swear by it. And similarly, there’ll be people in the audience who’ll say, no, tried it. It doesn’t work for me. It’s just like everything.   Joe 54:09-54:35 Right back to the low dose naltrexone. We are almost out of time, Dr. Mackey. And I would like to ask you two quick questions, one about auto hypnosis and how that can be beneficial for some. And then I’d like to get your perspective on how people can find a pain management specialist or program in the two minutes we have left.   Dr. Sean Mackey 54:35-56:03 Yeah. Yeah. Auto hypnosis can be effective in the moment for helping you with pain. I, I love going to treatments that don’t have any significant side effects, first of all, and that fits into one of those categories. And there are a number of these, whether it be auto hypnosis or binaural audio in some people that can be very effective. So give it a try.   It’s going to be like everything else. For some people, it’s going to work great and others, it’s not going to work at all. The last question is one of the challenging ones is how to find somebody. And, you know, ask your friends, you ask your family doc, and otherwise you can get a list of names through the American Academy of Pain Medicine has a website with a list of docs. I think Doximity these days is listing pain docs.   It’s actually a real challenge that we have is how to find high quality pain physicians who can help with your problem. Clearly a nut to be cracked. I think the key message is don’t suffer in silence. Seek out and get good quality help. And if you’re not getting it where you’re being treated, then look elsewhere because there is help that’s out there. And it is an exciting time in this field. We’re seeing more and more treatments and better and better approaches applied to chronic pain.   Terry 56:04-56:21 Dr. Mackey, you’ve laid out for us very clearly that pain isn’t actually pain until the brain processes it and says, ah, you’re in pain. So what is happening exactly in the brain when pain gets bad?   Dr. Sean Mackey 56:22-58:01 Yeah. What we find when there’s this persistent, continuous experience of pain, that circuits in the brain that are there to be released during stress, for instance, or during fear of pain become solidified.   They can become “sticky” and you can get into this “sticky” brain state. And we know that there are specific circuits involved from amygdala to the prefrontal cortex, from areas like the nucleus accumbens, which is involved with reward circuitries and mesolimbic areas into some of these frontal or thought-related processing circuits in the front of the brain, that they can also become solidified. And with these circuit stickiness, if you will, you get a perpetual state of pain. And a large part of what we’re trying to do is break up or reverse these sticky brain states and help return them to a sense of normalcy.   Most of our medications actually work on these brain circuits. All of the mind-body therapies that we have work on these brain circuits. And the beauty of working on these brain circuits is that you also can learn how to take some control of this and help reverse some of those states as well. That doesn’t remove the notion of going out and doing something out in the periphery or in your body. But if you’re going to treat pain, the key is to treat the whole person and not just a particular part.   Terry 58:01-58:02 Thank you.   Joe 58:02-58:57 Dr. Mackey, when people are in pain for a long time, what we call chronic pain, not just for a few weeks or a few months, but oftentimes for years, it can make them angry. I mean, really angry. And it can also lead to depression. And I cannot tell you how many messages we have received from readers of our newspaper column and visitors to our website who say, you know, if they take away my opioid medicine that I have been using absolutely according to the doctor’s instructions for 15 years. I’ve never increased the dose. I’ve never abused it. But if they take that away from me, I will have to contemplate suicide. I’ll be so depressed.   So help us understand the anger and the depression that goes with chronic pain.   Dr. Sean Mackey 58:58-01:01:33 Yeah. So we know that both of those, anger, depression, and if I may, there’s another one that is becoming increasingly recognized, which is social isolation. And indeed, social isolation, we find, is one of the biggest factors contributing to chronic pain.   All of those can be a consequence of that pain. And it takes a terrible toll on the individual. It just sucks their soul dry. And those are all associated with those circuits in the brain that I mentioned before, that can get really out of whack. Now, the second part of what you’re describing is related to the use of opioids.   In my practice, in my opinion, if somebody has been responsibly using opioids for a long period of time, they have tried all the other approaches and those approaches have failed. And the opioids are providing them with increased function and quality of life, my approach is typically to leave them alone and just support that. And I appreciate how they’re feeling because there’s a lot of fear out there around what we refer to as these legacy patients who have been using these medications appropriately. And I think we as a society and as a healthcare profession have to come to grips with this and figure out how to help these people.   Because the message is not simply take them away and don’t give something else back that’s going to help them. What we have found by running that experiment is tragic consequences. People commit suicide, They decompensate, they get worse, or they turn to illicit opioids. And I have seen that over and over again from stories and docs in the community that think they’re doing well by taking people off these long-acting opioids and those people turn to illicit substances.   So it’s a complex problem. It’s going to need a complex set of solutions, but let’s not lose sight of the fact that these are people’s lives. And as healthcare professionals, We’re here to help them. And yes, to do it in a responsible manner, but working in a clinician-patient partnership.   Joe 01:01:35-01:02:15 Dr. Mackey, there is a category of medications. They’re called gabapentinoids. It includes gabapentin and something called pregabalin. And they have never been approved by the FDA for general pain. They’ve been prescribed for nerve pain, for example, after a shingles attack. But as far as treating a variety of pain problems, they’ve never gotten the green light from the Food and Drug Administration. And yet the number one most prescribed pain medicine in America is gabapentin.   Terry 01:02:16-01:02:21 But pregabalin has been approved for treating fibromyalgia. Fibromyalgia, right.   Joe 01:02:22-01:02:57 And so I guess what we have heard is some people love gabapentin. Some people hate gabapentin. They say it makes me spacey. It makes me unsteady. There are a lot of side effects associated with it. And there are other people who say, don’t cut back on gabapentin. It’s the only thing that allows me to function. So sort of back to the low-dose naltrexone story, and that is some people benefit. Some people get no real relief, and some people feel horrible on this drug. Help us understand gabapentin better.   Dr. Sean Mackey 01:02:58-01:06:45 Yeah. You know, gabapentin is in this class of anti-epileptics or anti-seizure medications. It was originally, it has been used by the neurologist, as I mentioned, for seizure. And it was found to have some pain-relieving properties over 25 or more years ago.   It did get FDA approval for postherpetic neuralgia, as you mentioned, which is a terrible nerve-like pain condition after shingles. But we all started prescribing it off-label, and we found that it was having benefit for a variety of different pain conditions. And most importantly, it had a relatively low side effect profile.   Rule number one in being a physician is do no harm. We tend to be conservative. We don’t want patients to get harmed. So this was an easy drug to prescribe, and we still prescribe it all the time. Now, its use is broadened out well beyond the FDA guidance, and that’s pretty typical of medications.   Low-dose naltrexone does not have FDA approval for anything, but we prescribe it off-label. And as you alluded to, individual variability in it. For some people, again, it’s a major win. For others, they can’t tolerate some of the side effects.   I’m very careful about prescribing it to what I refer to as knowledge workers. These are people that are using their brain for a living. I live in Silicon Valley, so a lot of the people I care for, they may be software programmers or engineers. And at the higher doses, gabapentin can lead to word finding problems and some cognitive slowing. It reverses if you reduce the dose or come off it. But for those people, they can’t afford to have their work impacted.   So it’s a medication worth trying, starting low, going slow, and seeing if people get benefit. If they do, great. If they don’t, just come off it. When you come off it, and this is on the new labeling that’s out there, come down slowly. You don’t want to just abruptly stop this medication because it can be associated abruptly stopping with seizures and agitation and increased excitability. And you don’t want any of that. So one of the common medications we use, you’re seeing more and more media out there that are playing up the potential adverse effects related to this medication. And this is now because it has gotten out in so many millions of people that researchers like me can go into administrative databases now and we can study millions of people.   And from that, we can pull out tiny little signals that show increased incidences of bad things with this particular drug. And that’s useful because that gives us a signal that we should look for in better controlled studies. So there are recent studies that show potentially an increased incidence of dementia on gabapentin or an increased incidence of fractures on gabapentin. Well, these are what we refer to as observational studies. They should be treated as hypothesis generating, simply meaning there’s something interesting there and maybe we should look further into it. but by no means should we use this new information to set policies. So, I don’t know, did I get at your question?   Joe 01:06:46-01:07:28 You did. I think we’re back to the individual variability situation. Some people get great benefit, some people not so much, and other people have too many adverse reactions to be able to tolerate it. And so we’re basically recognizing that everybody’s different and everybody responds to some medications in a positive way and others in a negative way and many people in the middle. And that’s why it’s, I think, critical for people to have personalized medicine with a physician who is really knowledgeable about how to treat chronic pain.   Terry 01:07:29-01:07:34 Dr. Sean Mackey, thank you very much for talking with us on The People’s Pharmacy today.   Dr. Sean Mackey 01:07:34-01:07:35 Thank you for having me.   Terry 01:07:37-01:08:08 You’ve been listening to Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. He’s Chief of Stanford’s Division of Pain Medicine. His research strives to translate scientific discoveries into real-world pain relief. Dr. Mackey is a past president of the American Academy of Pain Medicine.   Joe 01:08:09-01:08:17 Lynn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Liederman composed our theme music.   Joe 01:08:36-01:08:43 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy.   Terry 01:08:43-01:09:12 Today’s show is number 1,445. You can find it online at peoplespharmacy.com. The show notes now include a written transcript of this conversation. At peoplespharmacy.com, you can also share your comments about today’s interview. Let us know about your experience with pain and its treatment. You can also reach us through email, radio at peoplespharmacy.com.   Joe 01:09:13-01:09:46 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In this podcast, learn what’s happening in the brain when we feel pain. We’ll also look at the anger and depression that can accompany chronic pain and talk about the pros and cons of gabapentinoids. That’s gabapentin and pregabalin to help people feel more comfortable. Look for video with Dr. Mackey on the People’s Pharmacy YouTube channel.   Terry 01:09:46-01:10:07 At peoplespharmacy.com, you could sign up for our free online newsletter and 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 would write a review of The People’s Pharmacy and post it to the podcast platform you prefer.   Joe 01:10:08-01:10:10 In Durham, North Carolina, I’m Joe Graedon.   Terry 01:10:10-01:10:42 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 01:10:43-01:10:52 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 01:10:53-01:10:57 All you have to do is go to peoplespharmacy.com/donate.   Joe 01:10:58-01:11:11 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.

Transcribed - Published: 18 September 2025

For the last several decades, nutrition scientists have been debating the pros and cons of various dietary approaches. The Mediterranean diet has a lot of proponents, and we have interviewed some of them on The People’s Pharmacy. Dr. Barry Popkin and Dr. Walter Willett endorse olive oil, whole grains, fruits and vegetables with only small amounts of animal-sourced food. Listen to Show 1359: Is the Food on Your Plate Real or Fake? for more information. Dr. Will Bulsiewicz is a fiber evangelist. You can hear him on Show 1312: fiber, Phytonutrients and Healthy Soil. Plant-based diets can fall along a spectrum from mostly plants with some meat, fish and eggs to completely vegan. In contrast, there are experts who recommend a low-carb, high-fat ketogenic diet. Carnivore diets consisting of only animal products (meat, poultry, fish) are a subcategory of keto diets. That is the focus of this episode. Carnivore Controversy: We know that people have strong feelings about food. The DIETFITS study, one of the best randomized controlled trials comparing healthy low-carb to healthy low-fat diets found that both led to weight loss. Learn more by listening to our interview with lead investigator Dr. Christopher Gardner on Show 1126: Can You Find Your Best Diet? We have heard from fans of ultra-low-fat diets like those promoted by Pritikin or Dean Ornish, MD. We acknowledge that hearing about a carnivore diet may put their teeth on edge, at the very least. But information from knowledgeable sources about controversial topics is what we aim for, and this is indisputably controversial. 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, treatment, or diet. How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Sept. 13, 2025, at 7 am EDT on 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 Sept. 15, 2025. Ketogenic and Carnivore Diets: Doctors have long prescribed ketogenic diets to treat children with hard-to-treat epilepsy (Epilepsy & Behavior, Sep. 8, 2025).  Studies suggest that people with migraines or depression might benefit from a ketogenic diet (Brain and Behavior, Sep. 2025; Translational Psychiatry, Sep. 10, 2025). Most people now following carnivore diets, which are more extreme than ketogenic diets, began following this eating plan to lose weight and have more energy. Our co-host for this show, AAAS Mass Media Fellow Bianca Garcia, has done some investigation of this approach to nutrition, including a personal trial. She joined us in interviewing Dr. Eric Westman, an advocate for ketogenic and carnivore diets to help people with obesity and diabetes. What is a ketogenic diet? It minimizes the carbohydrate available as fuel by including only low-starch vegetables such as greens. High-fat food sources make up the bulk of the energy in the diet. This forces the body to burn ketones derived from body fat instead of glucose derived from sugar or starch. In a carnivore diet, the vegetables disappear completely and the high-fat food sources are all derived from animals. How Do Dietary Guidelines Mesh with Carnivore Diets? We asked Dr. Westman about changing dietary guidelines, and he pointed out that most of the national dietary guidelines have limited scientific support. Of course, randomized controlled trials of people following carnivore diets are also few and far between. A survey of more than 2,000 self-selected volunteers following the diet was published in 2021 (Current Developments in Nutrition, Nov. 2, 2021). The DIETFITS trial, which compared a healthy low-fat, high-carb regimen to one high in fat and low in carbs found no significant difference in weight loss over the course of a year (JAMA, Feb. 20, 2018). What Are the Effects of a High-Fat Diet? In the clinical trials he conducted, Dr. Westman found that blood insulin levels were lower as people followed a ketogenic diet (Expert Review of Endocrinology & Metabolism, Sep. 2018). The body does not require insulin to utilize ketones for fuel. As a result, people with type 2 diabetes have better control of their blood glucose when following a low-carbohydrate ketogenic diet (Nutrition & Metabolism, Dec. 19, 2008). He and his colleagues have published a case series suggesting that a ketogenic diet could help people with food addiction (Journal of Eating Disorders, Jan. 29, 2020). There are also hints that people with other psychiatric conditions might benefit from a ketogenic diet as well (Psychiatry Research, May 2024). What Is Driving the Interest in Carnivore Diets? Bianca Garcia and Dr. Eric Westman agree that the internet has a huge influence on people’s interest in carnivore diets. Podcasters like Joe Rogan and multiple influencers have promoted this approach, especially to younger people. This can contribute to social pressure to try it. Dr. Westman warns listeners that adopting a ketogenic or carnivore diet should be undertaken under knowledgeable guidance. A drastic dietary change can alter how medications work, so people with chronic illness really need to work closely with health care professionals. That may require searching for someone who is open to this approach with the expertise to recommend when supplements or salt might be needed and provide information on doses. This Week’s Guest: Eric Westman MD, MHS, is an Associate Professor of Medicine at Duke University. He is Board Certified in Obesity Medicine and Internal Medicine and founded the Duke Keto Medicine Clinic in 2006 after conducting clinical research regarding low-carbohydrate ketogenic diets. Dr. Westman is a past President and Master Fellow of the Obesity Medicine Association and Fellow of the Obesity Society. He is a board member of the Society of Metabolic Health Practitioners and the American Diabetes Society. In addition, he has written and edited numerous bestselling books and is a co-founder of Adapt Your Life Academy (www.adaptyourlifeacademy.com), which provides science-backed education on a range of subjects rooted in the therapeutic effects of dietary carbohydrate restriction… including his newest course, Carnivore Made Simple, which is open now for enrollment for a limited time. Eric Westman, MD, Duke University Our Co-Host: Bianca Garcia is a Filipina-American anthropologist, foodie, and radio person. She holds a master’s degree in Media, Medicine, and Health from Harvard Medical School, where she created an audio documentary on the carnivore diet. She was a AAAS Mass Media Fellow covering health and science at WUNC, North Carolina Public Radio when we conducted the interview; her favorite stories to cover always involve what people eat, and why. Bianca Garcia, photo copyright Christina Thompson Lively Listen to the Podcast: The podcast of this program will be available Monday, Sept. 15, 2025, after broadcast on Sept. 13. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, you’ll hear the real patient story of a doctor who weighed 350 pounds and suffered from POTS (postural orthostatic tachycardia syndrome). Do we have any idea of how a carnivore diet affects the gut microbiome? Dr. Westman describes his study on how a low-carb diet helps GERD (gastroesophageal reflux disease). Years ago, Joe looked for evidence on the traditional heartburn diet limiting fat, alcohol, coffee and tomatoes and couldn’t find any. What we have found is that science changes as researchers pursue further studies and that is not a reason to mistrust science even though the changing recommendations may be frustrating. Dr. Westman offers a message to everyone trying to make the right dietary choices but feeling overwhelmed by many different messages about food. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript for Show 1444: 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. Americans have been fighting about food for decades. What’s healthier: low‑fat or low‑carb eating patterns? This is The People’s Pharmacy with Terry and Joe Graedon.   Terry 00:33-00:44 We’ve talked with many experts about the value of a Mediterranean diet, rich in produce and low in red meat. Today we’re going to find out about the carnivore diet.   Joe 00:44-00:49 What’s the difference between a carnivore diet and a ketogenic diet?   Terry 00:49-00:59 Our guest is Dr. Eric Westman of Duke University. He started as a skeptic of the Atkins diet. Then he conducted research that turned him into an advocate.   Joe 00:59-01:15 Coming up on The People’s Pharmacy, the food fight over fat. Learning about keto and carnivore diets.   Terry 01:13-01:56 In The People’s Pharmacy Health headlines, COVID cases are increasing, especially on the West Coast. Oregon has seen a late summer surge in cases. California has also seen an alarming increase. Hospitalizations for COVID patients have almost doubled in recent weeks. An objective measure of viral spread comes from wastewater samples. The CDC’s wastewater surveillance system reports very high genomic sequencing levels for the SARS-CoV-2 virus. There is hope, however, that the summer surge will ease soon, though public health officials worry another COVID wave could start as early as November, just in time for holiday travel.   Joe 01:56-03:07 People who are trying to avoid COVID-19 might want to consider an inexpensive, low-risk strategy to stay safer. A study published last week in JAMA Internal Medicine tested the nasal spray Azelastine for prevention of SARS-CoV-2 infections. This over-the-counter antihistamine is sold under the brand names Astelin and Astepro. Beyond its anti-allergenic and anti-inflammatory properties, this medication has antiviral activity against several respiratory viruses from SARS-CoV-2 to RSV and flu. A double‑blind, placebo‑controlled trial in Germany included 450 patients who spritzed either azelastine or placebo into their noses three times daily for roughly two months. During that time, five people spritzing the antihistamine came down with COVID. In the group using the placebo spray, there were 15 positive cases. The authors concluded that their results support the potential of azelostine as a safe prophylactic approach, warranting confirmation in larger multicenter trials.   Terry 03:07-03:57 A different study tested the effects of inhaled nitric oxide against COVID-19. The investigators note that this gas is produced naturally in the body and is well known as a vasodilator. It also has antiviral and anti inflammatory properties. In a recent study, fifty-five patients hospitalized with COVID associated pneumonia got inhaled nitric oxide or usual care. Those who had up to six hours exposure to high dose nitric oxide were released from the hospital more quickly and needed less supplemental oxygen. According to the investigators, the inhaled nitric oxide treatment was safe and well‑tolerated. They suggest this approach might be helpful against other pulmonary infections.   Joe 03:58-05:11 Generalized anxiety disorder, GAD, is one of the most common psychiatric conditions in the U. S. Doctors may prescribe anti-anxiety drugs such as alprazolam or diazepam. But these benzodiazepines may not be suitable for long-term use. SSRI antidepressants are also prescribed, but they too don’t work for everyone with anxiety problems. Now, scientists report a single dose of the hallucinogen LSD can have lasting effects. Nearly 200 patients were recruited for the study. The researchers randomly assigned them to take placebo or one of four different doses of the active compound. The two lowest doses of LSD did not have an effect that was significantly greater than placebo. People receiving the two highest doses—100 or 200 micrograms—were significantly less anxious one month later. Adverse effects included hallucinations, nausea, and headache during the treatment. This helps establish the groundwork for further research on the potential benefits of one dose of LSD to treat disabling anxiety under careful medical supervision.   Terry 05:11-06:17 Are you a coffee lover? How do you drink your brew? Previous studies have shown that regular coffee drinkers get substantial health benefits. They tend to have a lower risk of liver cancer, diabetes, dementia, and cardiovascular disease. Few studies get into the details of coffee consumption, though. Now a cohort study of more than 42,000 American adults participating in the National Health and Nutrition Examination Survey. demonstrated that higher coffee consumption was associated with a lower likelihood of dying between 1999 and 2018. People drinking one to three cups daily got the most benefit, but they needed to drink their coffee black. Adding sugar or cream or non-dairy creamer blunted the effects. And that’s the health news from The People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon.   Joe 06:17-06:30 And I’m Joe Graedon. You’ve heard a lot about the health benefits of the Mediterranean diet here on The People’s Pharmacy. We’ve also talked to guests like Dr. Will Bulsiewicz about the value of fiber in our diet.   Terry 06:30-07:02 Today we’ll be considering a different dietary approach. Is there any science to support the keto or carnivore diet? Joining us for this interview is Bianca Garcia. She holds a master’s degree in Media, Medicine, and Health from Harvard Medical School, where she created an audio documentary on the carnivore diet. She served as the AAAS Mass Media Fellow at WUNC. We invited Bianca to co-host this interview.   Joe 07:00-07:30 To help us better understand the carnivore diet, we turn to Dr. Eric Westman, Associate Professor of Medicine at Duke University. He founded the Duke Keto Medicine Clinic in 2006 after conducting clinical research regarding low-carbohydrate ketogenic diets. He’s written a number of popular books, such as End Your Carb Confusion and Keto Clarity, his newest course, Carnivore Made Simple, is open for enrollment.   Terry 07:31-07:35 Welcome to The People’s Pharmacy, Dr. Eric Westman.   Dr. Eric Westman 07:35-07:36 Thank you. It’s great to be here.   Terry 07:37-07:42 And we are… (DR. WESTMAN 07:38-07:38) Again. Yes, again for the I don’t know how many-eth time.   Dr. Eric Westman 07:42-07:43 I lost count.   Terry 07:43-08:00 Okay, me too. And we are really pleased to have with us in the studio helping us with the interview. Bianca Garcia, who is a journalist and I might say a medical anthropologist. We’re glad to have you here, Bianca.   Bianca Garcia 08:01-08:02 It’s my pleasure.   Joe 08:03-08:27 Dr. Westman, I have to tell you, when it comes to food, I get so confused It seems like the dietary guidelines have changed so much in my lifetime. How do you keep up and tell us what you think about this whole process? Because you’ve been studying food for decades.   Dr. Eric Westman 08:27-08:51 Well, so you have to think about uh the human body first. not the well this is my perspective. I’m an internal medicine specialist. So I got trained in an era where we were dealing with Oh, diabetes a little bit, high blood pressure a little bit. No obesity. I mean in the 80s in training, there’s really nothing there.   Terry 08:51-08:52 Obesity existed.   Dr. Eric Westman 08:53-13:16 Yeah, but not like today, right? So uh you know, my colleagues started giving pills and shots for everything. And I started to work here in Durham at the Durham Veterans Affairs Hospital. and started to learn about research and worked with the inventor of the nicotine patch for ten years, Jed Rose in Durham. So I got to learn about science and how to apply the scientific method to humans, I mean to clinical research. And so randomized trials were paramount. And really you might even say ignore everything until there’s a randomized trial. Well, that worked for a while. I after ten years I realized I was not fixing anything. I mean and after ten years of my patients at the VA I l I loved them dearly, and they were all kind of getting worse. So two patients show up in my office right about the same time having fixed their diabetes and obesity and I asked them what they did. They said, all I did is eat steak and eggs. I’m like, what the heck? This is nineteen ninety-eight, okay? And so I’m thinking to myself, uh, well, lightning strikes And yet then another patient comes in. All I did is do the Atkins diet. I said, What’s that? And he said, Well, you know This book, it probably came out before you were born. And that wait wait a minute. Now you’re getting personal. So I I go to the bookstore and sure, there’s the Atkins diet, there’s the Ornish diet. There back then there was the Uh even “The Zone” hadn’t come out yet. So there weren’t a whole lot of books on the shelf. But there was a doctor who had a clinic that you could visit, and that was Dr. Atkins. So I wrote him a letter, he calls back and invites me to his office with a couple of young researchers who were doing a different job at the time. And so I saw a clinic in action and after he seeing two people do the total opposite of everything that I was taught. And even then one of the patients who I was treating at the VA said, What are you worried about? And I said, Well your cholesterol. Your cholesterol will go up. Remember this is 1998 for me. And he looked at me and said, Well, why don’t you check it? And he the lab was down the hall at the VA and didn’t cost anything for me or him to do it. So in two cases, people lost weight. These were men- lost over fifty pounds and their cholesterol levels got better regardless of how you look at it total in LDL triglyceride and HDL Like, what the heck’s going on? So I had to learn basically for myself as an internist, as a clinical researcher, about nutrition. And when I went to the diet dietary meetings, the nutrition meeting, there was like, everything’s low fat, everything’s now plant-based. And I’m like, well, but but what about the patient sitting in front of me who’s fixed conditions that doctors can’t fix by doing the exact opposite of what they were taught. And I met uh Michelle Hurn who wrote the book, “The Dietitian’s Dilemma.” What if you have to do the exact opposite of what you were taught to fix yourself? And that’s Michelle, she is a dietitian and you know I’m on a board of a new society with her, so I’ve got to know her, uh gotten to know her pretty well. So I guess, you know, looking back, What do you eat matters? You know, if if I could be dean of the all the schools of medicine and even DO schools, I’d say, you know: nutrition should be key to your education of what a human body needs attention to And in my last 25 years, we’ve documented over and over again, and other people have documented, there’s no nutrition training for doctors. They’re or they get taught the wrong thing. So so here I am today asked to talk about low carb and keto and LCHF and, and I gave a talk in London recently, and it was The Fad That Never Fades. The Fad That Never Fades was the title of my talk. And so the concepts of what we’re talking about has been here you know, for hundreds of thousands of years, the name has changed.   Terry 13:16-13:25 Okay. Bianca, how did you get interested in the carnivore diet? Because you’ve been following up on this for at least a year now.   Bianca Garcia 13:25-14:39 That’s right. I was pursuing my master’s of science and I was thinking about media and health together. And I was as a social media user starting to see a lot of social media content on the carnivore diet. Someone who’s looked at nutrition, who’s been interested in nutrition, I thought it was really, really strange that people were eating, as Dr. Westman said, just steak and eggs. So I wanted to look into kind of the anthropology of this. What is, what is making people eat the way that they are eating? And how do we think about this personal sort of decision as it weighs up against the weight of the medical institution, and that kind of knowledge. And so I have a yet unpublished audio documentary on the carnivore diet called Against the Grain. And in doing that research, I’ve seen Dr. Westman’s content. I’ve seen the content of many other creators. I’ve spoken to carnivores and learned about their personal experiences, and I’ve spoken to doctors who are also equally skeptical of the diet. So there is a wide range of opinions out there that I have been interested in following up on as a journalist.   Terry 14:40-14:52 Dr. Westman, I can imagine that you get some reactions, probably not so much from your patients, because your patients are coming to you saying, This is what I want to do, right?   Dr. Eric Westman 14:53-15:34 Well, not necessarily. Although although that that’s uh a good expectation that no uh, I’ve in fact this week, that’s why I’m in clinic at Duke four days a week in a private practice insurance pay system. Um no, actually some people have no idea who I am. I and there was just recently someone who uh goes to the Lincoln Community Health Center was referred to me and I had to kind of figure out how do I help this uh person from Mexico navigate the foods and when I say you can have all the chicharron you want, the eyes light up. You can have all the pork rinds you want. That’s also a telltale sign for uh someone from North Carolina typically. Uh but uh so   Terry 15:34-15:38 But thank you for translating Chicharron.   Dr. Eric Westman 15:38-15:51 Chicharron is or uh I’ve had the best chicharron, in uh in Colombia. The kind it was really pork belly. But anyway, it has no carbs and it’s kind of a secret trick if you’re trying to (TERRY) it’s very high fat. It’s very high fat.   Terry 15:51-15:54 Which is great on a carnivore or keto diet.   Dr. Eric Westman 15:54-16:37 It it may not be great on a low fat diet. I, I understand. And I think there are a lot of ways to be healthy, just to kind of declare I’m not just a carnivore keto proponent. I in fact it was recently when Lucia Aronica at Stanford asked Christopher Gardner to do a sub study of his paper. It’s called the DIETFITS study. The substudy was let’s look at people who did ultra low fat and let’s look at people who do did ultra low carb. And and so it selected out people who were actually following those, and looked at health parameters and actually the ultra-low carb diet looked very similar to the ultra-low fat diet.   Terry 16:37-16:38 In terms of outcomes?   Dr. Eric Westman 16:38-16:41 In terms of improving insulin resistance.   Terry 16:41-16:41 Uh-huh.   Dr. Eric Westman 16:41-16:45 Improving what we understand now is probably the root cause.   Joe 16:47-17:04 Well we just have a minute before the break, but I would love to have you explain insulin resistance because we are hearing about it so frequently now and it’s so critical. But I fear that a lot of people don’t yet understand it. So you have one minute to give us the insulin resistance overview.   Dr. Eric Westman 17:04-17:52 Yeah, so insulin resistance uh actually is a term, I don’t like it. It, you really should say high insulin levels. Because insulin resistance gives the connotation that there’s something wrong in the person, something wrong in the cell, and you just need a drug. But what insulin resistance functionally is, is that insulin is not working to lower the blood glucose like it used to. So what you see is an elevated blood glucose compared to before or A1C, the hemoglobin A1C, the three month average of the glucose. And but you see the insulin resistance also means your insulin level is high. So I would rather have you talk about high insulin levels and how to get those down than insulin resistance, which is this, you know, term out there you need a drug for.   Terry 17:52-18:08 You’re listening to Dr. Eric Westman, Associate Professor of Medicine at Duke University. He’s a board member of the Society of Metabolic Health Practitioners and the American Diabetes Society Dr. Westman is a specialist in internal and obesity medicine.   Joe 18:09-18:13 After the break, we’ll consider why dietary guidelines haven’t made a difference.   Terry 18:13-18:19 There’s not impeccable evidence to support the current guidelines, but that’s also true for the carnivore diet.   Joe 18:19-18:21 What does science tell us about how it works?   Terry 18:21-18:25 How do carnivore and keto diets differ?   Joe 18:24-18:29 What are the pros and cons for patients following a carnivore diet?   Terry 18:39-18:48 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. This podcast is brought to you in part by Sonu.   Joe 18:48-19:12 Ready to breathe like never before? Meet Sonu, S O N U, the world’s first FDA‑approved wearable headband that gives you drug-free relief from nasal congestion in minutes. It’s safe for adults and kids 12 and up, making it perfect for families dealing with allergies, sinus issues, or chronic stuffiness.   Terry 19:12-19:31 Sonu uses personalized sound-based therapy to naturally open nasal passages. No meds, no steroids, no sprays. Even better, up to four users can share one account so the whole household can benefit. It’s compatible with both Apple and Android smartphones.   Joe 19:32-19:52 Learn more at getsonu.com and sonu.com. Welcome back to The People’s Pharmacy. I’m Joe Graedon.   Terry 19:52-20:15 And I’m Terry Graedon. On The People’s Pharmacy, you hear a lot about the value of vegetables. We’ve interviewed nutrition experts like Dr. Walter Willett and Dr. Christopher Gardner who are enthusiastic about a plant-based dietary pattern. Today we’re considering a different approach to eating. What are the benefits of a carnivore diet?   Joe 20:15-20:24 What’s the difference between a ketogenic diet and a carnivore diet? What are the benefits and risks of such eating patterns?   Terry 20:24-20:52 Our guest is Dr. Eric Westman, Associate Professor of Medicine at Duke University. He founded the Duke Keto Medicine Clinic in 2006 after conducting clinical research regarding low carbohydrate ketogenic diets. He’s a board member of the Society of Metabolic Health Practitioners and the American Diabetes Society. His areas of expertise include obesity and metabolic disorders.   Joe 20:52-21:12 We’re also joined by Bianca Garcia. We invited her to co-host this interview while she served as WUNC’s AAAS Mass Media Fellow. She holds a master’s degree in media medicine and health from Harvard Medical School where she created an audio documentary on the carnivore diet.   Terry 21:12-21:28 Dr. Westman, we’ve uh kind of reviewed the, a little bit of history of dietary guidelines and advice. Do we have any idea why so many of these dietary guidelines don’t seem to have done the job?   Dr. Eric Westman 21:29-22:07 Well, you know, uh the way I look at it is the there was never any science behind these dietary guidelines. That’s pretty clear. And people have written papers on uh there have been a paper uh was a thought piece of was there any evidence when the dietary guidelines were made that that there were we should have those guidelines and basically know there wasn’t any evidence. So I think it was the government being lobbied to make the foods America makes be consumed more by Americans. Thus we don’t have coconut oil in the guideline because we really are not big producers of coconut oil.   Joe 22:08-22:15 True enough. But before we go any further, when we say the guidelines, uh what are we even talking about?   Dr. Eric Westman 22:15-23:25 Well I know and you know I, fortunately, the guidelines are pretty much uninterpretable right now to the average consumer, except institutions are still somewhat beholden to them. I was just on a panel recently at a meeting where we all kind of agreed no guideline is better than a bad guideline. And I was past president I am past president of the Obesity Medicine Association. We lobbied the government at the time and I sat in the office of the woman who created the food pyramid, Susan Susan Davis. And we said, you know, people aren’t healthy. She said, well this is a guideline for healthy Americans. And we said, no, people aren’t healthy. I’m, you know, advocating for obesity treatment. So I think the first uh question is, are we giving guidelines to healthy people? Or like the studies say and you just look around at the mall, are should we give guidelines and guidance to people who need a corrective therapeutic diet generally. So I’m not a big guideline guy and and uh I work with the patient in front of me and get results. And I yeah I think the guidelines have been a bad idea. Even even the latest ones.   Bianca Garcia 23:26-23:49 And Dr. Westman, as you’re pointing out, there’s not a lot of evidence for the current guidelines, but from what I’ve seen, there is not a lot of published evidence about the carnivore diet either. But we can intuit from the keto diet and other similar low carbohydrate diets why it might work. So can you walk us through a little bit about the science of why the carnivore diet works?   Dr. Eric Westman 23:49-24:58 Absolutely. And I, I share your kind of assessment that there’s not a whole lot of published literature. If you search carnivore, you know, you’ll get a survey. There was a survey from the Harvard group, Belinda Lennerz and David Ludwig, where they surveyed self-described carnivores and what happened to their health and all that. We actually surveyed a a group who was of type one diabetics, as people affected by type one diabetes as well. It was a Facebook survey and it was the most cited publication in the journal Pediatrics at the time. So I, I don’t discount this information, but you have to keep it in, you know, it’s preliminary um information. The the grassroots change that we’ve seen over the last ten to fifteen years is that people are changing their own diet with influencers or or just word of mouth. And getting amazing changes, including keto, including carnivore, and I think the mechanism is that they both really fix insulin resistance, meaning they lower the insulin levels. And really any effective diet can do that.   Terry 24:58-25:10 Dr. Westman, we’ve been talking about the carnivore diet as if we all know what it is, but I don’t. So maybe you can tell us what are people eating? What is the carnivore diet?   Joe 25:10-25:15 And before that even, what is the keto diet? So how do they differ and what are they?   Dr. Eric Westman 25:16-25:30 Yeah, so uh I think there are many different versions of these things. Carnivore, I think, can be best described as just animal-based foods. So kinda like you’re used to saying plant-based, plant-based, plant-based, plant, uh oh. That’s kind of…   Terry 25:30-25:31 Or plant forward.   Dr. Eric Westman 25:33-26:09 Oh, it changed. Oh that’s one way to do things, but you know, uh people who come to me, yes, some do self-select, they want to follow what I, not everyone comes not knowing what I do. A lot of I would say two-thirds of the people come seek me out because of the teaching that I give. I I have to admit that. But so two years ago there was a textbook called “Ketogenic: The Science of Therapeutic Carbohydrate Restriction” and I use this as show and tell to people from a first visit to my office to just show that there is a body of knowledge now out there on the keto diet.   Joe 26:09-26:23 And keto really makes it Let me read the the subtitle of the book you’re holding up. It’s “ketogenic, the science of therapeutic carbohydrate restriction in human health.” That’s it. Tell us about it.   Dr. Eric Westman 26:23-29:28 Well, Dr. Will Yancey and I at Duke have been doing research since 2002 and we contributed chapters on obesity and type 2 diabetes reversal in this textbook. But it’s much more detailed. In fact, I I haven’t read every word in it yet because, you know, uh there’s a lot of information on the keto diet. Well, keto really means that you’re using ketones in your body to an extent that you didn’t before. Is there a certain level? No, no, not really. And i is there a maximal or greatest greater keto diet? I, I don’t think we know that yet. So to me, a keto diet is a very low carbohydrate diet that allows your body to access the fat stores in a flexible manner, so that you can be burning your body fat and and as a result your ketone level goes up compared to those who eat carbs. Uh and uh the idea of fat loss, weight loss has been implanted, and that’s how I learned it. The keto diet was a weight loss diet. But it does much more than that. And now I have people coming to me whom I’ve taught a keto diet for years and and there’s a few conditions that still remain I haven’t been able to fix; I can fix almost every internal medicine problem that my colleagues use drugs for. I can fix,  uh reverse type 2 diabetes, obesity, PCOS, heartburn, migraines, all these things. But there’s a a nagging uh uh uh uh component of problems that have to do with inflammation and autoimmunity that keto doesn’t quite fix. And and I have to say that the keto, the way I teach it, it’s unlimited meat, poultry, fish, and shellfish and eggs, till you’re comfortably full. And one cup of non-starchy vegetables, and two cups of leafy greens. Now I don’t enforce those vegetables and and so what I teach is not strictly a carnivore diet. It allows for these vegetables and leafy greens. But people are coming to me now over the last few years fixing these autoimmunity conditions by dropping those vegetables. And so I’m I’m just wondering it, you know, so what I teach is carnivore-ish. And I passively allow people eat a carnivore diet under my care. You know, I, I monitor things. And it the science I want to go in the direction They’re case series, case studies of people who fix their inflammatory bowel disease, ulcerative colitis, the rheumatoid arthritis, and and we have a case study brewing trying to get it published of of palindromic arthritis that was basically fixed by just changing the food. So, so keto means ketosis, keto means fat metabolism. Carnivore to me is a subset of a low carb keto diet so that it doesn’t seem as far afield to me as it might to someone else.   Bianca Garcia 29:29-29:50 Still, this is a pretty socially and scientifically divisive idea. So I wonder how your peers and your colleagues look at um this kind of keto carnivore-ish diet, especially without uh the immense evidence base that like a plant forward diet might have. Well what kinds of reactions do you get from your colleagues?   Dr. Eric Westman 29:51-32:32 So actually there will never be uh uh unanimity in diet. Let that be just my first statement. There were and and that’s one reason why I’ve kept keto out of the press. In fact, whenever I’d get onto the the press or something, they would try to find someone against it. Well you can always find someone against it. You can always find a plant-based is best. No, there’s no evidence that a plant-based diet is better than a carnivore, animal‑based diet. It’s all implanted in people’s minds. So, no, because that Stanford study where they finally looked at insulin resistance between these two different very extreme diets, they both worked. And you know, I remember, gosh, how long has it been, Joe and Terry? We were talking the Duke Rice diet started all this at the Duke campus in the nineteen thirties or you know the history of (TERRY) Yeah, before our time even. Yeah, well And then, you know, the rice diet no longer exists, although there’s still people who remember that. That was would be like an Ornish/Pritikin ultra‑low‑fat kind of diet. And and I I think it works, you know, but it doesn’t mean there’s no other way to do it. So I guess um coming around, uh Bianca, that there never will be agreement among the the experts. And so what I’ve learned is I, I, I put my head down, created a clinic. And over the last 15 years, I learned as much as I could about using a keto and carnivore diet in a clinical setting. And if other people say, well, it doesn’t work, that’s not true. The long-term effects remain unknown, but that’s true, true for any diet. So that, you know, w we get into this, you know, oh there’s no evidence. Well, there’s really precious little evidence even for the Mediterranean diet, which everyone believes is the best. So in evidence meaning randomized trials long‑term. So we’re we’re left with what is biologically sensible and and also therapeutic. I just want to loop back to this textbook. I think there’s general consensus that a keto diet can be a therapeutic tool. I mean, so even my naysaying colleagues who don’t like the idea of carnivore and keto will say, okay, well, you can reverse things and fix things, but then what? You know, you gotta get off that eventually. And I’m like, well, but if it reversed all their problems, why would you want that get them off it? You know? And because they just know that it’s bad. I mean, if it if it’s not known, it must be bad, which I learned, you know, you and I sat in a room like this. when that first Atkins paper came out and oh the controversy and now nobody really knows that name other than the the food on the shelf.   Terry 32:33-32:54 So, Dr. Westman, would you please tell us briefly what you have seen as the clinical benefits for people who are following this carnivore or even carnivore-ish diet? And then we’d also like to talk about some potential downsides.   Dr. Eric Westman 32:54-34:52 Absolutely. So from my bench or or clinic, um what I see for those who follow uh carnivore or keto kind of diet with instruction from someone who knows what they’re doing. Now you know, internet and carnivore internet and keto internet there are so many different places to learn, it’s very confusing. But so you want to learn from someone who knows what they’re doing and if you’re on multiple medications, you wanna be sure to be working with someone who knows how to get you off those medicines safely. And so what I see is uh the average patient coming to me is 60, 65 years old on seven to ten medications. Medications for diabetes, high blood pressure, heartburn, arthritis. Many of these people have already had hip and joint replacements, and and now they’re have they have obesity too. And so I simply tell people that we store fat on our bodies for energy and we want to get access to that fat store. And I could use a keto, a low glycemic, a a carnivore type of diet based on this someone’s preference. And over time I can fix, reverse all of those medical conditions by changing the food. It’s so unbelievable you won’t believe me. So for the last 10 years I’ve at medical conferences I’ve said, come to my office. And partly I set up this clinic so that it could be a teaching clinic, not only for for the patients, but for doctors. So residents and students at Duke come through my office. Other doctors have come even from around the world to see it in action. And so basically it’s the all the internal just about all of the internal medicine problems that are treated with medications today can be reversed or greatly reversed just by changing the food.   Joe 34:53-35:43 I want to ask you a little bit about a couple of conditions that are widespread in our society, and we don’t have good treatments for. Inflammation, which I’d love to have you define what that means from a biological perspective, and also the impact on the brain, on mental clarity, because there are a lot of people in the age bracket that you’re talking about who are complaining about mental fogginess, in you know just functionality. I, I can’t remember those names anymore the way I used to. And they were also complaining about their knees and their elbows and their fingers. What impact does this approach have on those two areas?   Dr. Eric Westman 35:44-36:12 Yeah, so inflammation is basically your body’s ability to clot, to fight infection, to to function. And you need some inflammation. So you don’t someone came to a meeting, an expert, and said, Well I don’t eat that ’cause it causes inflammation. I don’t eat that ’cause it causes inflammation. The first question at the microphone was, Well, what do you eat? Basically you said, I fast because eating causes inflammation. And I mean that’s to the absurd degree.   Terry 36:14-36:15 Not a long‑term strategy.   Dr. Eric Westman 36:15-37:26 Yeah. So so you w n you want some inflammation, but you don’t want too much. I guess it’s like Goldilocks, you know. You want a little bit uh of inflammation but not too much. And I I think the the elephant in the room is that food causes inflammation. Of course, stress causes inflammation and and so food, the carbs are uh and refined sugar and flour are really kind of the the ones that are causing most of the inflammation today. Uh you know, the brain function is fascinating and I think the common consensus is that insulin resistance, oh, remember that term? High insulin levels. over a period of time actually cause Alzheimer’s. Just cause. But the problem is once you get a a memory issue from Alzheimer’s, it’s too late. So it’s like the you know, the plane’s going down. So everything I’ve learned about Alzheimer’s is that you want to take action now. Like if you have a family history of it, uh a loved one where you want to address that insulin resistance and there are numerous uh dietary ways to do that.   Terry 37:27-37:59 You’re listening to Doctor Eric Westman, Associate Professor of Medicine at Duke University. He founded the Duke Keto Medicine Clinic in two thousand six after conducting clinical research regarding low carbohydrate ketogenic diets. His newest course, Carnivore Made Simple, is open now for enrollment by People’s Pharmacy listeners for a limited time. Bianca Garcia, a AAAS Mass Media Fellow at WUNC, joined us in co-hosting this interview.   Joe 38:00-38:05 After the break, we’ll find out what people are saying on the internet about the carnivore diet.   Terry 38:04-38:08 How long does it take for people to see weight loss from a carnivore diet?   Joe 38:08-38:13 What downsides might we expect from such a diet or the keto diet?   Terry 38:13-38:18 Bianca will share her experience trying a carnivore diet. How did that go?   Joe 38:18-38:23 Should we change our thinking on nutritional science?   Terry 38:35-38:39 You’re listening to The People’s Pharmacy with Joe and Terry Graedon.   Joe 38:47-38:51 Welcome back to The People’s Pharmacy. I’m Joe Graedon.   Terry 38:51-38:52 And I’m Terry Graedon.   Joe 38:52-39:06 What’s a healthy way to eat? Humans around the world have come up with different answers to this question. Most nutrition scientists agree that the standard American diet falls far short.   Terry 39:06-39:38 Our guest today is Dr. Eric Westman. He is Associate Professor of Medicine at Duke University, where he founded the Duke Keto Medicine Clinic almost 20 years ago. Dr. Westman is a co-founder of Adapt Your Life Academy, where his newest course is Carnivore Made Simple. It’s open for enrollment by people’s pharmacy listeners for a short time. Bianca Garcia, a AAAS mass media fellow at WUNC, joined us in co-hosting this interview.   Bianca Garcia 39:40-40:12 Dr. Westman, you were talking about the internet culture of this diet. And you were saying how, you know, it’s important to get instruction from people who know what they’re doing and how to get you off your meds in order for you to, you know, safely carry out this diet. But I think I want to talk a little bit about the internet culture and you know, how this diet is spreading popularly. What are you seeing out there? What do we have to be aware of as people might be encountering this diet in the wild?   Dr. Eric Westman 40:13-42:05 Uh yeah, great and you know I’m uh just kind of in awe of the internet compared to twenty years ago. And it’s a wonderful thing and a terrible thing all at the same time. So the big line of, of demarcation should be if you see a doctor for a a problem that you’re taking a medicine for. Be sure to do this with a doctor who knows what they’re doing, because medicines can become too strong on the first day. I’ve had people have low blood sugars from insulin and other diabetes medicines on the first day. So if you’re consuming this information online and it’s to the general healthy person, I’m not so worried about it. But once you get into that clinical population, now, you know, I don’t know uh uh any of my patients who are on TikTok. So that that might all automatically select the ’cause the people who come to me are generally older. But that’s that’s not always the case. So I I’m getting patients who come to me because I kind of passively endorse a carnivore diet as a subset of a keto diet. That uh I think uh you want to do things um that um and not only feel feel right isn’t the right word. It’s the thing uh changes that make you feel good. I mean that that may correct a problem that you have. And if it even if it’s excessive hunger and all you can do is think about food. Then this is something the food is really the answer and and um I’m afraid doctors don’t have that information and you know it it really is hard to police this, isn’t it? But uh to me I I try to make sure that if you’re you know older, you’re on medicines, that you have someone who knows what they’re doing help you.   Bianca Garcia 42:06-42:50 I also want to add though from my field work and from the interviews that I do that young people are exploring this diet. I think there’s a lot to say about the simplicity of it. People are attracted to it because unlike the Mediterranean diet, which has like very strict um ideas of what you can and can’t eat. This is just like take out everything and stick with just meat. And that’s pretty intuitive and simple. But at the same time, that can have some, let’s say bodily impact. I tried the carnivore diet for a little bit. I couldn’t stick with it. So what can we expect about people who just get on the diet? And I guess the the essence of this question is like: how long does it take for this thing to work?   Dr. Eric Westman 42:51-43:07 Well, I um it depends what you’re doing it for. So uh y I I have no problem compared to all the other things you can do in terms of nutrition. I think can we agree that the standard American diet just isn’t highest on the list?   Terry 43:08-43:09 I think we can all agree with that.   Dr. Eric Westman 43:10-43:21 So what’s then next? Can everyone do a super strict eat local, go to the farmer’s market, um, never go to McDonald’s and all or Burger King or Wendy’s?   Terry 43:21-43:22 Not everyone.   Dr. Eric Westman 43:22-45:38 Not everyone. So we have to have some sort of compromise, I believe. And and that’s also my doctor perspective. I don’t just preach as an influencer, do this and you have to be perfect. There are those who do that. They preach that and and I see people coming in worried about the the carblets, the the little microcarbs and the maltodextrin in the cheese and the I mean, come on. That’s not metabolically substantially anything you should worry about. So how you get it taught matters a lot. And the carnivore diet as it’s taught today, just eat meat. Well, I think it’s relatively healthy and and you know, if there’s if I could go back, Joe and Terry, twenty-five years ago, I would have said, show me a study that Atkins diet is bad. There never was one. And it took me just two years ago in with Jeff Volick, a researcher who’s been with me in this space for twenty-five years. For him to be on a podium and say, you know, there’s never been a study that showed that nutritional ketosis, the Atkins diet induction even, which now, you know, is carnivore, there’s never been a study to show that it’s bad. When I thought about that and look back, we had the wrong emotional reactive position of we had to try to prove that it was good, when nobody had shown that it was bad. It was prejudging. And I have that same feeling here. Yes, it’s a feeling, and I want science. I want more science. That that’s what’s going on today. Hey, it’s just eating meat, which is a lot better than eating all that other garbage and and you know in a scientific venue, I I do say things like, you know, prove that a keto diet is bad, you know, using the method that I use. Because we don’t see that it’s bad and if you just say a keto-ish diet from nutritional epidemiology shows that it’s bad, that doesn’t count. But so anyway, I I’m I you know me, I I was taught to to protect my data, and and protect what I saw in front of me, but then I cheated. I went to doctor’s offices who they’d done it for thirty years before me.   Terry 45:39-46:01 Well, Doctor Westman, here at The People’s Pharmacy, we rarely hear about a medical intervention that is just all good and has no downside ever for anyone. So can you tell us about some downsides that people might want to be aware of that could happen while you’re following a carnivore diet?   Joe 46:01-46:22 Or a keto diet. Because what we have learned over the years. And it took us about 40 or 50 years to recognize that some people will say, oh, this drug is marvelous. I love gabapentin, It takes away my nerve pain. And other people say gabapentin ruined my life.   Terry 46:23-46:23 Made me crazy.   Joe 46:24-46:58 I had hallucinations, it was, my brain stopped working. So nothing is ever really black or white. And some people, I am sure, as we’ve interviewed in the past, I love fiber, fiber, fiber fuel diet. It’s the best diet. And then other people say, oh my gosh, I just had so much gas I couldn’t tolerate it. So give us the pros and the cons. You’ve already given mostly the pluses, but are there some people who have problems with a keto or carnivore-ish diet?   Dr. Eric Westman 46:58-49:20 Well, that’s a great point. And that raises the issue and and the reason why formal research is necessary. Is that I learned a long time ago that if someone is just selecting out to come see me that because they have good results. Then I have a selection bias, what happened to people who couldn’t follow it? What happened to someone who had a problem and they didn’t come? So it’s important to have a study not only to I don’t think we need studies to show efficacy. I mean, I I could show efficacy with fifty people compared to a standard American diet for diabetes. We, our study of low glycemic versus low carb diets published in 2008 only had 50 people in it. So we can show efficacy. And it’s the safety side that you need more people involved and, you know, you get a hundred people, you get thousands of people. Then well, with a drug, then you get millions of people, then you start to really get an idea of the side effects. But so I I think the um side effects that most people have with keto or carnivore are manageable. We teach how to have keto adaptation at first where you add salt back in if you don’t have a salt sensitive condition. If someone has headache or cravings that goes away typically in a few days or a week. There might be change in bowel function where you you treat that with a little magnesium early on or some other electrolyte supplement. What s being able to stay on the diet to me i is is not only the biologic change that occurs, it’s also how that person perceives other people think of them and if they don’t want to go to the store and just have meat in their grocery cart. I mean that that’s a different so metabolically I have yet to see someone who cannot do a keto or carnivore diet metabolically because all of those problems are kind of screened out in pediatrics. So if if you have a serious fatty acid disorder, you can’t burn fat, you don’t really get out of childhood. So as an internist, as an adult I’m comfortable having people do a keto or carnivore diet. And most of the side effects, if if this were a drug, we’d say, well, these are mild and manageable.   Bianca Garcia 49:21-51:07 I’ll tell you a little bit about my perspective because like I mentioned I tried and I failed the carnivore diet. And before, before I get into that experience, I think I’ll frame it by saying like I’m a generally pretty healthy person. I was trying this as like a social experiment. There was nothing really keeping me going when I hit these roadblocks. And so for a lot of people who approach the carnivore diet, they’re doing it because they need something out of their health experience that they’re looking for at in the carnivore diet. That wasn’t my that wasn’t my case. So when I got the keto flu, as it’s popularly known, I was nauseous. I had headaches. I couldn’t get up in the morning. I was like, oh my gosh, this isn’t for me. But also, I felt the immense social pressure of the diet. I couldn’t go out and eat with my friends the way the the way I wanted to. I am a foodie and I felt a little depressed about not getting to eat the colors on my plate. Uh and also meat is kind of expensive. So, you know, I was feeling that in my wallet. These are all social things about the carnivore diet that are pitfalls of it, and I think that we need to talk about these because nutrition is inherently social. So while there could be and while there is evidence for these like immense changes to embodied health, there’s also the social health that’s important to think about. But I do want to follow up with a question for Dr. Westman, uh, which is about the common skepticism for this diet, which is like, what do we do with this information that we’ve all heard that red meat is carcinogenic and that if we don’t eat vegetables, we’re gonna get like a vitamin C deficiency? How do I think about that?   Dr. Eric Westman 51:08-51:16 Well, that’s a lot to unpack. Thanks for sharing your story. I wonder if you added salt during the keto adaptation.   Bianca Garcia 51:16-51:26 I learned afterwards that I should have been doing that. And I was going off the internet, you know? I think that’s the other thing. Which is…   Dr. Eric Westman 51:26-53:09 Ignore every internet thing except mine. Isn’t that funny? So but uh the the social things are are are real and but you know I I think back in the nineteen seventies, people started jogging and it wasn’t socially acceptable. In fact, people started starting to get treadmills and jogging I mean I’ve traveled to Europe and I was jogging and the Europeans looked at me like I was a nutcase ’cause you just didn’t jog in Europe. I didn’t see a whole lot of Europeans jogging even today. But so social acceptance can change over time. And i if you’re I think that trade-off for you w r wasn’t right. You know, you weren’t getting some benefit that you were, you know, fixing your ins incessant hunger. Or or um so I’m watching some influencers and I do React videos. One of the things that’s really important to remember if you’re exercising a lot, And if that’s part of your life. You’re at the gym and all that. That’s not where the the clinical application of keto and carnivore came from. It started with people who were unable to exercise, fixing metabolic issues. And so th there that’s a different context that you need to learn from people who’ve figured that out online. There are I think there are some good influencers online who’ve helped a lot of people. But again the the selection bias is a problem. So that perhaps your story or your your result is some biologic factor, not just social, and and maybe that’s underrepresented in the internet, you know, the highlight reel of, oh look me, look at I all I did all this And those who are not getting results don’t say it publicly.   Terry 53:10-53:21 Dr. Westman, how does what we have learned now about the carnivore diet change how we think about nutritional science?   Dr. Eric Westman 53:21-54:24 Well, that’s a great question, and I’ve always been a critic of nutritional epidemiology. Where you ask people what they eat periodically, sometimes once a year, and then you follow their health outcomes without any sort of experimental manipulation. And so I’ve I’ve always been critical of that and I’m a clinical trialist and so I value the Stanford paper with a couple hundred people on the diet and they were they know they were following it and and I trust the prospective data more than the cohort studies. So that so my perspective is we have to get to biology. So I’ve started to teach, let’s look at what the body’s made of. Let’s understand that we’re mostly water, protein, and fat. In fact, there’s no carbs stored on our body. I go over this with the body composition personally with my patients now. And I explain that we store fat on our body, not carbs.   Joe 54:25-55:23 Dr. Westman, people learn best from stories. And I know it’s not science. But on the other hand, we we can begin to have some sense of your many decades of experience with um first the Atkins diet, then the keto diet, now the carnivore-ish diet, you’ve had, you know, probably hundreds of patients, perhaps now thousands of patients. Tell us about some that stand out in your mind where they they came in perhaps overweight, perhaps with a diabetes problem, perhaps taking, as you said many medications and not feeling well. Tell us about, without actually naming someone who could identify him or herself, how your approach has changed their lives.   Dr. Eric Westman 55:24-55:39 Well, that’s a great question. And I I don’t know where to begin. I mentioned the kind of garden variety reversal of diabetes, hypertension, obesity, PCOS, and GERD. And I would say those are uh papers that we have published.   Terry 55:40-55:51 Now, Dr. Westman, I’m gonna call you on the alphabets. You need to tell us what PCOS means. And a lot of people know what GERD means, but not everybody, so you’ll have to explain that one too, please.   Dr. Eric Westman 55:52-58:03 Sure. PCOS means polycystic ovarian syndrome. And then GERD is gastroesophageal reflux disorder or heartburn. Heartburn. So these are things that either my colleagues who are internists can’t fix or they give drugs for. So uh I I think the extreme cases that I’m seeing now that I’m really kind of proud of, ’cause I stick to my guns. I I don’t I I just I’m a I’m a source where people can come and say, Hey I relapsed to sugar. And there are several patients who just when they relapse to sugar, they can gain 20 pounds in two months. And they come back and they have the safe zone almost like um I I don’t know, like be getting in a church and having sanctuary, because we know now that sugar is as addictive as any other drug. It was regarded as a drug and then in Gary Taubes’s “the case against sugar,” book he gives the history of that. So I think this um uh woman who’s stressed just stressful life and and and the sugar is just uncontrollable for that person. Um and and that’s kind of the new frontier of understanding that sugar is an addiction, uh and it’s okay not to have it. Um but the other the medical side if I put on my internist hat, it’s the inflammatory bowel disease that goes away. It’s the again, uh my my colleagues have super strong anti-inflammatory drugs now. They can give shots that cut out any symptom from inflammatory bowel disease, Crohn’s, or ulcerative colitis. The problem is those shots are so good, you’re at risk for having cancer, because you need that anti-inflammatory response to fight cancers. And so these drugs are so strong they’re being used and then most people don’t think they need to change their diet. So I like people to understand that there’s just another way to go about things. It’s not wrong to take the drugs and eat carbs and and all, but their lifestyle is so important and so powerful when it’s done right.   Joe 58:04-58:24 So I’m gonna ask you in your mind to imagine John Doe or Jane Doe, a patient, a real patient, who came in struggling, came in frustrated. Their diets haven’t worked in the past, their medications are only working so well. And tell us their stories.   Dr. Eric Westman 58:24-58:53 Yeah, well, uh a doctor comes to mind. who uh who’s weighing three hundred and fifty pounds ish, so it doesn’t matter how tall you are, you’re gonna find you’re gonna hit the high BMI obesity category. But he he also had a really serious metabolic problem called POTS, postural orthostatic tachycardia syndrome. I’m seeing a lot more of that. And it actually he was so skeptical. I mean, come on.   Joe 58:53-58:55 And what’s it like to have POTS?   Dr. Eric Westman 58:55-59:09 Well POTS makes you uncomfortable when you stand. You might get tachycardia at a fast heartbeat, you get flushing, and then you can even pass out. So he was finding himself on the floor at home. His family would come find him.   Terry 59:10-59:13 And so he’s at three hundred and fifty pounds they couldn’t lift him up.   Dr. Eric Westman 59:13-01:00:30 Yeah. Well that that that all goes without saying. The the problems of the obesity too. I mean, so it’s like, the obesity’s kind of become, oh yeah, I can fix that, no problem. I just explain w we have fat on our body, we need your body to burn fat. It’s these other conditions. So that when he came back thinking uh or uh seeing the weight loss, that was one thing. But then when he starts saying, you know, I’m not having those spells anymore. You know, you are starting to understand the metabolic changes that are happening go beyond just the weight loss. And this could apply to any number of things. It’s common today for people to be very skeptical and then they come back sort of the tail between their legs, you know, I didn’t think this was gonna work. Uh one gentleman in his seventies, uh and he and his wife came back and and they were like, Wow, this really does work, down, you know, twenty pounds in the first visit dur uh duration since the first visit. And so uh that kind of change can happen fast, and the idea that you could change these medical issues just by changing the food, that’s just not common knowledge. It’s not commonly known. And food really is is king   Terry 01:00:28-01:00:35 Do we have any idea how a carnivore diet affects the gut microbiome?   Dr. Eric Westman 01:00:36-01:00:37 Oh, it changes it for sure.   Terry 01:00:37-01:00:44 I would imagine it would because uh what what you eat does change the microbes inside you. Well what’s the impact?   Dr. Eric Westman 01:00:45-01:02:03 I I wrote a book with uh super smart uh writer that’s my my method is I team up with other people for books and we would go, not the microbiome again, you know, it’s another study, another distraction. So of course the microbiome changes, and it changes in a favorable way. Best way I can it can can explain it is like a a scientist who showed me at a at a world class meeting. He showed, click, here’s a slide of this jungle, like the Amazon, and here’s your microbiome. It’s beautiful, it’s of colors, and I’m like, well, there are things that can kill you there. It’s uh, you know, it’s the Amazon, little frogs and th and then he goes, Click, and here’s the microbiome on a low carb diet and it was like a desert. And I’m thinking, man, Zen meditation and and uh resort area. This is really calm. That’s what happens. Your microbiome calms down when you do a current, of course it changes. And it’s fascinating today. Well we, we study carb eaters and look at their microbiome and say, well, if we can just have that bacteria and put that in another person who doesn’t eat carbs, we’re gonna get all no, no. So the best thing for your microbiome is to cut the carbs out.   Joe 01:02:03-01:03:02 I’ve got a question, Dr. Westman, about GERD. I remember a paper that you wrote that was I would say semi-heretical, because at that time uh the H2 antagonist drugs were in the ascendancy, and then along came the proton pump inhibitors, which were going to be even so much better. And no more heartburn, no more GERD, we’ve got drugs. And you did a study, not a huge one, but it said a low carb diet could change everything for people suffering from GERD, from bad heartburn, esophagitis. And then we started writing about it and people started reporting, hey, you know what? It works. Even though conventional west wisdom from the medicine community was, oh, just give them a PPI.   Terry 01:03:02-01:03:06 Oh, and you should not be eating fat, obviously, if you have GERD, right?   Joe 01:03:06-01:03:06 Exactly.   Dr. Eric Westman 01:03:07-01:03:08 Or caffeine or chocolate.   Joe 01:03:08-01:03:09 Or any of that stuff.   Dr. Eric Westman 01:03:09-01:04:59 So that’s all the old, old stuff that doesn’t really work. (JOE) So give us an update. Dr. Eric Westman Well uh looking back, the studies we did really are proof of concept studies, right? So they aren’t big randomized trials looking at different types of diets. So differ many different diets could work. But this was a interesting study by a GI fellow at UNC. So we actually had a Duke UNC collaboration at the time and he put a pH probe down the nose into the stomach of these people with refractory heartburn. and and looked just over a few days of changing the diet, the acidity changed. So you actually were changing the diet was like taking an antacid. So whoa, yeah, so that was after the clinical signal is so strong. If I put someone on twenty grams, total grams, not net of carbs a day. The heartburn goes away almost uniformly, a hundred percent. But now time passes, so so uh another study comes out where they gave a hundred grams of carbs, you know, the typical American may have two to three hundred grams. And they changed, cleaned up the food so it wasn’t junky. A hundred grams of carbs a day reduced the heartburn as well. So if we do a study that says 20 grams or less can fix, you know, 10 people, it doesn’t mean 50 grams can’t or a hundred grams can’t. And so there’s all this level of carbs that needs to be studied in my mind, or you just try it yourself, uh if you uh but the problem with that a hundred gram fixing or reversing heartburn is it didn’t work a hundred percent like the twenty gram one did. So uh yeah, that was uh a signal that, you know, I I cheated and I read that in Dr. Atkins book. Dr. Atkins health revolution, because he had seen this in his clinical practice. You know, you know.   Joe 01:05:00-01:05:22 You mentioned the science. Oh, we’re always looking for the science because we hear, oh Evidence-based medicine, randomized controlled trials. I searched high and low for data to support the traditional heartburn diet. Which as you say, it was uh no chocolate, no coffee, no fat.   Terry 01:05:23-01:05:23 No alcohol.   Joe 01:05:23-01:05:33 No alcohol. I mean, I I I looked for the data. Because this diet was given out by gastroenterologists all across the country for anybody who came in with heartburn. I couldn’t find it.   Dr. Eric Westman 01:05:34-01:06:04 Yeah, and I I think we can understand why. The mechanisms have been key for so long. So there’s the oh well caffeine loosens the lower esophageal sphincter. So it is c chocolate and and protein makes the glomerular filtration rate go up, therefore it must be bad. So if you only talk about mechanism, you can get into these strange rabbit holes. I really value whole human research where you’re not just focusing on those little things.   Bianca Garcia 01:06:04-01:06:52 Yeah, I think this is a really great transition into what I wanted to ask because science changes. And the carnivore diet kind of rose in popularity around COVID-19. And this was a time when scientific mistrust started to grow in the public. And we saw that as COVID guidelines changed, people were like, wait, why is science so flip-floppy? And there’s kind of a parallel here with the carnivore diet too. We’ve all been told plant-based, plant forward. Now it’s like, okay, meat forward. What do we do about this? And I think, you know, you’re you’re telling us a little bit about how science changes, but what would you say to somebody who was trying to make the right choice, but maybe feeling a little bit overwhelmed with the scientific method.   Dr. Eric Westman 01:06:53-01:09:27 Yeah, well, uh we do the best we can, and the basic biology to me rules. And nutrition epidemiology, even that’s the red meat causes cancer thing, it’s weak, observational, and to me that’s not something I use in my clinic. I don’t value that. That red meat does not cause cancer to the level of certainty that I need to say don’t eat red meat. And I I know I’ve been on panels with folks and there are international organizations that are based on plant-based anti-red meat principles. I understand that. But the group at McMaster, whom I visited in the late 1980s is evidence-based medicine for the world, basically. Uh and they call out that this evidence about red meat and cancer is weak. And it’s not clinically relevant. So so I don’t worry about that. But getting back to the basic principle, don’t eat a lot of junk food. Uh ultra-processed food today unfortunately suffers from this definitional thing. And, and processed food, people come to me saying, You mean I can’t have bologna and it can’t have that I said, No, you can have bologna, but that’s processed. No, that that’s minimally processed. There’s more nitrates in beets and and broccoli than in these other you know, so I, yeah, it gets confusing, doesn’t it? So you want to eat protein, we’re made of protein. It doesn’t matter to me if it comes from an animal or a plant. We’re made of protein. Water is a given. You’re gonna have thirst. Then you can run your body on carbs or fat. It’s your choice. You can, you know, to sustain whatever kind of activity you’re trying to do. So that opens the idea that you might do a keto or carnivore diet because you’re running on fat. And that’s why we see people having such success with it. The body works just fine. If you don’t like that way of eating and the social things today, I mean but let’s get real. Were we really designed to eat at a Thai food place and then a Mexican place and then a and then a uh you know, all these great flavors, not you know, I don’t think that’s particularly a good thing, healthy thing to do. Uh it’s very new and and uh you want to be um honest about your ability to control things. If you’re out of control with sugar, you avoid sugar. If you’re out of control with bread, you avoid bread. You know, if you’re uh so I think protein comes first. Instead of plant forward, I wish we would say protein forward.   Joe 01:09:28-01:09:37 Final words? (Dr. ERIC WESTMAN) To summarize about a carnivore diet?   Dr. Eric Westman 01:09:35-01:10:14 I think it’s a reasonable tool, and it may even be a healthy way to eat in the long run. There’s a study that just came out, meaning in the last few years. where they looked at women who had been keto‑adapted for an average of three years and all of the biochemical parameters they were able to check looked great. They fed them a UK based diet with carbs and everything went to hell in a handbasket, I know, a great scientific term. And then they went back on a keto diet, and everything looked great. The average age was 32 years old. So what’s unknown is is this a long-term thing, but it might be.   Terry 01:10:15-01:10:21 Dr. Eric Westman, thank you so much for talking with us in The People’s Pharmacy today.   Dr. Eric Westman 01:10:21-01:10:22 My pleasure.   Terry 01:10:23-01:10:26 And thanks to you, Bianca Garcia, for helping us with the interview.   Bianca Garcia 01:10:27-01:10:28 Thank you.   Terry 01:10:28-01:10:43 You’ve been listening to Dr. Eric Westman, Associate Professor of Medicine at Duke University. He’s a board member of the Society of Metabolic Health Practitioners and the American Diabetes Society.   Joe 01:10:43-01:11:00 We had help today from Bianca Garcia, a medical anthropologist, foodie, and radio person. She served as a AAAS mass media fellow covering health and science at WUNC North Carolina Public Radio.   Terry 01:11:01-01:11:13 Lynn Siegel produced today’s show. Daenerys Thomas and Al Wodarski engineered. Dave Graedon edits our interviews. B. J. Leiderman composed our theme music.   Joe 01:11:13-01:11:21 This show is a co-production of North Carolina Public Radio WUNC with The People’s Pharmacy.   Terry 01:11:21-01:11:40 Today’s show is number 1444. You can find it online at peoplespharmacy.com. That’s where you can share your comments about today’s interview. You can also reach us through email, radio@peoplespharmacy.com.   Joe 01:11:40-01:11:51 Our interviews are available through your favorite podcast provider. This week we’re celebrating 10 million downloads.   Terry 01:11:51-01:11:52 That’s cool.   Joe 01:11:52-01:12:18 Yes. You’ll find the podcast on our website on Monday morning.   Terry 01:12:18-01:12:42 At peoplespharmacy.com, you could sign up for our free online newsletter. That way you get the latest news about important tell stories. When you subscribe, you also get regular access to information about our weekly podcast. We’d be grateful if you’d consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer.   Joe 01:12:42-01:12:45 In Durham, North Carolina, I’m Joe Graedon.   Terry 01:12:45-01:13:28 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 01:13:28-01:13:38 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 01:13:38-01:13:43 All you have to do is go to peoplespharmacy.com slash donate.   Joe 01:13:43-01:13:59 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.  

Transcribed - Published: 12 September 2025

Americans take a lot of medications. Luckily, the Food and Drug Administration only approves those that are safe and effective. However, the agency’s definition of “safe” includes medicines that can harm or kill some people, and the definition of “effective” covers some drugs that only work a little better than placebo. Has the FDA changed its standards? Maybe we should be rethinking medications. 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 on Saturday, Sept. 6, 2025, at 7 am EDT on 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 Sept. 8, 2025. Rethinking Medications: If you watch television or streaming video, you probably see a lot of commercials for prescription pharmaceuticals. Decades ago, prescription drugs weren’t advertised on television, and the prices for prescriptions were much lower. How has the pharmaceutical industry changed? On this episode, we talk with an expert observer of the industry and its regulation. Dr. Jerry Avorn is one of the country’s most respected pharmacoepidemiologists. He describes how the business of making and selling medicines has evolved. What Is the Role of Orphan Drugs? The Orphan Drug Act was passed in 1983. Its goal was to offer incentives to drug companies to develop medicines for rare diseases.  The FDA encouraged Congress in this, viewing these as “significant drugs of limited commercial value.” The idea was to make sure that even though only a few hundred Americans might have leprosy, for example, that drugs would still be developed to treat their condition. Tax breaks, patent extensions and market exclusivity made the proposition more appealing. In fact, one of the reasons Americans spend twice as much on drugs per capita as citizens of Canada, Australia or other countries is the cost of orphan drugs. Although these compounds were seen as having “limited commercial value,” the industry has figured out how to charge exceedingly high prices for anything considered an orphan drug. How Effective Is Your Medicine? When it comes to evaluating effectiveness, pharmaceutical firms have a powerful tool. Dr. Avorn considers it one of the best inventions of all time, although it is a concept rather than a thing. RCT stands for Randomized Controlled Trial, which in turn is shorthand for randomized placebo-controlled double-blind (or in the UK, double-dummy) clinical study. The idea is to take a group of people who are alike in some important ways, so that they are equally likely to develop some type of health problem. Divide them up using a random number generator or some other similar impersonal technique. Those on one side of the divide get the medicine, while those on the other side get an indistinguishable placebo. Neither the participants nor the investigators know who is in which group. At some pre-specified time, the researchers will check to make sure there have not been too many adverse reactions. They may also check that the intervention appears to be doing something. When the trial is over, the methods and results should be described in a publication so that doctors will know if they should incorporate the treatment into their practice. We love RCTs when the outcome is avoiding some serious problem such as a stroke or a cancer diagnosis. For us, biomarkers are less compelling, even though they have become far more common. What is a biomarker? It is easy to measure, like blood sugar or blood pressure. The biomarker is a stand-in or surrogate for a condition like diabetes or heart disease because they are often correlated. It is important to remember, though, that the biomarker is not the disease. Comparing Absolute and Relative Risk While Rethinking Medications: Once the company has completed its RCT, more than likely it will want to publicize the results to promote the drug. How it describes effectiveness can change the way people think about the medicine. One of our favorite examples comes from a print advertisement for Lipitor. It boasted that Lipitor (atorvastatin) lowered the risk of a heart attack (myocardial infarction) by 36 percent. That sounds great, doesn’t it? There was an asterisk next to that number, and in small print lower on the page was an explanation. During a five-year trial, out of 100 people on Lipitor, two had heart attacks. Out of 100 people on placebo for that trial, three had heart attacks. So you can see the absolute difference between Lipitor and placebo was just one heart attack per hundred (the absolute risk reduction). That probably would not have sold many pills. But stated as a relative risk reduction of 1 fewer heart attack compared to the baseline of 3 (1/3), using larger numbers because there were thousands of people in the study, you get 36 percent. What Do We Know About Safety? When patients see multiple health care providers who don’t talk with each other often, it may be difficult to detect serious safety problems. That was the case with the anti-inflammatory drug Vioxx. Early warning signs of cardiovascular problems resulting from this pain-reliever were overlooked for years. Researchers detected trouble as early as 2001, but the drug company resisted removing the drug until 2004. As a result, millions of people were needlessly exposed to danger and too many died. The silver lining to this cloud is stepped-up surveillance for side effects. Rethinking Medications with Respect to Side Effects: Some years ago, Dr. Avorn and his colleagues conducted a brilliant study (Drug Safety, 2009). They compared the side effect profiles from RCTs of different antidepressants. Mind you, they were not looking at the side effects of the drugs. They examined the side effects of the placebos in studies of tricyclic antidepressants and compared them to side effects of placebos in studies of SSRI antidepressants. All the participants had depression, so there should have been no differences due to the underlying condition. Yet the placebos had vastly different side effect profiles, mirroring the divergent side effects of the active agents. This striking difference might be due to changes in the way researchers elicited symptoms. Or it might be due to the nocebo effect, in which a person who expects to feel nauseated becomes queasy. Nocebo is like an inverse of the placebo effect. Either way, it suggests that when side effects of the placebo are similar to those of the investigational drug, we shouldn’t assume that the drug has no side effects. How Can You Protect Yourself? In rethinking medications, it is important to make sure that you really need all the drugs you are taking. Dr. Avorn strongly recommends a brown bag review periodically, in which the patient brings in everything he or she is taking, including OTC meds and dietary supplements. The health care provider reviews them, looking for duplication or incompatibilities. If they find problems, it’s time for a conversation about alternatives or deprescribing. Some medicines cannot be stopped suddenly, so the prescriber should provide detailed instructions about tapering and should monitor progress as the patient reduces the dose. This Week’s Guest: Jerry Avorn, MD, is a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham health-care system. He built a leading research center at Harvard to study medication use, outcomes, costs, and policies and developed the educational outreach approach known as “academic detailing,” providing evidence-based information about medications to prescribers. One of the nation’s most highly cited researchers, Dr. Avorn is the author of Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs, and he has written or cowritten over six hundred papers in the medical literature as well as opinion pieces in TheNew York Times, The Washington Post, JAMA, and The New England Journal of Medicine. Dr. Avorn’s new book is Rethinking Medications: Truth, Power, and the Drugs You Take. His website is www.RethinkMeds.info Jerry Avorn, MD, author of Rethinking Medications Listen to the Podcast: The podcast of this program will be available Monday, Sept. 8, 2025, after broadcast on Sept. 6. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, we discuss sourcing medications from abroad. How does that affect drug shortages? How will tariffs affect costs? In addition, you’ll get more details on a brown bag review. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1443: Rethinking Medications: Uncovering the Truth About Common Drugs 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. Americans spend more on drugs and have less to show for than people in other countries. Today, rethinking medications. This is the People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:41 The FDA used to be the envy of the world. Has it been captured by the pharmaceutical industry it’s supposed to regulate? Joe 00:41-00:52 You’ve heard of Ozempic and Wegovy. They both contain semaglutide as the active ingredient. How could they have dramatically different rates of side effects? Terry 00:52-00:59 Are you fed up with all the prescription drug commercials on TV? What about the high price of many prescriptions? Joe 00:59-01:15 Coming up on the People’s Pharmacy, uncovering the truth about common drugs. Terry 01:14-02:31 In the People’s Pharmacy Health Headlines, lowering sodium intake is good for cardiovascular health, but increasing potassium intake may be just as important, if not more so. A Danish study of twelve hundred patients with implanted cardioverter defibrillators, or ICDs, compared usual care to a strategy designed to get potassium levels into the upper end of the normal range. All of these study participants were at high risk of atrial fibrillation and all started with potassium levels at the low end of the normal range. The outcomes of the study were ventricular tachycardia, which is a dangerous heart rhythm, or having the ICD kick in appropriately. In addition, the investigators looked at hospitalization for arrhythmias. The patients assigned to the high-potassium group were prescribed potassium-sparing blood pressure medicines, such as ACE inhibitors. They were encouraged to follow a diet rich in potassium, including foods such as cabbage, beets, white beans, bananas, spinach, nuts, and fish. If those steps were unsuccessful at nudging potassium into the high normal range, the researchers prescribed potassium supplements. Joe 02:29-03:12 In this vulnerable population, targeting high normal potassium was helpful. They had significantly fewer episodes of ventricular tachycardia or hospitalization for arrhythmia, and their ICDs activated less frequently. A hundred and thirty-six of them experienced such an event, a rate of 7.3 per 100 person-years. In the usual care group, 175 volunteers had one of these dangerous episodes, a rate of 9.6 per 100 person-years. The patients in the high normal potassium group were also less likely to die during the three years of the study. Terry 03:11-04:10 The VITAL trial is a randomized controlled study of vitamin D and omega-3 fatty acid supplementation. The initial findings were that neither supplement reduced heart attacks or cancer in otherwise healthy middle-aged people. After four years, however, people taking 2,000 international units daily of vitamin D3 had longer telomeres than those taking placebo. Telomere length is a powerful measurement of aging. Telomeres are located at the tips of chromosomes and appear to protect them. As a result, shorter telomeres are associated with chronic diseases such as cancer and cardiovascular disease. Longer telomeres are a biomarker for slower aging. The authors conclude that vitamin D3 supplementation reduced telomere attrition and preserved telomere length, supporting an anti-cellular aging effect of vitamin D. Joe 04:11-05:17 Scientists have known for years that people with high blood pressure can benefit from drinking beet juice. British scientists have now done a more thorough study of this effect. They compared the reaction of 39 people under 30 to that of 36 volunteers in their 60s or older. Each group took nitrate-rich beet juice every day for two weeks or a placebo juice that had the nitrate removed. After a two-week washout period, they took the other treatment for two weeks. During this time, the researchers monitored participants’ blood pressure and their oral microbiome. In older volunteers, both oral microbiome and blood pressure improved with beet juice. A healthier mix of microbes in the mouth helps metabolize the nitrates in beet juice into nitric oxide that relaxes blood vessels. The investigators point out that beet juice is not a substitute for prescription blood pressure medication, but it can help. People who don’t like beets might consider other nitrate-rich vegetables such as spinach, celery, and kale. Terry 05:17-06:16 For decades, cardiologists prescribed beta-blocker heart drugs to almost everyone who had a heart attack. A new study published in the New England Journal of Medicine calls that practice into question. The randomized controlled reboot trial assigned over 8,000 patients to receive either a placebo or the beta-blocker bisoprolol. After nearly four years of follow-up, there was no difference in outcomes. The new consensus is that many heart attack patients with good heart function don’t need beta blockers. Those with poor ejection fractions may still benefit. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:29 And I’m Joe Graedon. Americans love pills. We take more medicines, spend far more on them, and see way more prescription drug ads than anyone else in the world. Terry 06:29-06:43 The Food and Drug Administration was once regarded as the best regulatory agency. Over the past decade, though, standards for drug approval have changed. Are Americans more vulnerable now than they were before? Joe 06:43-07:19 To help us tackle questions about drug safety and effectiveness, we turn to Dr. Jerry Avorn. He is a professor of medicine at Harvard Medical School and a senior internist in Mass General Brigham Healthcare System. He built a leading research center at Harvard to study medication use, outcomes, costs, and policies. Dr. Avorn is the author of “Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs.” His new book is “Rethinking Medications: Truth, Power, and the Drugs You Take.” Terry 07:19-07:23 Welcome back to the People’s Pharmacy, Dr. Jerry Avorn. Dr. Jerry Avorn 07:24-07:25 It’s good to be back. Joe 07:26-08:00 Dr. Avorn, during your really long and illustrious career at Harvard Medical School, you have focused so much of your research on the benefits and risks of pharmaceuticals. I would have to say you are probably the country’s most respected pharmacoepidemiologist, and we have been tracking your work for decades. We’re honored, honored to have you as a guest today on the People’s Pharmacy. So thank you so much for writing Rethinking Medications and joining us today. It’s a pleasure to be with you. Terry 08:01-08:11 Dr. Avorn, I’m wondering, how has the pharmaceutical industry changed since you started studying medications that Americans are taking? Dr. Jerry Avorn 08:11-08:35 Well, it has become even bigger business than it was, which is something we need to all be kind of cognizant of. But also the science has gotten more and more impressive, both within the industry and also within medical schools and academic medical centers where we’re just really discovering things and putting them into practice in ways that would have been unthinkable even 30 years ago. Joe 08:36-08:46 What about the FDA, Dr. Avorn? I mean, it seems as if the FDA has also changed over the last couple of decades. Dr. Jerry Avorn 08:46-10:10 Yeah, and that’s I think a less happy story, in the sense that uh a lot of the mischief began with the best of intentions back in the nineties at the height of the AIDS epidemic and there was concern that FDA was being so careful about reviewing drugs that maybe it was taking longer than it should. And the idea came up of let’s have a system of accelerated approval in which even if a drug hasn’t really been shown in a clinical study to benefit patients, if it looks promising, let’s approve it and then have the company do follow up studies so we know what we’re dealing with. That was a sensible idea back in the early nineties, because we did have no good treatments for AIDS at that point, and we did want to get anything that looked promising out there. But unfortunately, that accelerated approval program has become a loophole that has been widened and widened well beyond what anybody ever intended. And we now have drugs, you know, like for ALS or muscular dystrophy or other conditions, which are approved on the scantiest of evidence. And then the companies don’t quite get around to always doing the follow-up studies that they promised to do. And we have a lot of medications that actually should not have been approved hanging around on the market and costing money and presenting risks and not doing any good for patients. Joe 10:10-11:31 Well Dr. Avorn, you brought up a really, uh hot topic for us. Because it used to be that the FDA was very clear and it said, we will not approve any medication unless it’s proven safe and effective. And I think the FDA’s definition of safe and effective is obviously quite different from what the average citizen would define as safe and effective. And all you have to do is turn on the television and watch one of the uh commercials for for pharmaceuticals where they say this drug can cause heart attacks and strokes and severe infections and cancer, and even death, and uh uh it’s like, well, how could that medicine be considered safe if those are potential side effects. And then when it comes to the effectiveness side, we have drugs that are barely better than placebo, as you’ve sort of alluded to. And in particular, I’m thinking of the FDA’s approval of the most recent Alzheimer’s drugs that uh don’t actually do very much. So tell me about safe and effective and what that means to you versus what it means to the FDA versus what it means to the average citizen. Dr. Jerry Avorn 11:31-13:51 Boy, is that a good question? Yes. Let me say something encouraging for starters, and that is all of those adverse effects that we see rattled off on the TV commercials that you can’t possibly avoid if you want to watch the evening news, um, are there because they are required to be there by the FDA. But you know, if you were to look at the adverse effects of, you know, aspirin or Tylenol, uh it would be a pretty scary list as well. What we have relied on the FDA for is to say, in effect, over the years: Every drug can cause side effects, some of which are very scary, but we want some assurance that it’s been looked at carefully. And that the good that the drug does is overwhelmingly better and more common and more useful than the rare side effects that it can cause. Because there is no drug, as you both know so well. that doesn’t have side effects. We just want that balancing to be done by the FDA and then by the prescribing doctor or other healthcare professional. That’s the ideal. Where things have really gone off the rails is with FDA paying less attention to the real does it help patients question And then frankly, as you mentioned for the Alzheimer’s drug, the worst of which was this drug called Aduhelm that did not benefit patients at all. Was approved kind of over the objection of the outside advisors and the FDA’s own staff, and turns out to actually have some substantial side effects And it was initially priced, uh, as you know, at $56,000 a year for getting an infusion intravenously every other week. to achieve no important clinical benefit. You know, that was really kind of the low point of of FDA’s recent history and it got pulled off the market a couple of years ago because it was such a stupid drug. But so I think where FDA has gone astray is that it has really lost its uh value system or a sense of balance. and has really lowered the standards of, okay, if you can make a lab test look a little better, then we’ll let you have approval. And even if you’ve not been able to show benefit to patients. And that that’s really not what the FDA was designed to do in the modern era Terry 13:49-13:59 Oh well Dr. Avorn, how did the FDA get to the point where it was willing to lower its standards so much? You do write about that in “Rethinking Medications.” Dr. Jerry Avorn 13:59-15:02 Well, you know, as as you both know so well, this is a half a trillion dollar a year industry in the US alone, probably more than that by now. And that brings with it an enormous amount of political pressure. And it used to be that the FDA would kind of rise above political pressure and just do what the science said. But over a number of years, the pharmaceutical industry became the most powerful and richest lobbying entity in Washington, and they’ve got more lobbyists than there are people in Congress. And there’s a lot of pressure both on Congress people from both sides of the aisle and on the administration under Democrat and Republican presidents. To, you know, have the FDA kind of go easy on industry and just approve stuff that hasn’t really been shown to pass muster. And the more dollars go into medications and the bigger business it is, the more firepower there is behind that political pressure. And the political pressure has been sort of winning out over the science more and more in recent years. Joe 15:02-15:39 Dr. Avorn, when you started your career and when we got started, there were no prescription drug ads on TV. You know, there were you know Anacin ads and Alka-Seltzer ads, but there there weren’t ads for Jardiance. And for um oh you go down the list, there’s so many that it’s almost takes your breath away these days and they come on every other every other commercial. Can we get your perspective on the direct-to-consumer prescription drug advertising that’s everywhere? Dr. Jerry Avorn 15:40-18:03 Yes. As your listeners will know, and as you both know very well, we are the only country on earth that allows drug companies to advertise prescription drugs direct to consumers. And every other country, with the one exception of New Zealand, which is kind of an asterisk, but every other kind of wealthy industrialized country that we often compare ourselves to has said, no, these are too complicated issues. They are not something you can boil down into a 60-second commercial with people dancing around and singing songs and having the adverse effects flash by quickly on the screen. Everybody knew that this is not something you can condense into a quickie commercial and then get the patient to go to their doctor and say, gimme this. And actually the industry was pretty the drug industry was pretty okay with that for many, many years because ads to consumers, especially the kind that are on prime time, are very, very expensive to buy airtime. and they’re expensive to produce. And as long as uh the industry felt it was okay not competing with shampoos or cars or toothpaste or any of the other things you see ads for, they were willing to go along with that ban. And then in the 90s, with the rise of managed care and health maintenance organizations that said, no, this drug is not on our formulary. It’s way overpriced. It’s not particularly good. We’re not going to cover it. The industry said, hey, wait a minute, we gotta try to get around that prohibition. And they said to themselves, we can make every patient into a potential sales rep. And by, you know, having releasing our our our self-imposed w unwillingness to have drug ads. Let’s have the FDA say it’s okay because we need to get to the patients to make them into agents of sales to go to the doctor and say, I want Ozempic because I saw a commercial for it. And so in 1997, for the first time ever, the FDA said, okay, it’s all right for there to be direct-to-consumer drug ads, again, alone in the entire world. I don’t think we can say that this has somehow benefited the public health or made prescribing of medications better or safer or more effective, but it is something which billions of dollars get spent on. by the companies. And of course those billions of dollars just get added on to the drug price. Terry 18:04-18:21 You’re listening to Dr. Jerry Avorn. He’s a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. Doctor Avorn is the author of Rethinking Medications Truth, Power, and the Drugs You Take. Joe 18:21-18:28 After the break, has the FDA been captured by the industry it’s supposed to regulate? Joe 21:03-21:07 Welcome back to the People’s Pharmacy. I’m Joe Graedon. Terry 21:06-21:08 And I’m Terry Graedon. Joe 21:08-21:20 Today we are putting the FDA and the pharmaceutical industry under a microscope. Should we be rethinking how our medications are regulated, priced, and advertised? Terry 21:20-21:52 Our guest is Dr. Jerry Avorn. A professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System, he built a leading research center at Harvard to study medication use, outcomes, costs, and policies. Dr. Avorn is the author of Powerful Medicines, The Benefits, Risks, and Costs of Prescription Drugs. His most recent book is Rethinking Medications: Truth, Power, and the Drugs You Take. Joe 21:52-23:00 Dr. Avorn, the cost of prescription drugs has skyrocketed, and in particular for something called orphan drugs. Now, I have to be honest with you, I visited Dr. Marion Finkel at the FDA shortly after the Orphan Drug Act was passed, because she had led the Committee on Drugs of what were called limited commercial value. I wonder what happened to those ideas about kind of facilitating the development of medications for rare conditions, because the FDA thought, you know, no drug company is going to make money from medications for these so-called orphan drugs. That is not the way it turned out, and I Fear that Marion is turning over in her grave. Your thoughts on drug prices for orphan drugs and drugs in general. Dr. Jerry Avorn 22:59-25:52 Well, as you both know, Americans spend twice per capita what citizens of other wealthy countries spend on medications. Whether it’s uh Canada or England or um Japan, Australia, all of Europe, um, they pay literally half of what we do for the same drugs made by the same companies in the same factories. And orphan drugs are one important example, but it really is across the board. Even Ozempic, which we’ve talked about in the last segment, is a drug which in the uh in most of Europe costs half of what it costs Americans. Why is that? It’s because America is the only country on earth that says to the drug companies, set your price at any amount you want, and that’ll be the price. Not only is that weird, it’s also not the way we pay for anything else in our economy. It’s certainly not the way the federal government pays for anything. They don’t um you know, go to a um airplane manufacturer and say, charge whatever you want uh for this new fighter plane and we’ll pay whatever you ask. It’s up to you. That’s a crazy way to do business. For people who are fans of a functioning marketplace, you know, it’s not a marketplace. It’s just this weird arrangement that is only there because we have legislated it into being. And in fact, when the Medicare program started paying for drugs in the early 2000s, the guy that shepherded the program through Congress. Passed a law that said that no company can be negotiated with over the price of its drugs in the Medicare program. And then he promptly left Congress and took a job at a million bucks a year to head the pharmaceutical lobbying group. So he was well rewarded for that legislation. And we then are left with this crazy system where, you know, there was there was a one drug company CEO when he raised the price of a drug by thousands of percent when he bought the rights to it, and they said. How can you possibly do that? And his answer was, because I can. And sadly, although that was more crude and he ended up doing some jail time for some fraudulent activity in other ways. He was he was ruggedly honest. Yeah, because they can. So when you have companies that understandably want to please their shareholders and they’re allowed to charge anything they want, why wouldn’t they? And and we’ve in our group at Harvard have talked to folks from other countries where they have a much more thoughtful process for looking at what a medication is worth. Drug companies ought to earn handsome profits on the work that they do. And if they discover a new drug, they ought to be richly rewarded for it. But if they’re just taking a same old, same old little modification and they say it’s a new molecule and we want our own patent and then charge whatever they damn please, that that really shouldn’t be allowed, as it isn’t most everywhere on earth. Joe 25:53-26:54 Dr. Avorn, I had mentioned orphan drugs and you know there are now designated orphan drugs for cancer, for example. That cost literally hundreds of thousands of dollars a year per patient. And there are some other rare diseases, muscular dystrophy, et cetera, where the cost can be, you know. uh close to a million dollars a year. Uh and these were supposed to be drugs of limited commercial value. Um It’s not unusual for some of these so-called orphan drugs to bring in billions of dollars a year for the manufacturer. I, I’m I’m just wondering what will happen if there is truly an effective drug for Alzheimer disease. The company could easily charge couple hundred thousand dollars a year and say, hey, it’s a bargain keeping people out of nursing homes, and yet that would break the bank on Medicare and break the bank of insurance companies almost overnight. Dr. Jerry Avorn 26:54-28:52 Absolutely. And of course, Alzheimer’s would not be an orphan condition because it is so appallingly common, but other conditions, and you you mentioned cancer drugs. If a company says this drug is going to attack a particular kind of mutation or a particular kind of receptor or a particular kind of pathway in a particular kind of cancer, they can manage to narrow it down to the point where that condition affects less than 200,000 Americans a year. And that is the legal definition of an orphan drug. But, you know, we think of cancer as a relatively common condition. But if they’re able to structure the application to the FDA for a particular kind of a particular kind of lung cancer. They can say, oh, this is now an orphan drug, so we get to have all the goodies that come with it, which is much uh more generous research and development money and much more freedom to get it approved uh with perhaps lower standards. And so that that’s a particular um anomaly for drugs that are for conditions that are uncommon. You mentioned muscular dystrophy. That has got to be one of the more egregious examples of companies. There’s one company here in the Boston area called Sarepta that got through on not the orphan drug pathway primarily, but on the accelerated approval pathway. And they said, look, we’re changing the level of a certain protein in muscle. And that’s you know by just a tiny bit, but I bet that’ll help patients It didn’t help patients, but the FDA said, well, you did change that level a little bit. Maybe that might work, even if you didn’t show any benefit. And that company then went on to not just market that drug, but several other drugs of exactly that approach with tiny modifications, none of which have been shown to be very helpful. And the FDA’s excuse was they wanted to bring cash into the company because that will help them to do more research to find a cure. Terry 28:52-28:53 So wait a second. Dr. Jerry Avorn 28:53-29:14 That’s not FDA’s job to bring cash into companies. And B you, it actually had the opposite effect. It said to the companies. Hey, you can get by with a drug that has a trivial change in a lab value and you’ll get yourself a drug. So that’s why we now have multiple ones of these drugs, each of which cost hundreds of thousands of dollars per person per year, and none of which work hardly at all. Terry 29:15-29:55 All right, so Dr. Avorn, this really brings up the issue of the FDA is supposed to be reviewing drugs and the research that has been done on these drugs to make sure that they’re safe and effective. And we we haven’t really talked about how do you tell if a drug is safe enough. We have talked about the fact that every drug that we know of has some side effects for some people some of the time. But has the FDA actually changed its objectives? Has it, in fact, been captured by the industry it’s supposed to be regulating? Dr. Jerry Avorn 29:53-32:54 I think that’s a great question, and the quick answer is yes, they have. To look separately at effectiveness and safety. The effectiveness, as we’ve discussed, if you are going to be willing as FDA to now accept a tiny change in a lab test as your replacement for this helps patients, then you know the horse is really out of the barn. And we’ve seen that with the accelerated approval of these muscular dystrophy drugs, the Alzheimer’s drugs and so forth. So they’ve lowered the bar so low that you almost, you know, it’s kind of rubbing on the ground. So that’s on that’s on the effectiveness side. And that’s not what the nation had in mind in the 1960s when they said for the first time anywhere, The government can require a company to show that a drug works before you can sell it. That was a revolutionary advance in 1962, and we’ve really bit by bit backed away from that. Safety-wise, I think there’s a somewhat happier story, but it followed a kind of tragedy, and that is the drug that you both know well. which is Vioxx, which was made by Merck as a treatment for arthritis and pain. And it appeared that it was likely to cause heart disease. And we actually did a fair amount of research uh on that question in in our group at Harvard. And it turns out that we found, as did other groups, around the country that yeah, it if you take this drug, it’s going to increase your risk of heart disease. And is that worth it, you know, to get a little bit better pain relief or a little bit gentler on your stomach? And the company said no, no, no. They said we should not publish our research because we would become laughing stocks. And they denied it up until the moment, after five years on the market. That a randomized trial that they themselves at Merck had funded showed that the drug doubled or tripled the risk of heart attack and stroke. And then once that data was available from a randomized trial, they kind of had to take the drug off the market and they ended up spending the next several years paying out five billion dollars or so to patients who had had heart attacks and strokes after taking Vioxx. So the good news, if you can to come back to your question and How is this leading to good news? Is that there were congressional hearings right after that drug was withdrawn? Because after all, 20 million Americans had had taken the drug. Medicaid spent a billion dollars on just that one drug. And Congress said, essentially, to Merck and to the FDA, how the hell did you let this happen? And that unleashed a program that many of us had been advocating for years. which is FDAs performing more proactive surveillance of side effects for drugs that are in widespread use so that they get claims data. anonymized from people all over the country so they know who took which drug and who had what side effect. And so the the happy outcome of that tragedy is that uh we are now much better able to spot a side effect of a drug while it’s on the market before it’s affected millions of people. Joe 32:55-34:48 We’ll talk a little bit about the MedWatch program in a moment and how firings at the FDA may have affected that, but I want to go back to the issue of effectiveness first. Because I don’t think the average patient, and maybe even the average physician or prescriber Understands the difference between relative risk reduction and absolute risk reduction. And our favorite example is atorvastatin. And the commercial for the brand name Lipitor. There were ads in magazines that showed Lipitor lowered the risk of MI, myocardial infarction, heart attacks, by 36%. And I think a lot of people thought, oh, that sounds terrific. You know, 100 people take Lipitor. 36 of them out of 100 will avoid a heart attack. Wow, that’s impressive. But there was a little asterisk next to that, and it said three percent of the people on placebo experienced a heart attack after five years. Whereas two percent of the people on Lipitor experienced a heart attack after five years, so the absolute risk reduction was actually one percent, not thirty-six percent. And I I think this idea of absolute versus relative risk gets hidden because drug companies love to talk about relative risk reduction. How does the average physician understand the difference between absolute and relative risk reduction when it comes to, for example, statins? Dr. Jerry Avorn 34:49-37:23 To answer your question, we often don’t understand it as well as we should. Uh my view of how we train doctors is that while we do fill the heads of our very smart students with a lot of important facts, and we gotta do that, What we do a less good job at is helping them think about data in the way that you just described. And the fact that we are always, whenever we prescribe a medication, not only balancing risks and benefits, but also needing to think about the magnitude of those risks and those benefits. And that’s something which, you know, I’ve often felt that The facts that we cram into students’ heads, um, half of them may turn out to be wrong in ten years, but giving them the ability to think in the way that you were just describing about, you know, it still may well be that a statin is if it’s if it’s as safe as they are, is still, you know, for a high risk patient a good thing. But you want to come to that conclusion or not, based on thinking carefully about that issue of absolute risk reduction and relative risk reduction, and also about the the magnitude of the risks that are involved with taking any drug. And that’s where FDA could do a much better job. And that’s where we doctors, frankly, and we medical educators need to also do a better job. FDA’s standard has been If you have a drug that works better than placebo, unless it’s unethical to do a placebo-controlled study, like for AIDS or cancers. But if you have a drug that works better, which was the standard for that awful Alzheimer’s drug, Aduhelm, it it changed the level of amyloid in the brain a little bit tiny bit more than a placebo did. That’s not a comparison that I as a prescriber want to hear about. I want to hear how well does it work compared to other alternatives that we might want to offer? And then of course the the big granddaddy question is is whatever change it causes worth the exorbitant amount that we might be asked to pay for it. And that’s a level of analysis that is tricky to do. And you can’t just tell patients, Or doctors for that matter, go do your own research, you know, look up the papers and decide for yourself. We need to say this is a public good kind of question. And just as we don’t ask everybody to build their own section of roadway or make sure that you know, the water in their tap is you know clean and forget about where it’s coming from. These are things societies need to provide to their citizens. And it’s something we need to do a much better job of as a society. Terry 37:24-37:53 And we certainly have not done that very well for uh prescription medications. Consumer Reports uh offers you evaluations if you’re going to buy a car or a computer. You can take a look at the various categories in which you might rank such a consumer product, there is nothing like that for prescription drugs and they’re more important to our lives than uh a car or a computer, one could argue. Dr. Jerry Avorn 37:54-38:40 Mm-hmm. Absolutely. And I’ve tried to provide people with lists of reliable websites that you can go to without feeling like you’re being barraged by advertising or or just scammery. And you know those sites do exist and I tried to make that list available to people because While I’m not encouraging people to always just figure out for themselves what they need to take for their diabetes, it does help for to kind of even the playing field so that when a patient does go to the doctor, they at least can come equipped with questions like You know, is this drug just better than a placebo or is it really effective? What about the newer drugs? Is this affordable? Are there generics? And the kinds of things that everybody needs to be able to think about when they’re talking with their doctor about a prescription. Terry 38:39-39:07 You’re listening to Dr. Jerry Avorn. He’s a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. He developed the educational outreach approach known as academic detailing, providing evidence-based information about medications to prescribers. Dr. Avorn’s new book is “Rethinking Medications: Truth, Power, and the Drugs You Take.” Joe 39:07-39:11 After the break, we’ll talk about side effects. Terry 39:11-39:16 All medicines have some side effects. How do we learn which ones to watch out for? Joe 39:16-39:27 Dr. Avorn did a groundbreaking study comparing the side effects of placebos in antidepressant studies. What lessons can we take away? Terry 39:27-39:33 We’ll also get tips on the questions we should ask before we start taking a medication. Joe 39:34-39:39 And what should you know about stopping your prescription? Joe 40:59-41:01 Welcome back to the People’s Pharmacy. I’m Joe Graedon. Terry 41:02-41:04 And I’m Terry Graedon. Joe 41:04-41:18 One of the fastest-selling drugs in the pharmacy is semaglutide. You’ve probably seen commercials for its brand names, Wegovy or Ozempic. Why are the side effect rates for the same medicine so different? Terry 41:18-41:35 Our guest today is Dr. Jerry Avorn. He’s a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. His most recent book is Rethinking Medications: Truth, Power, and the Drugs You Take. Joe 41:36-42:10 Dr. Avorn, we’d like to segue a little bit into the side effect profile of medications. and how drug companies do their data collection. And we were so impressed with a study that you did many, many years ago. comparing placebo rates of an old-fashioned antidepressant category called tricyclics, drugs like amitriptyline. versus the side effects in the placebo group of the so-called SSRI. Terry 42:10-42:24 So comparing placebo to placebo So first explain please to the listeners why you compared placebo to placebo. Dr. Jerry Avorn 42:22-44:55 Well, one of the best inventions of all time is not a thing, but is a concept, the randomized control trial. Because it in the old days, um, people you know used to say, like if you were a doctor, in my experience this drug works well, or in my experience this one causes side effects. And it turns out As most of your listeners will know, you can’t figure that out from the perspective of any one doctor or any one patient. You’ve got to look at this systematically. And the beauty of a randomized control trial, which simply means that patients are given a new drug or a dummy pill, a placebo, And they look exactly alike, and they are randomly allocated to who gets the new drug and who gets the placebo. And neither the patient nor the doctor knows who got what. That is a very, very effective way of getting a handle on moving beyond this, in my experience, this drug works, you know, because if it doesn’t come across in a randomized controlled trial, then you got to wonder what in the world is is going on. But then we introduce the other really interesting issue of what some people call the nocebo effect And most listeners will know about the placebo effect, which is you give somebody a dummy pill and they say, thanks, Doc, that made me feel much better. There is the opposite um effect called the nocebo, which is from the Latin word for noxious, which is you give somebody a dummy pill and I mean I I don’t encourage ever doing this in practice, but in research, and they say, boy, that that pill really made me have side effects. And you know it’s not the pill because the pill just had, you know, some lactose powder in it. And so this has been a real boon to thinking about research studies because it gives you a handle on what is from the pill and what is just the patients. expectation that either they’re going to feel better or that they’re going to sometimes feel worse. And so what what we’re talking about in comparing Well the placebo rate of side effects is there shouldn’t be any difference if you have ideally people getting a dummy pill. in one study or another, if the patients are similar enough, you shouldn’t have it vary based on what the studied drug is that you’re testing. But we do see this, and it uh reminds us that an awful lot of the effects that people report from meds, both for good or for ill, may be not from the med, but may actually just be from the patient’s expectations or or perceptions. Joe 44:56-46:14 And one of the things that we think we’ve discovered is that drug companies have become ex- Extraordinarily skilled at influencing the reports of side effects. So let’s just compare two identical drugs Semaglutide is the ingredient in ozempic, which is a drug that was approved for diabetes, followed by Wegovy, the same exact drug that was approved for weight loss. In the clinical trials that the drug companies performed, 20% of the people who got Ozempic reported nausea. Forty to forty-four percent of the people who got Wegovy reported nausea, so almost twice as many on the same exact drug, but more interestingly, the people who were given placebo, that is to say, a dummy injection, 6. 1% reported that they experienced nausea on the dummy shot, whereas 16 to 18 percent of those getting the placebo shot complained of nausea. How did the drug company create those kinds of numbers? Twice as many. Dr. Jerry Avorn 46:12-47:45 Well, I think that they were probably as surprised as you were when they looked at those numbers because in principle, giving somebody a dummy shot should not create nausea or diarrhea or any other side effect. And so the reason it’s so important that we as prescribers and and the FDA have access to well-done randomized placebo-controlled studies is that we can look for things like that, and then we can say, well, gee, maybe there was there is a dose difference in the active drugs in those two examples. But the placebo doesn’t have a dose because it’s basically salt water. Why is this going on? And that makes me think as someone who evaluates drug evidence. Maybe there was a difference in the underlying patient populations, maybe because one was mostly for obesity and one was mostly for diabetes, or maybe there was some difference in the way they elicited the um symptoms. That is, you know, if they said, did you have any queasiness in the last week, as opposed to were you severely nauseated and vomiting? You know, you’re going to get very different answers depending upon how you ask the question. Now, ideally, the randomization should take care of that. And when you see a difference, you know that the difference is from the ingredient and not from any kind of expectation by the patient or the doctor. But it’s it’s a little hard to explain why it would be. And it must come down to either the underlying patient population and or the way they asked about the nausea, the vomiting, the diarrhea that created that. Joe 47:45-48:30 I am a bit cynical and I do think it has something to do with the way they asked the question because when they asked about diarrhea, the people on placebo had ten times the diarrhea rate if they were in a uh trial for Wegovy compared to a trial with Ozempic. But I I know we’re now in the weeds. And I guess what I’d like to do is segue quickly to the questions that patients should ask their doctor. whether it has to do with benefits or whether it has to risks, so that a patient will really have some substantive data to be able to evaluate whether they should be taking this medicine or not. Dr. Jerry Avorn 48:31-50:38 Absolutely. And as both of you have advocated for many, many years, patients need to be informed consumers and informed um patients when they go to the doctor. And that’s getting harder and harder every year because doctors are more and more rushed than ever. You know, it’s not their fault, but they’re asked to see more and more and more people. And it makes it hard for them to find time to actually sit down with a patient and talk about meds. But, you know, a as you both know, this is some of the most important conversations that we doctors can possibly have with our patients. And what I used to say was if your doctor doesn’t have time to that to do that, find another doctor. That was before it became impossible to find another doctor because we’ve so depopulated the field of primary care in our healthcare system. But still, I think the patient needs to advocate for him or herself, and come in with a list of questions. Because I know when I go to my doctor, I forget half the things I wanted to ask him before the visit, unless I write it down. And then I forget half the things he tells me and that’s, you know, and I’m a professor. So um people should go in knowing that you’ve got to advocate for yourself. Uh and in the book I try to give some questions that people should go in and ask their doctor, like, what is this medication for? Do I take it forever or until my symptoms are better? You know, in some drugs we say Take as little of this as you can and stop as soon as you can, like an opioid. Other drugs like drugs for high blood pressure or diabetes, we say you’ll take this probably for the rest of your life. And patients aren’t born knowing the difference between those categories. So how long will I need to take it? Is there a more affordable alternative that will work just as well? What side effects should I be on the lookout for? And what is the goal here? Is it to get my blood pressure down to a certain number? Is it to make me feel better? Is it to get rid of a target symptom? And you know, unless you know what the doctor is is going for, uh you’ll not be able to tell if you’ve gotten there or not. So it’s hard to extract that amount of time from a doctor, but I think patients really do need to use those, that list of questions of that they can ask their doctor. Terry 50:38-51:11 I think that idea of goal is really important and it’s not one that’s always incorporated into the conversations that we have with our doctors. Um and especially important, how will I know when I have reached the goal? Uh because If if you aren’t clear on the metric, you’re not going to know that, oh, okay, that’s that’s all I needed to do. And now I can look at something else that might be uh getting my attention. Joe 51:12-51:24 Well you know, Dr. Avorn, there’s another question that is rarely asked, and uh we think it’s really important, and that is how Should I stop this medication? Terry 51:24-51:25 And when? Joe 51:25-51:58 Because you know, there are a lot of Americans, literally tens of millions of them, taking antidepressant medications. uh, like Prozac, Paxil, and sertraline and we go down the long list. And you just can’t stop cold turkey Because this quote-unquote sudden discontinuation syndrome can be quite devastating. So finding out how to discontinue a medicine may be almost as important as how to start it Dr. Jerry Avorn 51:56-53:49 Exactly correct. And there has been an interest in the last number of years in this relatively new term of deprescribing. And seeing all these people that and I’ve I when I was in active practice people would come in with these long lists and I would ask them to please bring me a list or even better, a bag of all the drugs you’re taking. And, you know, things I would say, gee, you know. I thought I stopped that two years ago. Or who gave you that? Or, you know, all sorts of things that your doctor may not No, despite their being diligent because maybe it’s somebody else prescribed it or they thought it had long since gone away. So this issue of deprescribing is useful. However, there was a period where it was almost I would consider kind of a fad that, you know, let’s get everybody off of everything as much as we can. And it turns out there have again been, you know, the the answer for me to everything is rigorous clinical research. Studies where people were randomly assigned to stop a drug, and particularly antidepressants, was one of the drugs studied. Or keep going, but it was done as a placebo-controlled trial where neither the doctor nor the patient knew who was still getting a placebo and who had been switched over uh who’s still getting an antidepressant and who is switched over to placebo. And the answers are not always what one would expect from one’s armchair. That is, there are some people that um really when you stop their antidepressant, even if you do it carefully, really get worse and really get depressed. And then there’s others who don’t have any problems at all, might even feel a little bit better, but you can’t know that without really having good research data. And that’s not a topic that, you know, the drug industry is keen on funding clinical trials of stopping medications. But we do need more than more information on that because it comes up, you know, like millions of times a day in medical practice. Terry 53:50-54:20 Dr. Avorn, I’d like to turn a little bit to the topic of uh current events, as it were. I’d I’d like to ask you for your thoughts on what is going on with the FDA currently. Is the agency going to have the personnel it needs to carry out the functions we expect of it? What reforms if the FDA were to be reformed, what reforms would you see as beneficial? Dr. Jerry Avorn 54:20-57:46 Okay, I’m glad you asked that because I am scared out of my mind at these dramatic cuts that are being made wholesale. Not just at FDA, but at CDC, the Centers for Disease Control, and at the National Institutes of Health, that seem to be getting made without a whole lot of attention to are these cuts a good idea? We know that FDA has been understaffed for many, many years. And a solution that was proposed decades ago was that the drug industry said, gee, Congress doesn’t want to give you enough money to hire the people you need to review our drugs, FDA. Why don’t we just pay you to review our drugs? And the so-called User Fee Act, which was put in place in 1992 and has been renewed every five years ever since, has gotten us to to a situation in which the drug industry is now paying for about half of the salaries that FDA spends on the scientists who review the drug company’s products. Which does not seem like an ideal plan, but FDA was not able to get the money it needed from Congress going back many decades, many administrations, many different parties in power. They just never got the staff they need and they were all too willing to let the FD the uh drug companies pay for fifty percent of their salaries. So we were already starting from a bad place. And then these draconian cuts that do not seem to be getting made in a thoughtful way. And we know that because they were done so abruptly, have put the whole drug evaluation activity at risk. They’ve also put at risk apparently the people who are trying to figure out how to negotiate lower drug prices, which was a reform put in by the prior administration. Many of them have let have been let go, so the government is kind of down on its staff who are supposed to be negotiating with the drug companies But what scares me the most is these draconian cuts in the National Institutes of Health funding who are funding the research that, as we all know, leads to the drugs of tomorrow. The drug companies do research themselves, to be sure, but our our group at Harvard has shown that an awful lot of the best drugs we’ve got came from NIH funded research in universities or or academic medical centers. And then when the product is kind of ready for prime time it comes to be owned by a drug company that then charges whatever it wants for the drug. But what nobody is really talking enough about is if we stop that pipeline of discovery of basic biological insights as we are doing now at NIH. And my own institution, Harvard, is being hit with all kinds of billions of dollars of cuts by the administration. It’s not like we are all driving around in limousines and, you know, taking six-month vacations in the Caribbean. You know, most of us earn way less than we would earn in the private sector, and are doing this work because we really believe in it and then to find out that active grants are being just absolutely canceled with stop work orders going out. Is really going to come to a head, not in the next month or two, but in the next couple of years, where all the basic research that led to the development of new drugs will have been shut down or at least crippled. And then so sometime around 2027, people might say, hey, where’s all these new pharmaceutical wonders that we were expecting? You know, they’re not going to be there and that’s going to be a tragedy. Joe 57:47-58:22 Dr. Avorn, a lot of our medications now come from abroad. It’s been reported that over 90% of our generic medications come from places like China and India. And I do worry about the FDA’s ability to monitor the manufacturing process. D do you have any thoughts about A: the drug manufacturing abroad, and uh and B: the drug shortages that have resulted over the last couple of years. Dr. Jerry Avorn 58:22-01:00:40 And if I may add a C, which is what is going to happen to drug prices when tariffs kick in, given that so many of our drugs, as you just said, come from India and China. And if there are huge tariffs slapped on any imports from those countries, that is going to make not only make drugs harder to afford. But it also, I think, is gonna make our shortage problem worse, because a lot of generic manufacturers, and we’ll we’ll get back to the inspection thing in a second, a lot of generic manufacturers based in India and China operate on very, very thin margins, because generics are very, very cheap. That’s one of the great things about generics for the consumer. But if they find that their thin margins are now being essentially erased by these crippling tariffs, They’re just gonna say, hey, I’m gonna lose money with every pill I make. I’m just gonna stop making these pills. And that is gonna, and we’ve seen that before with cancer drugs and and other medicines. That is going to get exponentially worse because of the tariffs if they are handled in as careless a way as many of us worry that they might. But to come back to your earlier question, which is so important about inspection. Yeah, this is another thing that I referred to before as a public good. You know, it’s it’s the right of every citizen to know that their tax dollars are going to be used by government agencies working on behalf of everyone to make sure that somebody’s inspecting the meat, and that the water in your tap is is pure, and that the drugs that you are getting that come from another country–that those factories are being inspected adequately and are passing muster. And FDA has had a very hard time keeping up with that. And they’ve not had enough budget to do it. And as a result, uh particularly if the cuts at FDA extend to this part of their mission, we’re not going to be able to be as sure as we want to be that our blood pressure pill, diabetes pill, cholesterol pill, whatever, that may have been made in India or China, leave aside the unaffordability and leave aside the shortage, is that factory being inspected as well as it should be, especially if FDA has gotten staff cuts that it’s getting, and they don’t have the people to do that work. So it’s it’s pretty scary. Terry 01:00:41-01:01:34 Dr. Avorn, I’d like to ask about primary care. You mentioned during our interview that uh at at one point at least you were doing brown bag reviews with your patients in which They would put everything they’re taking into a brown bag and bring it in so that you could review everything they’re taking, including over-the-counter stuff and dietary supplements. And I think more and more patients are anticipating that they will be seeing specialists. So they’ll see the cardiologist, they’ll see See the podiatrist, they see the ophthalmologist, they don’t see one person who is looking at the whole patient. Can you give us some idea of the difference between the practice and the effect on the patient of primary care versus these very siloed specialist cares? Dr. Jerry Avorn 01:01:35-01:04:14 That that’s a really important point. I did my residency in in Boston when in in the 70s when we thought this is now the era of primary care. And you know, we’re going to train people particularly to be general internists who will deal with most everything that walks in the door and once in a while you’ll need a specialist to help with particularly complicated problems. But we’ve really, as a healthcare system, been beating up on primary care doctors mercilessly for the last several decades. They get paid much less than the specialists. The hours are not compatible with having a life. The emotional and intellectual responsibility of taking on whatever walks in the door, which is I think what most of us would like to have as patients as our first stop in the healthcare system really takes stall. I think primary care doctors ought to be, you know, rewarded the most and made their lives as easy as possible, but that’s quite the opposite has happened. So as a result, as you’re pointing out, somebody might be getting medications from their diabetes doctor and their heart doctor and their arthritis doctor. And it is not always possible for every doctor to be aware of what all the other doctors are prescribing. And uh I’ve written about how somebody may be taking, you know, Advil for headaches, and ibuprofen for their sore knee, and Motrin because they have low back pain, and aspirin because they think it’ll prevent a heart attack, and not ever knowing that those are all basically the same class of drugs, and they’re just multiplying the potential risk for for side effects. That’s where a primary care doctor can really shine. And, you know, we are an endangered species. It’s imperative. I’ve found some of the most useful time I would spend with patients. would not be listening to their heart or listening to their lungs, but actually saying, next visit, bring in a brown bag and fill it with not just what I’ve prescribed, but what you’re getting from all your other doctors and as you said in the question, whatever dietary supplements you’re taking and whatever herbal remedies you’re taking, whatever over-the-counter meds you’re taking, and dump it out on my desk and we’ll talk about every one. The reason that’s so useful is that you find stuff that actually is uh you know can kind of chill your blood about, oh my God, who put you on that? And you’re still taking that? I’s a very useful activity, and I urge all patients, if their doctor doesn’t ask to do it because every doctor is just so horribly overloaded with not enough time and too much to do is to offer to bring it in and you know include those supplements and over-the-counters and things from the other doctor and see what happens when you dump them on the doctor’s desk and see what his or her reaction is. Terry 01:04:14-01:04:59 And they may actually say, oh my God, we got to fix this. Well, one of the examples that you gave in rethinking medications, that is something we have heard from probably hundreds of people. is the idea that um you may have a chronic cough, that it doesn’t go away no matter what cough medicine you take and you’ve been worked up for allergies and you’ve been worked up for this and that, sometimes people get worked up for um acid reflux to see if that’s the cause of the cough. And if you just looked at the blood pressure medicine that the patient is taking. Exactly. If they’re on an ACE inhibitor, the chronic cough might be a reaction to their blood pressure medicine. Dr. Jerry Avorn 01:05:00-01:05:43 You said it. Right. I think the the figure I know is about 15% of people. And by the way, ACE inhibitors are wonderful drugs. They do a great job of lowering blood pressure. But as as you’re as you’re saying, about 15% of people on ACE inhibitors will develop a cough from them. And there’s ways of fixing that. You know, there’s angiotensin receptor blockers you can switch people to, you can use another category of drugs. But if it doesn’t come up in the conversation with a doctor, you know, they could, as you point out, they could get worked up for lung disease or put on meds for, you know, asthma or things that they don’t really need because it’s their blood pressure med. It may be a great med for most people, but if like one in seven people gets a chronic cough, that’s something that ought to be part of the doctor’s questioning of the patient. Joe 01:05:43-01:07:16 Uh Dr. Avorn, you’ve mentioned how important it is for patients to bring in all the medications and the dietary supplements and the vitamins and the goodness knows what they’re taking. for the physician, but I’d also suggest that it’s important for pharmacists to also be part of the process And also do these brown bag uh examinations, but there’s a a problem that we hear from pharmacists all the time. A patient comes into the pharmacy and they get a flag on their computer that says, uh, this antibiotic should not be taken at the same time you’re taking one of these blood pressure medications. It, it could cause potassium levels to go through the to the roof and it it could cause cardiac arrest. So this is a dangerous combination and the patient is waiting to g to get their antibiotic And now the pharmacist has to contact the physician. But when the pharmacist calls the doctor’s office, the receptionist says, I’m sorry, doctor is seeing patients now. And as you said, so many doctors are overworked and overwhelmed, it may be hours before that physician can call back to the pharmacist. And we hear from pharmacists who say, I never got a call back. What do I do when I’ve got an interaction and a patient sitting right there in front of me waiting for their prescription to be filled? What what would you recommend in a situation like that? Dr. Jerry Avorn 01:07:17-01:08:59 Absolutely. And as you both know from what I’ve written over over many years, I think pharmacists are one of the most potentially valuable and underused and abused healthcare professionals that we have. You know, they know so much about medications and yet most pharmacists find themselves working in increasingly in chain drugstores where the entire premium is on throughput and fill them and send them home and get, you know, make sure they pay. And the idea that a smart enlightened pharmacists can be part of the healthcare team just has not caught on as much as I had hoped because it could deal with a lot of these issues that that come up. It’s and then of course it puts the pharmacist in a rough spot. And sometimes, as you both know, some of these alerts are really not very sensible. But it you know the computer flashes a red light and then the pharmacist says, oh my God, I can’t do this. And then you can’t reach the doctor. I mean my vision, which is very naive and and probably unrealistic, is that practices would increasingly have pharmacists embedded in the practice who are part of the whole healthcare team. And that when the question comes up, first of all, they might even be involved in the dispensing of the drug. But if not, uh the outside pharmacy could call and they talk to the inside pharmacist, then he or she would be able to look at the patient’s records. They may even be able to snag the doctor as he or she walks by. Or they would have their own expertise and say, yeah, it’s okay. That’s one of those automatic computer flashes. Or they might say, holy cow, don’t fill the prescription But leaving everyone holding the bag because everyone is too busy to be able to just get their work done is not a good solution for anyone. Terry 01:08:59-01:09:05 Dr. Jerry Avorn, thank you so much for talking with us on the People’s Pharmacy today. Dr. Jerry Avorn 01:09:06-01:09:09 I’ve really enjoyed talking with you both again. Thanks for having me. Terry 01:09:10-01:09:44 You’ve been listening to Dr. Jerry Avorn, a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. He built a leading research center at Harvard to study medication use, outcomes, costs, and policies, and he developed the educational outreach approach known as academic detailing Providing evidence-based information about medications to prescribers. Dr. Avorn is the author of Rethinking Medications: Truth, Power, and the Drugs You Take. Joe 01:09:44-01:09:46 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:09:52-01:10:00 This show is a co-production of North Carolina Public Radio WUNC with the People’s Pharmacy. Joe 01:10:00-01:10:14 Today’s show is number 1443. You can find it online at peoplespharmacy.com. That’s where you can share your comments about today’s interview. You can also reach us through email, radio at peoplespharmacy.com. Terry 01:10:15-01:10:38 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, we discuss sourcing medications from abroad. How does that affect drug shortages? How will tariffs affect costs? In addition, you’ll get the details on a brown bag review. Joe 01:10:38-01:11:13 At peoplespharmacy.com, you can 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 are pleased to announce we are now launching transcripts for selected interviews, including our conversation with Dr. Jerry Avorn. We would be grateful if you would consider writing a review of the People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:11:13-01:11:48 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 01:11:48-01:11:58 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 01:11:58-01:12:03 All you have to do is go to peoplespharmacy.com/donate. Joe 01:12:03-01:12:19 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.

Transcribed - Published: 5 September 2025

A randomized controlled trial published in the New England Journal of Medicine confirmed what some cancer specialists have long hoped: physical activity can prolong cancer patients’ lives. Last week, we heard from the senior author of that study, medical oncologist Christopher Booth. In this episode, we hear from an exercise physiologist who has been helping cancer patients with exercise prescriptions. The goal was for them to feel better. Many also lived longer. How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Aug. 23, 2025, at 7 am EDT on 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 Aug. 25, 2025 Who Needs Exercise Prescriptions? We start our conversation with exercise physiologist Claudio Battaglini, PhD, by asking about his career trajectory. How did he go from playing soccer in Brazil to studying how to coach Olympic-level athletes to providing exercise prescriptions tailored to cancer patients’ unique needs? You will want to hear his story. What Is the Cancer Gym? Dr. Battaglini describes how he initially resisted working with young cancer patients. How did that experience affect him? He eventually ended up setting up the cancer gym at the Rocky Mountain Cancer Rehabilitation Institute at the University of Northern Colorado (UNC for those in Greeley). After earning his doctoral degree there, he began teaching and research at a different UNC (the University of North Carolina at Chapel Hill). He established the Get REAL & HEEL Breast Cancer Rehabilitation Program and credits the breast cancer patients for pointing out the benefits of group exercise training. In addition to positive physiological effects, participants experience emotional support. This also helps motivate patients to continue their physical activity consistently. How to Motivate People to Exercise: Let’s face it: most of us could benefit from exercise prescriptions. But would we follow through? It turns out that personal relationships are hugely important in helping to motivate people to show up. That could be with their personal trainer who is expecting them for their appointment. It could also be one or more friends counting on them to participate in the activity. If others are holding you accountable, you are far more likely to get with the program. Another important factor is matching the right kind of exercise to each patient. Most people are motivated to do what they enjoy. Do you love pickleball or swimming? Dancing or hikes in the woods? If the recommendation is right, staying motivated is far less of a problem. Physical Activity for Young People: Decades ago, physical education classes were mandatory in public schools. In recent years, some school boards have been tempted to drop them as too expensive. (North Carolina and some other states have statewide policies requiring all students in grades K-8 to have the opportunity of 30 minutes of exercise daily.) How important is it to encourage youngsters to be physically active? Do they need exercise prescriptions? Practical Advice for an Exercise Program: For those of us writing our own exercise prescriptions, we discussed the pros and cons of counting steps. Where can you find exercise programs suited to you? The YMCA might be one place to start. Dr. Battaglini also mentioned online resources and qualities to look for in a personal trainer. Above all, whatever you choose to do should feel like fun. This Week’s Guest: Claudio L. Battaglini, PhD, FACSM, is a Professor of Exercise Physiology and the Director of the Graduate Exercise Physiology Program at the University of North Carolina at Chapel Hill. He is Co-Director of the Exercise Oncology Laboratory in the Department of Exercise and Sport Science at UNC Chapel Hill. Dr. Battaglini is also a member of the UNC Lineberger Comprehensive Cancer Center. Listen to the Podcast: The podcast of this program will be available Monday, August 25, 2025, after broadcast on August 23. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, you’ll find information about walking speed and how much it matters. We also discuss swimming or cycling as ways to protect your joints if walking is difficult. Does cross-training become more important as you grow older? What kinds of activities can slow osteoporosis? Be sure to tune in if you are interested in the importance of family and friends supporting our exercise goals. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 21 August 2025

Physical activity, aka “exercise,” is a cornerstone of good health, just like adequate sleep and a balanced diet. No one questions the benefits for people who are already healthy. But doctors may assume that cancer patients are too debilitated and demoralized to exercise. They may think physical activity wouldn’t be much help to patients who have just suffered through radiation or chemotherapy. Such assumptions are wrong and could be harmful, as a recent study shows. In actuality, structured exercise can help cancer patients survive and even thrive. How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Aug. 16, 2025, at 7 am EDT on 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 Aug. 18, 2025. Does Exercise Belong in Cancer Treatment? An exciting study published in The New England Journal of Medicine demonstrates that a personalized exercise program can be an important component of the treatment for colorectal cancer (New England Journal of Medicine, July 3, 2025).  We spoke with the senior author, Dr. Christopher Booth, who explained that originally he and his colleagues wondered if exercise can help cancer patients feel less fatigued while undergoing chemo. Then they decided to design a trial that would go much further. They intended to answer two questions: can cancer patients exercise during treatment? And does that improve their likelihood of survival? Increasing Physical Activity Can Help Cancer Patients Survive Longer: The study, known as the CHALLENGE trial, hit a home run. The investigators recruited 889 people who had just had surgery and chemotherapy for their colorectal cancer. They randomly assigned half of them to get a health education booklet urging them to eat right and stay active. The other half got the booklet (usual care) PLUS a personalized exercise prescription designed to increase the amount of moderate to vigorous physical activity people did over the week. How Did This Challenge Work? The exercise prescriptions were devised by personal trainers who met with the “intervention” patients every two weeks for a year. Half of the meeting was devoted to motivational coaching and the other half to moving. Patients loved it. Increasing their fitness also improved their quality of life. In addition, patients in the exercise intervention group had better immune function and lower inflammation and less insulin-like growth factor, which can contribute to tumor expansion. Both men and women participated in this trial. During the follow-up period, women who were active were less likely to develop breast cancer than those in the control group. Similarly, men in the intervention group had a lower chance of a prostate cancer diagnosis. The most exciting part of the story, however, is about their colorectal cancer treatment. Not only did patients in the physically active group have longer overall survival, they also had longer disease-free survival. Remember, these two groups have the same type of cancer and got the same kind of treatment, except for the exercise prescription. The overall 8-year survival was 90.3% in the exercise group and 83.2% in the health education control group. That means the exercisers lowered their chance of dying during those eight years by 37%. The Number Needed to Treat (NNT) was 14 exercisers to prevent one death. That is a remarkable statistic. How Did Cancer Patients Get Motivated to Move? If you’ve ever started an exercise program only to drop it a few weeks later, you are not alone. Keeping ourselves motivated to stay active isn’t always easy unless you really love what you are doing. (Joe needs no extra motivation to show up for tennis.) Consequently, it is impressive that a very high proportion of the cancer patients in the CHALLENGE trial kept exercising. Part of that perseverance might be due to the motivational coaching. No doubt another big part was the relationship with the personal trainer. Meeting with a person every two weeks for a year can help build friendships and creates a relationship in which accountability is a factor. After the first year, patients and trainers met every month for the next two years. Being able to increase physical activity was empowering for patients, giving them a sense of control that can otherwise be missing in a cancer patient’s life. What Did Cancer Patients Do? The exercise prescriptions were personalized, so people undertook a wide range of activities. Jogging and walking were popular, but some people swam, and others kayaked. There were patients who bicycled, and possibly some who rode horses. (Dr. Booth does not mention that.) The point was to find an activity you love and stick with it religiously, which they did. The most popular activity by far was also the simplest: walking. The idea was to walk at a pace so you looked like you were late for a meeting. Is It Feasible to Help Cancer Patients Survive & Thrive? One of the most exciting aspects of the CHALLENGE trial was to see that people responded to coaching. Personalized exercise prescriptions with accountability could be instituted into many cancer treatment programs. After all, if insurance pays for cardiac rehab, why shouldn’t it pay for cancer rehab? The cost of a personal trainer is about $3,000 to $5,000 over three years. That is a lot less than the next-level chemotherapy drug is likely to cost, and unlike chemo, the side effect is that the patient feels better. Not only is it feasible to help cancer patients survive through targeted exercise, it should be a part of most cancer treatment protocols, In Summary: Dr. Booth offered us this explanation of how the treatment works: “Exercise is inducing physiologic, hormonal, inflammatory, immunologic changes in the body that are helping the body eradicate a proportion of these cancer cells. ‘ Learn More: Dr. Booth is a medical oncologist. To complete this trial, he called on the expertise of a lot of colleagues, including exercise physiologists. Next week, we will speak with Claudio Battaglini, PhD, to get the exercise physiologist’s perspective on this important approach. This Week’s Guest: Christopher Booth, MD, is a medical oncologist and health services researcher at Queen’s University in Kingston, Ontario, Canada. • Director, CCE Division, Queen’s Cancer Research Institute (QCRI) • Medical Oncologist • Clinician-Scientist, Cancer Centre of Southeastern Ontario • Professor, Departments of Oncology and Medicine, Queen’s University • Canada Research Chair in Population Cancer Care https://scri.queensu.ca/faculty-staff/christopher-booth Christopher Booth, MD, Queen’s University Listen to the Podcast: The podcast of this program will be available Monday, August 18, 2025, after broadcast on August 16. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 15 August 2025

We may not often stop to think about it, but our water, food, furniture and other ordinary items are frequently contaminated with toxic chemicals. In this episode, Dr. Aly Cohen describes these threats to our health. You may have heard of compounds that can disrupt hormonal balance (endocrine disruptors). Everyday toxins like these can also interfere with the ability of the immune system to function properly. What can you do to reduce your exposure? How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Aug. 9, 2025, at 7 am EDT on 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 Aug. 11, 2025. Doing an Environmental Assessment: As a rheumatologist, Dr. Cohen frequently treats patients whose immune systems have turned on them to produce conditions like lupus or rheumatoid arthritis. As an integrative medicine practitioner, she has learned to look at the patient’s environment for clues about the toxic compounds that may be causing the problem. The first environmental assessment she conducted was actually for her beloved family dog, Truxtan. When he developed autoimmune liver disease, she tried to figure out why. How Everyday Toxins Disrupt the Immune System: Dr. Cohen wasn’t able to save her dog, but the experience made her realize just how many potentially toxic chemicals we are exposed to in the course of our daily lives. If you look around your kitchen, you may discover that most of your food containers might be suspect. Plastic is incredibly convenient, since it is lightweight, break-resistant and cheap. But it often contains plasticizers such as bisphenols or phthalates that are endocrine disruptors. Some can disrupt the immune system as well. After all, immune system cells interact with the endocrine system on a regular basis. The two are tightly linked. Other food packaging can also contribute undesirable compounds such as PFAS. Exposure to these may lead to chronic inflammation. Dr. Cohen tells about a patient, Massimo, who ran a pizza shop. A young man, he had troubling fatigue. Changing his routine so that he wore nitrile gloves while handling pizza boxes helped a lot. So did bicycling to work. Everyday Toxins in Our Water: How safe is your water? One of Dr. Cohen’s patients had moved to New York from a Latin American country. Although she had filtered her water in her home country, she believed the tap water in New York was safe. It turned out the old plumbing in her building was contaminated with lead. In addition, she was relying on rice as a food staple, and it was contaminated with arsenic. Lead and arsenic are well-recognized as toxic chemicals. Filtering her water and washing her rice helped her feel much better. How do you make sure your water is free of everyday toxins? Dr. Cohen says several types of filtration devices can be useful, if they are used according to instructions. That means changing the filter medium on the recommended schedule. Any filter is better than no filter, but by far the best approach is known as reverse osmosis. This results in clean water you can trust to be free of toxins. Can You Avoid Plastic? The topic of water is almost inextricably linked to the question of plastic. Much of the water sold for consumption away from home is bottled in plastic. In addition to environmental considerations, this can expose us to plasticizers such as phthalates or even to tiny bits of plastic known as microplastics. These are accumulating in our bodies and may be harming our immune system. Bottles are not the only source of plastic in our food supply. Most cans are lined with a resin to prevent corrosion. This frequently contains BPA, bisphenol A, as a plasticizer. Some manufacturers have switched to another bisphenol instead. Thus, they can claim that the can is BPA-free, but it isn’t necessarily safer. Don’t Use Plastic Containers in the Microwave! One simple rule that can cut down on a lot of exposure to immune-disrupting plasticizers is don’t microwave food in plastic containers. Heat tends to speed leaching of plasticizers from the containers into the contents. Yes, we know a lot of frozen meals come in plastic containers that are supposedly microwave-safe. Don’t believe them. Instead, transfer the food to a glass or ceramic dish or bowl and heat it in that. That way you know you’re not getting any extra plasticizer in your snack. Prioritize! Dr. Cohen points out that to get the best results from efforts to avoid everyday toxins, we need to figure out where the exposure is greatest. That’s why she usually likes to start with cleaning up the water supply, since for most of us that is our top exposure. Analyzing your diet and focusing on foods you eat often is another way to prioritize. Those are the foods that should be free of toxins if at all possible. She recommends using the EWG (Environmental Working Group) lists of the “Dirty Dozen” foods that often contain pesticides and the “Clean Fifteen” foods that are generally safe.  For the Dirty Dozen, it makes sense to purchase USDA Organic produce whenever possible. Removing Pesticides: Dr. Cohen offers some simple, inexpensive ways to wash your produce and get the pesticide off. Add 1 part vinegar to 3 parts filtered water and let the fruit or vegetables soak in that for several minutes. Then rinse it off well with filtered water. The 21-Day Plan: To make it easier for people to implement the changes and avoid everyday toxins, Dr. Cohen offers a 21-day plan. It offers steps to avoid lots of harmful chemicals including obesogens (chemicals that make us fat). One simple way to take the first steps, after filtering the water you drink, is to carry a metal spoon and fork. That way you won’t have to resort to using plastic utensils to eat hot food, especially soup. Another step is to be cautious with skin care products. Using the online EWG guide SkinDeep can help you find sunscreen or moisturizer that is mostly free of undesirable agents. When shopping, make it a habit to seek out USDA Organic certified products for those items you eat most. Learn More: Dr. Cohen is not the only doctor concerned about toxic exposures. A summary of research into the “exposome” was published in JAMA last spring. Here’s a link. This Week’s Guest: Dr. Aly Cohen is a board-certified rheumatologist and integrative medicine physician. A member of the faculty of the Academy of Integrative Health and Medicine, Southern California University of Health Sciences, and the University of California, Irvine, she is a leading medical and legal expert in environmental health. Dr. Cohen is creator of TheSmartHuman.com social media platform, and the co-author of the bestselling consumer guidebook Non-Toxic: Guide to Living Healthy in a Chemical World. Her latest book is Detoxify: The Everyday Toxins Harming Your Immune System and How to Defend Against Them. Her website is https://alycohenmd.com/ Aly Cohen, MD, author of Detoxify 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, August 11, 2025, after broadcast on August 9. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 7 August 2025

In this episode, our guest, Dr. Andrew Armstrong of Duke University, discusses recent advances that men should know to overcome prostate cancer. We ask about former President Joe Biden’s diagnosis. What does it mean to have Stage IV prostate cancer and a Gleason score of 9? News outlets have reported that Mr. Biden’s previous prostate screening test was in 2014. How often should men be tested for this common cancer? What does the PSA (prostate specific antigen) test really tell us? How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Aug. 2, 2025, at 7 am EDT on 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 Aug. 4, 2025. How Do We Detect Prostate Cancer? Prostate cancer affects one man out of every eight in the course of a lifetime. Fortunately, if it is caught early and treated appropriately, most men do not die of this disease. They die of something else, even if they may still have prostate cancer cells. For years, the mainstay of prostate cancer screening has been the level of PSA, prostate specific antigen. Although it is specific to prostate, it is not really specific to prostate cancer. All prostate cells make it, so doctors watch for unusual increases in PSA. That suggests a rapid growth of the prostate, which could be caused by prostate cancer. Not every prostate cancer produces large amounts of PSA, though. That’s why urologists watch for changes rather than using a threshold number. Men with a family history of prostate cancer are at higher risk for developing it themselves. Ideally, they would start screening at a younger age and possibly have it done more frequently. In men who have a limited life expectancy, doctors may not recommend prostate screening. PSA alone is just the first step. If PSA is elevated or if it is rising, men will need further workup. What Is Next to Overcome Prostate Cancer? Often the next step is imaging. Magnetic resonance imaging of the prostate can be very informative. If there is a suspicious area on the MRI, the doctor will schedule a biopsy. Current practice is to use the MRI and ultrasound to guide the biopsy, so that the tissue examined is from the area thought to harbor the tumor. Grading the Tumor: The tissue removed during the biopsy will be examined by a pathologist. That expert will use the characteristics of the cells in the tissue to assign it a Gleason score. These range from 6 (not very worrisome) to 10 (the most aggressive). Former President Biden’s cancer had a Gleason score of 9, which is serious. Doctors also want to know if the tumor has spread beyond the prostate gland itself. To find out, they may conduct a PSMA PET scan. This picks up prostate-specific membrane antigen (hence PSMA) wherever it may be in the body. Stage IV, like former President Joe Biden’s cancer, has spread outside the prostate to other parts of the body. In his case, the cancer has metastasized to his bones. In some cases, prostate tissue will be sent for genetic testing. BRCA2 is associated with breast and ovarian cancers, but men who carry this gene are more vulnerable to prostate cancer as well. Approaches to Preventing Prostate Cancer: The risk of prostate cancer appears to be roughly half hereditary and half environmental. That means there are things that men can do to reduce their risk. Avoiding environmental toxins is crucial. Plastics and plasticizers don’t belong in our food or our bodies. Diet matters, of course. Not everyone loves broccoli, Brussels sprouts, cabbage and cauliflower, but getting plenty of these cruciferous vegetables can help reduce the risk of prostate cancer. Another important step is to focus on exercise. Not only can regular vigorous physical activity reduce the chance of developing prostate cancer, it also is very useful in counteracting the side effects of the powerful drugs used to overcome prostate cancer. Options for Treating Prostate Cancer: Blocking Testosterone: Often the doctor prescribes leuprolide (Lupron) to shut down testosterone production. That part of the protocol is referred to as “androgen deprivation therapy” or ADT for short. An even more powerful androgen blocker such as abiraterone (Zytiga), apalutamide (Erleada), darolutamide (Nubeqa) and enzalutamide (Xtandi) may be added. These drugs can help men overcome prostate cancer, which seems to thrive on testosterone. Blocking the androgen receptors with one of these medicines has made treatment for prostate cancer more effective. Androgen blockers stop testosterone formation even further and thus discourage the growth of the cancer. That’s the benefit. The downside is that men suffer the effects of “low T.” Here is where exercise stars, helping men feel better even when their testosterone levels are nonexistent. Other Treatments for Prostate Cancer: There are nonhormonal approaches to treating prostate cancer that may be used in conjunction with androgen blocking or in some cases independently. One is surgery, in which the prostate is removed. That used to be the standard treatment. With new approaches available, it is one option among many. Another is radiation. Dr. Armstrong describes some of the different types of radiation, which can be very effective when used together with androgen blocking medication. There are also immune therapies. One exciting new therapy, called Pluvicto uses radioligands that seek out and attach to PSMA. Because it can find prostate cancer cells wherever they are in the body, it is being considered for treating metastatic prostate cancer when ADT may no longer be working well. What to Know to Overcome Prostate Cancer: Dr. Armstrong wants men to know that prostate cancer can be detected early; when it is, it is often curable. Even in the case of advanced disease, there is hope. He urges men to ask for second opinions on treatment and take advantage of a multidisciplinary team when possible. Above all, he says: “The good news is that treatment can extend life often dramatically, and that many men, most men in fact with prostate cancer, don’t die of prostate cancer. They die of other stuff.” This Week’s Guest: Andrew J Armstrong, MD, ScM, FACP, is Professor of Medicine, Surgery, Pharmacology and Cancer Biology at Duke University. He is Director of Research at the Duke Cancer Institute Center for Prostate and Urologic Cancers. His appointments are in the Division of Medical Oncology in the Departments of Medicine and Urology at Duke University. Dr. Armstrong is one of the country’s leading prostate cancer researchers. Andrew Armstrong, MD, Professor of Medicine, Surgery, Pharmacology and Cancer Biology at Duke University. Listen to the Podcast: The podcast of this program will be available Monday, August 4, 2025, after broadcast on August 2. In this week’s podcast, Dr. Armstrong describes how to find trustworthy information online. We discuss diet, exercise and natural approaches that can be helpful in preventing and recovering from prostate cancer treatment. When will medical centers recognize the value of personalized, structured exercise for cancer rehab, as they already do for cardiac rehab? You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 1 August 2025

In this episode, two experts draw on the latest research about avoiding Lyme disease and other infections that may be transmitted through tick bites. Why are these conditions so difficult to diagnose? Most importantly, how can people with lingering symptoms from Lyme get help and start to feel better? We consider both conventional and alternative approaches. You may want to listen through your local public radio station or get the live stream at 7 am EDT on 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 July 26, 2025. The Basics of Lyme Disease: We begin with a quick review of the history of Lyme disease, which was first identified in Old Lyme, Connecticut, in the 1970s. Researchers eventually identified the pathogen causing the symptoms as Borrelia burgdorferi and means of transmission as bites from a black-legged tick (aka deer tick). Even though it was originally thought to be limited to New England, epidemiologists now recognize that Lyme disease is widespread across the country. Half a million people will come down with Lyme disease this year. Many others will suffer symptoms from other pathogens transmitted through tick bites. Persistent Symptoms of Lyme Disease: For much too long, doctors thought that any symptoms persisting after a course of antibiotics were psychosomatic. Patients were understandably distressed by this dismissal of their suffering. Many people report fatigue, body aches and brain fog. Some have difficulties with balance or feeling weak or faint when they stand and have been diagnosed with POTS (postural orthostatic tachycardia syndrome). Headaches, rashes, heart palpitations and joint pain may also be part of the picture. If you think some of these symptoms ring a bell, you are right. Many people with long COVID or even chronic fatigue suffer with similar problems. Avoiding Lyme or Treating It Over the Long Term: One of our expert guests, Dr. John Aucott, does research on Lyme disease and directs the Johns Hopkins Lyme Disease Clinical Research Center. His study utilizing functional MRI was very revealing. When regular imaging studies are done on people with persistent Lyme disease symptoms, the results are not particularly striking. But functional MRI results, when people are asked to do cognitive tasks while undergoing magnetic resonance imaging, show a different picture. These people’s brains are not functioning normally. No wonder they are upset about brain fog or struggling to concentrate! There are several possible explanations for why Lyme disease symptoms may persist. The spirochete responsible for these symptoms does not require oxygen and is very good at “hiding out” within tissues. When reactivated, it could cause symptoms. On the other hand, the immune system may become hyper-activated and have a hard time calming down. That too could contribute to symptoms. Non-governmental organizations have funded the Study of Lyme Immunology and Clinical Events (SLICE). In this trial, researchers have identified some risk factors associated with post-treatment Lyme disease (PTLD, aka long Lyme). They are also enrolling patients in a treatment trial. Standard of Care for Lyme Disease: Naturopathic doctor Alexis Chesney points out that there are different standards of care for Lyme disease. The CDC has published guidelines for treating “four important manifestations of Lyme disease.” Those are erythema migrans (the classic “bulls-eye” rash), neurologic Lyme disease, Lyme carditis and Lyme arthritis. The International Lyme and Associated Diseases Society (ILADS) offers its own treatment guidelines. Both experts agree that early treatment is preferable to late treatment. Dr. Chesney describes the ability of the Borrelia spirochete to protect itself by changing to a “round form” as well as by forming a biofilm that wards off antibacterial medicines. One way to combat this is by utilizing herbs that can counteract biofilm formation, such as cats’ claw or Japanese knotweed. She also pays attention to supporting patients experiencing a Herxheimer reaction, in which dying spirochetes release toxins. This can make a person feel very ill indeed. Natural ways to mitigate this response include milk thistle, burdock or Epsom salt baths. Avoiding Lyme Disease by Preventing Tick Bites: Even better than early treatment is prevention. The best prevention is to avoid tick bites. Wear shoes and socks that have been treated with permethrin. (Do not apply permethrin directly to the skin.) Using an effective insect repellent also helps, and a thorough tick check upon coming in from outdoors is indispensable. It takes ticks some time to transmit Borrelia, so prompt tick removal can help prevent illness. This Week’s Guests: Dr. John Aucott is the Barbara Townsend Cromwell Professor in Lyme Disease and Tick-borne Illness at the Johns Hopkins University School of Medicine. An infectious diseases specialist and Lyme disease expert in the Division of Rheumatology, he is the director of the Johns Hopkins Lyme Disease Clinical Research Center. https://www.hopkinslyme.org/ John Aucott, MD, Johns Hopkins University Alexis Chesney, MS, ND, Lac, is a naturopathic physician, acupuncturist, author and educator. Since 2010, Dr. Chesney has worked with people of all ages on chronic disease, general wellness, nutrition and lifestyle counseling. She has dedicated herself to working with clients who have complex chronic illness, and who often have diagnoses such as Lyme and vector-borne diseases, mold toxicity, mast cell activation syndrome, among other conditions. Dr. Chesney is the author of Preventing Lyme & Other Tick-Borne Diseases: Control Ticks in the Home Landscape; Prevent Infection Using Herbal Protocols; Treat Tick Bites with Natural Remedies. Dr. Chesney offers an online course, Preventing Lyme and Tick-Borne Disease: Ticks and Tick-Borne Diseases, Prevention, and Acute Lyme & TBD Treatment. Here is the link: https://health-transformations.teachable.com/p/preventing-lyme-and-other-tick-borne-diseases. Her website is https://www.dralexischesney.com/ Alexis Chesney, MS, ND, Lac, author of Preventing Lyme and Other Tick-Borne Diseases Listen to the Podcast: The podcast of this program will be available Monday, July 28, 2025, after broadcast on July 26. 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.

Transcribed - Published: 24 July 2025

This week, we welcome dermatologist Dr. Chris Adigun to our studio to answer your questions about summer skin problems. You can call in your stories and questions about bites, burns and blisters between 7 and 8 am EDT on Saturday, June 21, 2025, at 888-472-3366. Or you can send us your question or story ahead of time by email: radio@peoplespharmacy.com. You could listen through your local public radio station or get the live stream at 7 am EDT on 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 July 21, 2025. The Link Between Sun Exposure and Skin Cancer: Intense summer sunshine can cause sunburn and skin damage. The most worrisome consequences are skin cancers that may show up on cheeks, ears, noses, lips or other unexpected places. How can you recognize a potential skin cancer? What will the dermatologist do about it? Even more important, can you reduce your risk for basal or squamous cell carcinoma? (Those are technical terms to describe skin cancers that are not melanoma.) What are the best ways to avoid harming your skin while you are enjoying the great outdoors, whether you are at the beach or on the hiking trail? Are there criteria you can use to choose the best sunscreen without spending a fortune? How often do you need to apply it? Can you get enough vitamin D compounds if you wear a high SPF sunscreen? Are there skin conditions that might actually benefit from a bit of sun and salt water? Lowering Your Chance of Melanoma: The relationship between sun exposure and melanoma is less clear than that between sun and basal or squamous cell cancers. Find out what might make a spot suspicious. Where should you be checking your skin? What can a dermatologist do to help? Heat and Humidity Challenges: In addition to sun, heat and humidity can challenge our skin. Fungal infections may proliferate under those conditions, resulting in athlete’s foot, jock itch or under-breast rash. Can we make our sweaty skin less hospitable to fungi? Have you been troubled with heat rash? We’ll find out what it is and what to do to get rid of it. Other Summer Skin Problems: Long summer hikes can result in more trouble than sunburn or sore muscles. Unless you are very careful with your shoes, sweaty feet can develop blisters. Are there good preventive strategies? If you get a blister anyway, what can you do to ease the pain–and keep it from getting worse? Bug bites may also be the bane of your existence. Chiggers hang out in grass or brush waiting to take a bite of a tasty mammal walking by. Can you avoid or discourage them? And if you do get chigger bites, how can you manage the dreadful itch? We also want to avoid bites from ticks and mosquitoes. They may have different niches and behaviors, so avoiding them may require different tactics. What works best? How can you choose a good insect repellent for outdoor activities, and will it interact with your sunscreen? Poison Ivy and Its Cousins: Poison ivy, poison oak and poison sumac all contain the resin urushiol, which can be extremely irritating to sensitive skin. Do you know how to identify these plants so you can avoid them? If you find yourself in the middle of a poison ivy thicket, can you take quick action and reduce the chance of a rash? If you end up with a rash–it happens–we’ll find out how you can ease the suffering. Call in Your Questions About Summer Skin Problems: Dr. Chris Adigun will be in our studio to answer your questions about bug bites, blisters, burns and other summer skin problems from 7 to 8 am EDT on July 19, 2025. Give us a call to ask a question or share a story: 888-472-3366 or email us ahead of time: radio@peoplespharmacy.com This Week’s Guest: Chris G. Adigun, MD, FAAD, is a board-certified dermatologist who practices both general dermatology and cosmetic dermatology at the Dermatology and Laser Center of Chapel Hill, NC. Dr. Adigun is devoted to increasing public awareness of skin cancer and the harmful effects of UV rays—both medical and cosmetic. She specializes in both nail disorders and laser treatments. Dr. Chris Adigun, dermatologist, with People’s Pharmacy hosts Joe & Terry Graedon Listen to the Podcast: The podcast of this program will be available Monday, July 21, 2025, after broadcast on July 19. 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.

Transcribed - Published: 18 July 2025

In this episode, we acknowledge the many reasons that people may be feeling anxious or depressed. It often seems that current conditions are designed to break our brains. Perhaps that’s why 60 million Americans suffer from depression or anxiety. Not everyone who might be feeling nervous or down in the dumps deserves a diagnosis. However, they can benefit from the practices we discuss in this hour. Pharmaceutical approaches such as antidepressants can be helpful for people with depression, especially in the short term. Over the long haul, though, we might want to consider whether changing our habits could help us develop the resilience we need. After all, antidepressants frequently result in side effects. Moreover, many people find it difficult to discontinue an antidepressant. Anti-anxiety agents carry similar risks. Scientific research has shown us the importance of neuroplasticity. Can we tweak our neurochemistry by embracing some simple tenets for living? We don’t really have broken brains, but we might be lacking the skills we need to pursue robust mental fitness. Where will we learn them? How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, July 12, 2025, at 7 am EDT on 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 July 14, 2025. Staying Connected Protects Our Brains: Good nutrition, adequate sleep and regular exercise are all pillars of mental as well as physical health. Our guest, integrative psychiatrist Drew Ramsey, says staying connected with others is equally important. Cultivating a variety of connections is crucial for our mental health, including friends, family and even casual acquaintances. We should keep in mind that building community is different from building friendships; we need both for mental fitness. Social isolation can be damaging both for teenagers and for older individuals. Can we use social media to bolster our support systems rather than allowing them to wither? What skills can we help our teens acquire? Dr. Ramsey described a study, the AMEND trial, that combined social connection through social media with learning to cook. The young men in the study posted their cooking experiments on Instagram and bonded with each other over the experience. Adopting a more healthful diet also reduced the youths’ risk for depression. Maybe Ultra-Processed Food Breaks Our Brains: One aspect of nutrition that is important to consider is how our food affects our microbiota. Our gut microbiome has a powerful influence on inflammation in our bodies. After all, the immune system is in part anchored in the gut, especially in the gut microbiome. When the microbiome gets disrupted and inflammation rises, our mood and mental health can suffer. What should we be eating to feed our microbes and keep them happy? Dr. Ramsey offers a little rhyme as a mnemonic: “Seafood, greens, nuts & beans…and a little dark chocolate.” We admit the last line breaks the rhyme, but it isn’t too hard to remember! When we asked what foods to focus on for healthy gut microbes, he suggested lentils. Although they are not technically beans, as in the rhyme, they are legumes and contain lots of fiber that helps gut microbes flourish. Dr. Ramsey also extolls the benefits of microgreens, another food that gut microbes love. The microbiome acts as a master dial on our immune system and inflammation levels. Beyond Diet and Activity: Dr. Ramsey provides nine tenets for reclaiming robust mental health, even when we may feel like our situation breaks our brains. In addition to thoughtful nutrition, adequate sleep and reliable physical activity, he also stresses the importance of unburdening yourself of past trauma. This need not have been anything as major as a traffic accident or losing a parent, though such experiences are certainly traumatic and deserve attention. Even minor traumas like being picked on as a child can affect our sense of well-being. Unburdening is the process of acknowledging those and trying to understand where our past is tripping us and blocking our efforts to be mentally healthy in our present. Unburdening yourself can leave you feeling freer to pursue your goals. It helps ground you so that you can pursue your purpose. Journaling, therapy or creative pursuits could all help with unburdening. How Can You Find Your Purpose? Finding your purpose might not sound like a step towards better mental fitness, but it is. How do you know when you have found your purpose? Focusing on a sense of identity and of fulfillment will help you with this. Finding a sense of purpose is important at every stage of life, but it may be especially important for older individuals. A job is not synonymous with purpose, although at times they may overlap. Sometimes, people who have relied on work to provide their sense of purpose find themselves at loose ends when they retire. This Week’s Guest: Drew Ramsey, MD, is a leading board-certified integrative psychiatrist, best-selling author and leading proponent of Nutritional Psychiatry and Mental Fitness. He served as an Assistant Clinical Professor of Psychiatry at Columbia University in the Vagelos College of Physicians and Surgeons for twenty years. Dr. Ramsey is founder of the Brain Food Clinic in New York City and Spruce Mental Health in Jackson, WY. He is the author of several books, including his latest book, Healing the Modern Brain: Nine Tenets to Build Mental Fitness and Revitalize Your Mind. 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). Drew Ramsey, MD, author of Healing the Modern Brain Listen to the Podcast: The podcast of this program will be available Monday, July 14, 2025, after broadcast on July 12. In this week’s podcast, Dr. Ramsey offers further discussion of the idea of finding your purpose and how to do that even after retirement. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 10 July 2025

In this week’s episode, our guest explains why treating hypothyroidism isn’t always as simple as it seems. He is a leading researcher on questions relating to thyroid hormones. What Is Hypothyroidism? Hypothyroidism, a condition in which the thyroid gland doesn’t make enough thyroid hormone, is one of the most common hormonal disorders. It was first identified near the end of the 19th century but is far more widely recognized now. More than 20 million Americans produce too little thyroid hormone for their needs, either because their thyroid glands have been removed or because they are under attack from the immune system. Inadequate thyroid hormone has an impact on every cell in the body. As a result, the symptoms are wide-ranging, from lethargy and cognitive troubles to hair loss and constipation. Why Should We Be Rethinking Hypothyroidism? Most medical students learn that this is a simple straightforward condition to diagnose and treat. For decades, doctors used a single test–the TSH, or thyroid-stimulating hormone–for diagnosis. In addition, they learn that a single medication, the hormone called levothyroxine, is the sole treatment. People may know levothyroxine by its brand names, such as Synthroid or Levoxyl. Doctors often refer to it as T4, because the molecule contains four atoms of iodine. Not everyone knows that T4 itself is not biologically active. Enzymes within the cells must remove one of those iodine atoms to create the active hormone, T3. You might recognize it by its generic name, liothyronine, or by the brand name Cytomel. What’s Wrong with Levothyroxine Only? Back in 1970, researchers discovered the enzymes that convert T4 to T3. That’s when doctors decided that patients would do well on a simple synthetic form of T4. In fact, 80 to 85 percent of patients with hypothyroidism have no great difficulties with this treatment. However, about 15 to 20 percent continue to suffer despite treatment. Some feel infuriated when the doctor tells them that their normal TSH levels mean they are fine. They don’t feel fine. They still feel exhausted, confused and miserable. Researchers, including our guest, have begun to recognize that people who do not convert T4 to T3 efficiently may suffer from residual symptoms of hypothyroidism. How Should We Be Rethinking Hypothyroidism? Lingering symptoms of hypothyroidism, such as fatigue or brain fog, are not very specific. As a result, doctors may need to utilize more sophisticated testing techniques. Moreover, rethinking hypothyroidism means considering different forms of treatment. A person who has residual symptoms despite a normal TSH level might need a trial of combination therapy. This might be in the form of desiccated thyroid extract such as Armour or Westhroid. An alternative would be a prescription for both T4 (levothyroxine) and T3 (liothyronine) as combination therapy. Doctors making such a change to their prescription need to adjust the dose carefully so that the patient does not end up with too much thyroid hormone. They also need to make sure during the diagnostic workup that the problem truly is hypothyroidism. Symptoms such as low energy don’t go away with thyroid hormone treatment unless that is the underlying problem. What Should Patients Do? For too long, patients have heard that their residual symptoms are psychological in nature. A doctor might have insisted that a normalized TSH on treatment means nothing is wrong with the thyroid gland. People who still feel bad despite such treatment may need to hunt for a clinician willing to explore ways to address those residual symptoms. This Week’s Guest: Antonio C. Bianco, MD, PhD, was professor of medicine and a member of the Committee on Molecular Metabolism and Nutrition at the University of Chicago at the time this episode first aired. He ran a laboratory funded by the National Institutes of Health to study thyroid hormones. Dr. Bianco is a former president of the American Thyroid Association and author of Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do. Twitter handle is @Bianco_Lab. 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). Antonio Bianco, MD, PhD, is now The Nelda C and H.J Lutcher Stark Professor in internal medicine. VP, Vice-Provost for research and Chief research officer university of Texas Medical Branch, Galveston, Texas. Antonio Bianco, MD, PhD, University of Chicago Listen to the Podcast: The podcast of this program will be available Monday, July 7, 2025, after re-broadcast on July 5. 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.

Transcribed - Published: 3 July 2025

In this episode, Joe & Terry speak with two scientists studying mosquito preferences. Why are some people mosquito magnets while others barely get bitten? A range of factors influences mosquito behavior and may explain why mosquitoes bite you and leave your neighbor alone. Learn how to outsmart them. You could listen through your local public radio station or get the live stream on Saturday, June 28, 2025, at 7 am EDT on 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 June 30, 2025. Why We Worry About Mosquito Bites: You may think of mosquitoes as annoying insects with itchy bites. That’s certainly a reasonable summary in many places and times. But there are large swaths of the globe where mosquitoes carry deadly diseases. Malaria, for instance, kills an estimated 600,000 people a year. The majority of these victims are children under 5 years old living in sub-Saharan Africa. Even in the US, where malaria was eradicated in the mid-20th century, mosquitoes transmit some dangerous diseases, including dengue in some southern regions, West Nile virus, and in the northeast and the Gulf Coast, eastern equine encephalitis (EEE). The best prevention for these serious infections is to outsmart mosquitoes and avoid getting bitten. Depriving Mosquitoes of Breeding Grounds: One problem is that a few species of mosquito have evolved to live in close proximity to humans. They have adapted to breeding in standing water, but it doesn’t take much. An upturned bottle cap, a saucer under a potted plant or leaves lying on the ground can all offer mosquito breeding opportunities. Emptying those saucers and raking away the leaves should be a priority to reduce the risk of mosquito bites. Do You Smell Delicious? Both our guests have been studying what makes some people more appealing than others. To that end, Dr. Conor McMeniman and his team have set up the world’s largest multiple-choice smell test for mosquitoes in Zambia. They constructed a mesh greenhouse the size of two tennis courts that could be surrounded by eight single-person tents. A person sleeps in each tent and that person’s scent is wafted into the enclosure where mosquitoes are given a chance to congregate where the preferred scent appears. This scent buffet for mosquitoes demonstrated that microbial metabolites from our skin microbiome have a significant impact on insect behavior. Mosquitoes seem to home in on short chain carboxylic acids as well as acetoin. How Can We Outsmart Mosquitoes? One simple and obvious step to avoid mosquito bites is to use window screens on our homes. That helps protect us inside. Air conditioning and ceiling fans also help. We asked Dr. McMeniman how he protects himself when he is outside and what we should do. He recommends repellents. DEET is the gold standard, but some people find it unpleasant. An effective alternative repellent is derived from plants. Whether you use oil of lemon eucalyptus or DEET, it is important to read the instructions for applying the product properly. How Do Mosquitoes Change Their Behavior? In addition to smell, mosquitoes also use vision and temperature sensing to find humans to bite. (Did you know mosquitoes sing to each other? It is part of their courtship behavior.) Dr. Clément Vinauger studies how mosquito brains react during different activities. They also pay attention to people who swat them and seem to avoid those individuals who come close to killing them. Mosquitoes can also change their behavior to adapt to human behavior. For example, a species of Anopheles mosquito that was nocturnal shifted to early morning biting over a period of a few years. That happened after the human population started using effective bed nets that protected them during sleep. More on How to Outsmart Mosquitoes: Dr. Vinauger made a casual observation that some soaps seemed to attract mosquitoes while others repel them. In a study, he found that most of the soaps his team examined appealed to mosquitoes. On the other hand, coconut scented soap (Native brand tested) kept them away. We asked him about Listerine. He has not studied it, nor has he studied some remedies that our listeners like such as eating garlic. However, he suggested consulting the local gardening center or nursery in selecting plantings around the home that are not attractive to mosquitoes. This Week’s Guests: Conor McMeniman, PhD, is Associate Professor of Molecular Microbiology & Immunology at the Johns Hopkins Malaria Research Institute. Dr. McMeniman studies the molecular and cellular basis of mosquito attraction to humans. Conor McMeniman, PhD, Johns Hopkins Malaria Research Institute Clément Vinauger, PhD, is Associate Professor at Virginia Tech in the Department of Biochemistry. His research area is the molecular genetics of host-seeking behavior in insects. His website is:  https://www.vinaugerlab.com/ Clément Vinauger, PhD, Virginia Tech Listen to the Podcast: The podcast of this program will be available Monday, June 30, 2025, after broadcast on June 28. This week’s episode features bonus material, including exclusive content we couldn’t fit into the radio broadcast. In this week’s podcast bonus material, Dr. McMeniman explains why it would be really difficult to conduct a scientific study on whether taking vitamin B1 reduces your attractiveness to mosquitoes. We also discuss how climate change is likely to put Americans at greater risk for mosquito-borne diseases. Could malaria become a problem in the US once again? And we talk about “skeeter syndrome” in people who get nasty allergic reactions to mosquito bites. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 26 June 2025

This week, our guest in the studio is veterinarian Dr. Chuck Miller. You can call in your stories and questions about the animals in your life between 7 and 8 am EDT on Saturday, June 21, 2025, at 888-472-3366. Or you can send us email: radio@peoplespharmacy.com. We’ll be focusing on transforming relationships between humans and animals. Have you ever had to euthanize a beloved pet? We would like to hear your story. What was it like to lose such a close companion? You could listen through your local public radio station or get the live stream at 7 am EDT on 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 June 23, 2025. One Health: You may have already thought about One Health without realizing it has a name. This is an interdisciplinary approach to promoting the health of animals as well as humans that share an environment. If you have companion animals that move between inside and outside, your already know that protecting them from ticks and fleas also offers you a measure of protection. Another example of the importance of this approach would be control of bird flu. So far, we have paid it relatively little attention as it spread through cattle herds and to cats and other animals. If we learned more about its behavior in other animals, might we be able to reduce the impact on humans? How Do Pets Promote Human Health? Not long ago, a friend shared a blog post she had written about the death of her chicken. The bird had reached the end of its natural lifespan, and the memorial essay was an appreciation of its special spunky personality. Probably few people who interact with animals on a regular basis can keep from noticing that each one, whether it is a chicken, a cat, a mouse or a hedgehog, has its own particular take on the business of living. That observation in itself helps make our lives richer. Quite a bit of research has shown that having a pet present can help alleviate anxiety and lower blood pressure. One study examined the impact of therapy dogs on children’s anxiety in the emergency department (JAMA Network Open, March 3, 2025). Children interacting with a therapy dog and its handler for 10 minutes in the ER had less anxiety than those whose emergency visits were dogless. Young children aren’t the only ones to respond well to dogs. A study in Thailand introduced well-socialized dogs to 122 university students feeling stressed out (PLoS One, March 12, 2025). Students’ self-reported stress, pulse rate and salivary cortisol (a stress hormone) all dropped during and after interacting with the dogs for 15 minutes. Does Lifespan Difference Cause Trouble? A dear friend just sent us a very sad email. His golden retriever Abby just died after 13 joyful years together with him and his wife. Moreover, he noted, there will not be another dog in their family because they are both getting on in years. Adopting a dog that outlives you doesn’t seem fair to the dog. When a pet dies first, the owner grieves. But if an owner dies first, someone must find the animal a new home. How do we do that? How many people make contingency plans for a surviving pet? Should we? What about grieving animals? Here we’d like to put in a recommendation for a beautiful movie, The Friend. The dog star is magnificent, and the humans are pretty great, too. Call in Your Stories about Relationships Between Humans and Animals: Dr. Chuck Miller will be in our studio to answer your questions and hear your stories about transforming relationships between humans and animals from 7 to 8 am EDT on Saturday, June 21, 2025. Give us a call to share your story or learn what you can about that bond: 888-472-3366 or email us: radio@peoplespharmacy.com This Week’s Guest: Charles Miller, DVT is the owner of Triangle Veterinary Hospital in Durham, North. Carolina. Dr. Miller has been serving the pets and animal owners of the area for 32 years. You may wish to listen to our previous episode with Dr. Miller. It was Show 1379: The Healing Power of Pets. https://trianglevet.com/ Charles Miller, DVM Listen to the Podcast: The podcast of this program will be available Monday, June 23, 2025, after broadcast on June 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.

Transcribed - Published: 19 June 2025

In this episode, Joe & Terry speak with two physicians who have examined ways that artificial intelligence might contribute to patient care. Can AI help with better diagnoses? Is robotic surgery better? Could AI save lives or is it more likely to cause trouble? You could listen through your local public radio station or get the live stream on Saturday, June 14, 2025, at 7 am EDT on 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 June 16, 2025. Digital Doctoring: We begin our conversation with Dr. Jonathan Chen, who has found that chatting with a robot made him a better doctor. (He challenged ChatGPT with an ethically difficult conversation and was surprised at the sensitivity of the observations it offered.) When researchers studied diagnostic acumen pitting human doctors against AI, the results were surprising. Some doctors did the diagnosis without help, while others used ChatGPT-4 to help them. The investigators also had the AI do the diagnosis unaided (or unhindered) by humans. Doctors got a score of 74 percent on their own and 76 percent when using AI. But ChatGPT by itself scored 90 percent. (JAMA Network Open, Oct. 28, 2024). AI is certainly not perfect, and there are times when it is not the appropriate tool to use. But results like this suggest that we should be learning more about when it might be an indispensable technology for improving patient care. After all, human doctors are not perfect, either. Paging Doctor Google: Health care professionals are not the only ones who are putting artificial intelligence to use in health care settings. Many physicians dread the patient who arrives with a large stack of papers printed off the internet. Our guests suggest that doctors should welcome these patients and collaborate with them. Pointing them to more reliable sites and better search strategies, if the healthcare provider is able to do so, could yield better results overall. Who is more motivated to spend time researching the details of an unusual syndrome or its treatment? It may well be the patient. There are, of course, some cautions that people should keep in mind. One is privacy. You may not want to disclose your medical history to the internet at large. Most sites are not constrained by HIPAA, which protects patient privacy in medical settings. Another consideration is the reliability of the information you find. Robots are designed to produce answers that will please the humans asking the questions. That might mean that they make things up. If the question is how to connect your camera to your computer, an invented (“hallucinated”) answer is inconvenient. When it concerns your health, a fabricated answer could be dangerous. Could AI Save Lives in Dermatology? Our second guest, Dr. Art Papier, has been involved in developing large libraries of images of skin problems. With artificial intelligence powering it, VisualDx helps doctors recognize dermatological problems such as skin cancers. He describes one situation in which misdiagnosis is common and can cause harm. Cellulitis is a dangerous inflammation due to bacterial infection that can lead to sepsis. Red skin can be a signal of cellulitis, but sometimes it is caused by other problems. Misdiagnosis can lead to hospitalization and inappropriate antibiotics being administered. Utilizing a clinical decision tool like VisualDx reduced unnecessary hospital admission and antibiotic use (Journal of the American College of Emergency Physicians Open, June 8, 2023). Another strength of the system Dr. Papier has helped build is that it offers doctors views of atypical presentations of common problems. Hopefully, this keeps them from focusing on a single feature of an illness, such as a bulls-eye rash, as the only defining characteristic. The builders of VisualDx have deliberately included many images of skin of many different shades, as rashes sometimes look different depending upon the background coloration. Both our guests emphasize that AI is a tool. To get the best results, it must be used intelligently, not indiscriminately. This Week’s Guests: Jonathan Chen, MD, PhD, assistant professor of medicine at Stanford Medicine, works at the intersection of artificial intelligence and medicine in the hopes that combining human knowledge with AI will deliver better care than either can alone. His expertise lies in developing innovative AI-driven solutions that enhance diagnostic accuracy, treatment efficiency, and patient outcomes. Dr. Chen focuses on integrating machine learning algorithms and predictive modeling into clinical practice, revolutionizing the way healthcare is delivered. His goal is to use real-world clinical data, such as electronic medical records, with machine learning and data analytics to reveal new clinical insights that will inform patient care. Jonathan Chen, MD, PhD, Stanford Medicine Art Papier, MD, is a dermatologist and medical informatics expert and the co-founder and CEO of VisualDx. He has led the development of VisualDx, a professional, point of care decision support system as well as Aysa, a freely available consumer and patient facing AI app for dermatology (www.askaysa.com). A thought leader in clinical informatics, Dr. Papier maintains the overall vision for the company with a keen focus on product integration and impacting costs in healthcare through clinical accuracy. https://www.visualdx.com/blog/our-team/art-papier/ Dr. Art Papier is founder & CEO of VisualDx Listen to the Podcast: The podcast of this program will be available Monday, June 16, 2025, after broadcast on June 14. In this week’s podcast, Dr. Chen describes the effort by Dr. David Fajgenbaum to use AI to search the medical literature and find potential treatments for rare diseases. Dr. Papier discusses the use of AI to reduce the chance of misdiagnosis. How should patients and doctors negotiate the use of AI? You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 12 June 2025

In this episode, our guest, award-winning science journalist Carl Zimmer, describes the hidden dangers in the air we breathe. He begins with the concept of the aerobiome–the collection of living things from ground level to the stratosphere. While that includes eagles and dragonflies, the most insidious inhabitants are those we can’t see. Often, we are totally unaware of their presence. Yet bacteria like the one that causes tuberculosis or viruses like those that cause COVID or flu have the power to make us ill even if we don’t know they are there. You could listen through your local public radio station or get the live stream on Saturday, June 7, 2025, at 7 am EDT on 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 June 9, 2025. Hidden Dangers in the Air We Breathe: You have surely heard of the microbiome, but perhaps you thought it only applied to the microscopic beings living in our digestive tract. Lately, scientists have learned that humans have a microbiome for every different part of our bodies, including our eyes, ears, mouth and lungs. The air around us is also full of microorganisms. And even though we can’t see them and we may not be able to smell or taste them, they can still have a big impact on our health. What are the hidden dangers in the air we breathe? Florence Nightingale and the Science of Ventilation: Back in the mid-19th century, Florence Nightingale insisted that fresh air and sunlight were essential for patients to recover. Even though she didn’t know the scientific reason for this, her observation was correct. Good ventilation can help lessen the risk of disease transmission. But infectious disease specialists were not paying much attention to air quality until COVID-19 came along. At the beginning of the pandemic, health experts actually resisted the idea that SARS-CoV-2, the virus that causes COVID, could be airborne. Public health authorities stressed the importance of hand washing, social distancing and disinfecting doorknobs, groceries or other items that someone else might have touched. Those turned out to be of much less significance than the dangers in the air we breathe. The Skagit Valley Chorale Superspreader Event: In the spring of 2020, the Skagit Valley Chorale got together to rehearse for an upcoming concert. There were about 60 singers who took the advised precautions: social distancing and hand sanitizing. The room in which they rehearsed was poorly ventilated, and no one was wearing a mask. This was at a time when the CDC was urging Americans NOT to wear masks, for fear there wouldn’t be enough for healthcare workers. Within a few days, six of the singers were sick. Eventually, 52 of them came down with COVID from this single exposure. Two women died. The Skagit Valley Chorale provided an irrefutable example that the virus could be airborne. Have We Learned the Lessons of COVID-19? If we learned the lessons we should take from the pandemic, we will be on the lookout for other hidden dangers in the air we breathe. We know that measles is incredibly transmissible and that the measles virus is airborne. In areas where measles is spreading, people would be smart to wear effective masks, such as N95, in public. Unfortunately, masks have been politicized, although viruses do not care. Another pathogen that spreads through the air is tuberculosis. Americans don’t think of this as an important problem, but drug-resistant TB is a world-wide threat. Approximately one-fourth of humans carry this pathogen. It can become active whenever stress or other problems knock the immune system down. Many other countries responded differently to the pandemic. Perhaps some will improve the ventilation and filtration in public spaces. That is unlikely in most parts of the US, due to cost. Perhaps we should take to carrying carbon dioxide monitors wherever we go. That will not tell us if there are hidden dangers in the air, but it will indicate how many people have been breathing it. This Week’s Guest: Carl Zimmer writes the “Origins” column for the New York Times and has frequently contributed to the Atlantic, National Geographic, Time, and Scientific American. His journalism has earned numerous awards, including ones from the American Association for the Advancement of Science and the National Academies of Science, Medicine, and Engineering. Carl Zimmer is an adjunct professor at Yale, where he teaches writing. He is the author of fourteen books about science, including Life’s Edge. His most recent book is Air-Borne: The Hidden History of the Life We Breathe. 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). Car Zimmer. Photo credit Mistina Hanscom Listen to the Podcast: The podcast of this program will be available Monday, June 9, 2025, after broadcast on June 7. In this week’s podcast, we discuss the value of CO2 monitors as well as the potential effectiveness of ultraviolet light for purifying the air. Could UV be a helpful part of our toolchest? Might there actually be benefits to breathing in certain microorganisms, similar to the probiotics you might take for gut health? You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 5 June 2025

This week, the topic is lead. A hundred years ago, chemists discovered that adding lead to gasoline decreased engine knock and gave the cars of the day more power. It remained a popular additive for decades. At the same time, companies were adding lead to house paint to help it last longer. We know now that lead exposure harms children, but what about adults? Could lead in our environment have contributed to the horrific toll of heart disease over the past century? Find out about the chemical roots of chronic disease on this week’s nationally syndicated radio show! You could listen through your local public radio station or get the live stream on Saturday, May 31, 2025, at 7 am EDT on 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 June 2, 2025. The Chemical Roots of Chronic Disease: When the nascent automotive industry began adding tetraethyl lead to gasoline early in the 20th century, scientists did not fully understand the potential health impacts of this compound. They knew by 1889 that lead poisoning could result in saturnine (ie, lead-induced) gout, an inflammatory condition accompanied by atherosclerosis. And at first, public health officials worried that adding it to gasoline might not be safe, especially after large numbers of refinery workers suffered lead poisoning in 1924. According to chemical warfare expert Yandell Henderson, “The use of tetraethyl lead will cause vast numbers of the population to suffer from slow lead poisoning with hardening of the arteries.” (New England Journal of Medicine, Oct. 30, 2024). He made that statement at a meeting in 1925. Why didn’t regulators pay attention? The Kehoe Problem: One reason there wasn’t more regulatory attention is that the industry was new and the government hadn’t figured out how to regulate it to make it safer. Another reason is a persuasive individual named Robert Kehoe. As the chief medical officer of the Ethyl Corporation, he had a substantial conflict of interest. But he argued that no one had the right to ban the use of lead in gasoline until someone had proven that it was dangerous. Mind you, not whether lead was dangerous, which scientists knew, “but whether a certain concentration of lead is dangerous.” Unfortunately, the Kehoe rule held sway and has helped shape the American approach to chemical regulation ever since. Lead was used very widely during the 20th century. People put it in insecticide and in jet fuel. We already mentioned its use in paint. The 21st-century water disaster in Flint, Michigan, reminded the country that many cities still contain lead pipes as part of their plumbing infrastructure. In the 1960s, lead levels in the most recent layers of glacial core samples were 1000 times higher than those in more ancient pre-industrial cores. Moreover, people were also carrying around 1000 times more lead in their bones than skeletons from pre-industrial times. Even now, the total amount of lead in our bodies is 10 to 100 times higher than that of pre-industrial people. How Does Lead Affect Health? We asked our guest, Dr. Bruce Lanphear, whether public health improved when we got lead out of gasoline late in the 20th century. The answer is yes; blood lead levels have dropped dramatically. Consequently, many fewer children are dying of acute lead poisoning. But we are still underestimating the overall health effects of chronic low-level lead exposure. Lead exposure, even at low levels, is linked to hypertension and heart disease. People who are exposed to lead have higher blood pressure. In addition, they are more likely to have damage to the endothelium of the blood vessels. This can result in plaques that cause heart attacks. Scientific assessments show that people with blood level levels at the 90th percentile have double the risk of death from cardiovascular disease as those at the 10th percentile. The conclusion is that chronic low-level lead exposure is a leading cause of heart disease. Worldwide, there are about 5.5 million deaths a year due to low-level lead poisoning. How Do We Learn About the Chemical Roots of Chronic Disease? Some critics have objected that association is not causation. That is certainly true. When we have the opportunity to use randomized placebo-controlled trials, we can have more confidence in the conclusions. Yet when there is an overwhelming amount of evidence, we should pay attention. Just as no one now doubts that tobacco harms health, we do not need to doubt the lasting harm caused by lead exposure. We can learn from the lead saga and apply those lessons to other toxic chemicals. First off, lead poisoning is preventable. Cutting lead exposure reduces the harms. In general, chronic disease risk rises with environmental exposure. To prevent disease, we need to clean up the environment. Just as Robert Kehoe objected to eliminating lead from gasoline, current manufacturers defend their own toxic chemicals, whether those are PFAS, cadmium, arsenic, phthalates or the herbicide glyphosate. If we want a cleaner environment, resulting in less chronic disease, we need to demand action. This radio show is a wake-up call to all those politicians calling for less regulation. This Week’s Guest: Bruce Lanphear, MD, MPH, is Professor of Health Sciences at Simon Fraser University in Burnaby, British Columbia. Professor Lanphear’s research, at the intersection of preventive medicine, pediatrics, public health, toxicology, and infectious disease, is driven by a commitment to prevent death, disease, and disability. He has published over 350 peer-reviewed studies about the impact of toxic chemicals on intellectual deficits, behavioral problems, and brain structure in children. He is ranked among the top 1% of most-cited scientists globally. Bruce and his brother, Bob, co-founded Little Things Matter to make the science on toxic chemicals publicly accessible. They produce videos to show how human health is inextricably connected with exposures to toxic chemicals and to elevate efforts to prevent disease. Professor Lanphear’s new video, Toxic Hearts, will soon be released. May 20th, 2025, was the 100th anniversary of the US Surgeon General’s report on the safety of tetraethyl lead. Follow Dr. Lanphear on Substack at https://blanphear.substack.com/ Bruce Lanphear, a health sciences professor at Simon Fraser University and an expert on lead toxicity. Listen to the Podcast: The podcast of this program will be available Monday, June 2, 2025, after broadcast on May 31. This week’s podcast has a more extended discussion of how industry tries to blame the victim. What is Dr. Lanphear doing to upset that dynamic? You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. You may also want to listen to a prior interview with Dr. Lanphear: Show 1418: More About the Pros and Cons of Water Fluoridation (Part 2). You can download the mp3 file at this link. There is also Show 1417: Examining the Pros and Cons of Water Fluoridation (Part 1). We try to bring you a variety of perspectives on The People’s Pharmacy. If you find this kind of balanced approach worthwhile, please consider a donation at this link. It will help us keep moving forward with our radio show, podcast, newsletter and this website. Thank you for your support. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 29 May 2025

This week, two scientists discuss the evidence on using vitamin C to treat colds and as part of the treatment for cancer. For years, the medical establishment has maintained that such claims could not be considered seriously. But new studies vindicate Linus Pauling, the Nobel Prize winner who postulated that vitamin C would help. You could listen through your local public radio station or get the live stream on Saturday, May 24, 2025, at 7 am EDT on 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 May 26, 2025. Studies That Vindicate Linus Pauling: In 1970 the Nobel Prize-winning chemist, Dr. Linus Pauling, published a paperback book titled Vitamin C and the Common Cold. Although this idea captured the public imagination, it got a lot of pushback from scientists. Most of the American medical establishment rejected Pauling’s claims that vitamin C could help people recover from the common cold. They were especially dismissive of the idea that vitamin C might be helpful in treating cancer. However, there have been a number of studies conducted over the decades since then. The weight of the evidence now seems to vindicate Linus Pauling. Does Vitamin C Help Recovery from the Common Cold? Our first guest, Dr. Harri Hemilä of Helsinki, Finland, has done several meticulous systematic reviews of the research. Although some people expect supplemental vitamin C to prevent colds, it does not appear to prevent colds except among people doing extreme physical activity (Polish Archives of Internal Medicine, Jan. 30, 2025). Instead, however, studies show that at doses considerably higher than the RDA vitamin C can reduce the duration and severity of these upper respiratory tract viral infections (BMC Public Health, Dec. 11, 2023). To achieve this, people take a dose of 6 to 8 grams per day. That is a lot more vitamin C than you would get from a morning glass of orange juice. Of course, we worry about the potential harms of consuming an excessive dose of vitamin C. According to Dr. Hemilä, taking this amount for as long as a cold might last does not produce serious side effects. If one were to take it for a lot longer, that might not be the case. Some reports suggest that long-term high-dose vitamin C supplementation might trigger kidney stones. Cancer Studies Vindicate Linus Pauling on Vitamin C: We turn our attention next to a surgeon who treats patients with pancreatic cancer. This type of cancer usually has a grim prognosis. Dr. Joseph Cullen was intrigued by a report that high-dose vitamin C could inhibit the growth of cancer cells, so he and his team tested that possibility in tissue culture. They were impressed at the excellent results they achieved at this first step of the research. However, the benefits were only seen at extremely high doses of vitamin C. This is consistent with preliminary research conducted by Linus Pauling and a colleague testing intravenous (IV) administration of vitamin C in cancer patients. To get exposure to that level of vitamin C (ascorbate) requires IV dosing. The next step in Dr. Cullen’s research was to test vitamin C in mice with experimentally induced cancer. His team administered vitamin C in conjunction with radiation. Once again, the results were promising. How Does Vitamin C Affect Cancer Cells? At low doses, such as those we can get by eating strawberries, bell peppers or oranges, vitamin C is an antioxidant. At the very high doses achieved only by IV administration of 75 grams of ascorbate, this compound acts as a pro-oxidant. It generates hydrogen peroxide that attacks cancer cells. Dr. Cullen’s team continued their research with a preliminary clinical trial (Redox Biology, Nov. 2024). By administering IV vitamin C together with the usual chemotherapy drugs for pancreatic cancer, they were able to help those patients survive twice as long as those getting chemotherapy alone. Of course we asked about side effects; Dr. Cullen reports that people become very thirsty during the infusion. The scientists did not observe any serious adverse reactions. Using IV Vitamin C for Other Cancers: In addition to pancreatic cancer, Dr. Cullen and his collaborators have tested the effects of this treatment in another cancer that is notoriously difficult to treat. They found that cells of the brain cancer glioblastoma were far more vulnerable to radiation In the presence of high-dose ascorbate. On the other hand, normal cells suffered less radiation damage. With such success, Dr. Cullen’s team and some others are conducting pre-clinical research on some other cancers. Not all types of cancer appear to respond to high-dose IV vitamin C. Apparently, a trial of prostate cancer was disappointing. However, there is now adequate evidence of the potential benefits of vitamin C when used properly to vindicate Linus Pauling and his conviction that this remarkable compound could contribute enormously to human health. This Week’s Guests: Harri Hemilä, MD, PhD, is an adjunct professor at the University of Helsinki in Finland. His research has focused on vitamin C, vitamin E, and zinc lozenges for respiratory infections, and he has also analyzed the effects of vitamin E on mortality. Dr. Harri Hemilä Joseph J. Cullen, MD, is Professor of Surgery, Gastrointestinal Surgery and Radiation Oncology at the University of Iowa College of Medicine. His website is https://surgery.medicine.uiowa.edu/profile/joseph-cullen Listen to the Podcast: The podcast of this program will be available Monday, May 26, 2025, after broadcast on May 24. This week’s podcast contains additional discussion with Dr. Hemilä about the use of zinc in treating the common cold. What type of zinc is best? Should you take tablets or suck on lozenges? Are there any worrisome side effects? We explore briefly the possibility of using both zinc and vitamin C to reduce the duration of a cold. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 21 May 2025

In this week’s episode, find out what everyone gets wrong about weight loss. Why don’t diet and exercise work very well? Do official guidelines and weight loss drugs offer a clearer path to success? Health Consequences of Excess Weight: With nearly three-fourths of American adults either overweight or obese, we can’t ignore the problem any longer. For decades, people have acted as though packing on extra pounds was simply a matter of poor willpower. “Eat less and exercise more” is the standard mantra. But that is just one of the things we get wrong about weight loss. In truth, obesity is far more complex than we may imagine. In fact, neuroendocrinologist Robert Lustig has spent decades studying obesity and diabetes in children. During the past 25 years, the weight of newborn babies has risen by about 200 grams. No reasonable person could imagine this is the babies’ fault! As a result, he says we need to grapple with the concept of different obesities with different causes and diverse consequences. When we come to terms with what we get wrong about weight loss, we may be able to start helping people achieve it. One Thing We Get Wrong About Weight Loss–Not Distinguishing Different Fat Depots: Dr. Lustig points out that not all fat is identical. In fact, the most visible fat depot, the subcutaneous fat, may be the least dangerous. Many people could handle as much as 20 pounds of subcutaneous fat visible on the arms, legs or butt without serious health consequences. Visceral fat, wrapped around the internal organs, is associated with high cortisol levels much more than with overeating. As little as 2 pounds of visceral fat could make trouble. However, the deadliest fat depot is the liver. As little as ½ pound of fat in the liver can damage health. Dr. Lustig traces fatty liver to overconsumption of alcohol or sugar. Fructose, an important component of sugar, is one of the bad actors driving the epidemic of non-alcoholic fatty liver disease among children (Nature Reviews. Gastroenterology & Hepatology, May, 2010). Consequences of Obesity: The obesities can increase our risk for a number of serious conditions, including hypertension and diabetes as well as metabolic syndrome and heart disease. Fatty liver disease, whether associated with fructose or alcohol consumption, can damage the liver and lead to cirrhosis. It also triggers severe inflammation and is linked to a greater chance of kidney disease. The Impact on Mitochondria: Every cell in our body relies on mitochondria to produce its energy. These tiny organelles take the energy from food and turn it into ATP, the form of chemical energy that our cells need to function. Unfortunately, the fructose in sugar or high-fructose corn syrup can mess mitochondria up in the context of a high-fat diet (Cell Metabolism, Oct. 1, 2019). High-Powered Weight Loss Drugs: Recently, people have gotten excited about the potential for drugs originally designed to treat type 2 diabetes to help people with significant weight loss. Medications like semaglutide, sold as Ozempic or Wegovy, have become so popular that there have been shortages. Dr. Lustig discusses their use and the symptoms that may be associated with them. Importantly, such drugs can lead to weight loss, up to 16% of total body weight in some studies. However, many people report nausea, sometimes vomiting, lack of appetite and diarrhea. Perhaps we should not consider these side effects; they may be contributing to the effectiveness of the drugs. (Dr. Lustig points out that if people are provided with a healthier diet of real food, they can reduce their risk of metabolic disorders by 29 to 45 %.) Earlier versions of these GLP-1 analogs such as exanetide (Byetta) may increase the risk for pancreatic cancer or certain types of thyroid cancer. We don’t yet know if Wegovy will have similar risks. But we do know that when people stop taking one of these pricey pills, they often gain the weight back. You can read more about this “boomerang” effect at this link. How to Correct What We Get Wrong About Weight Loss: Dr. Lustig points out that the subsidies that the US provides to major food companies mean that ultra-processed foods containing corn syrup or sugar are cheap. As a result, many Americans rely on these inexpensive sources of calories instead of paying more for real food. But they are paying a price far beyond dollars and cents, because the cheap and easy foods are making Americans fat. Can we get food companies to do the right thing? Promoting Good Health in Children with Real Food: School cafeterias across the nation serve kids a tremendous amount of junk food, like pizza or potato chips. But they don’t have to. Dr. Lustig and his colleagues operate a pilot program with schools that serve real food instead. Happily, they do not have to increase their budgets to do so. Providing youngsters with tasty real food can set them up for success in resisting weight gain as they grow older. Finally, we ask Dr. Lustig what people can do to help themselves with healthful, lasting weight loss. This Week’s Guest: Dr. Robert Lustig Robert H. Lustig, MD, MSL, is Professor emeritus of Pediatrics in the Division of Endocrinology at the University of California, San Francisco (UCSF). He specializes in the field of neuroendocrinology, with an emphasis on the regulation of energy balance by the central nervous system. His research and clinical practice has focused on childhood obesity and diabetes. Dr. Lustig is the author of several books, including his most recent, Metabolical: The Lure and the Lies of Processed Food, Nutrition, and Modern Medicine.  You may also be interested in his previous books, Fat Chance and The Fat Chance Cookbook as well as The Hacking of the American Mind. His website is https://robertlustig.com/ The nonprofit organization improving food in schools is https://eatreal.org/ Listen to the Podcast: The podcast of this program will be available Monday, May 19, 2025, after re-broadcast on May 17. 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.

Transcribed - Published: 15 May 2025

In this episode, investigative journalist Gardiner Harris delves into the dark secrets of one of the country’s most admired pharmaceutical firms. Johnson & Johnson sold talcum powder–Johnson’s Baby Powder–for decades even though it contained asbestos, an acknowledged carcinogen. How did the company maintain its superb reputation for so long? You could listen through your local public radio station or get the live stream on Saturday, May 10, 2025, at 7 am EDT on 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 May 12, 2025. Dark Secrets: Johnson’s Baby Powder was as American as apple pie. The company counted on the emotional associations with its baby products. The fragrance of its Baby Powder was linked to feelings of love and security. That was smart marketing. Continuing to sell a product contaminated with asbestos was something else, though. How did the company deal with this problem? And what did it tell the FDA? What About Tylenol? Johnson’s Baby Powder is not the only iconic product the company sells. Tylenol is another famous J&J product. Johnson & Johnson has long promoted this pain reliever as one that hospitals and doctors trust. Advertising does not feature the fact that the recommended dose and the maximum safe dose of the active ingredient, acetaminophen, are extremely close. As a result, people can inadvertently overdose, especially if they are taking several different types of medicine for symptoms of a cold or the flu, for example. Exceeding the maximum dose of acetaminophen puts a strain on the liver and, over time, may cause liver injury. This is especially worrisome if someone drinks alcohol on a regular basis. J&J’s response to a crisis in which Tylenol was deliberately adulterated with poison is held up to business students as a case study in doing the right thing. The company pulled millions of bottles off shelves and introduced tamper-proof packaging. This decision bolstered the company’s reputation. The Dark Secrets of the Opioid Crisis: Not all of the company’s business decisions are so laudable, and most are not so well-known. Few people are aware that the Johnson & Johnson company developed fentanyl, a potent opioid. It was originally invented by Dr. Paul Janssen, head of Janssen Pharmaceutica. When J&J acquired Janssen, it also acquired the rights to fentanyl, which it sold in a transdermal formulation as Duragesic. According to our guest, the company initially presented it to physicians as a non-addicting pain reliever. You are no doubt aware that is far from the case. Johnson & Johnson’s Antipsychotic Drugs: Gardiner Harris points out that Johnson & Johnson was one of the first companies to offer “atypical” antipsychotics such as Risperdal (risperidone). This drug, also developed by Janssen, was originally designed to treat the symptoms of schizophrenia. That market is relatively small, however. Later, the company started suggesting to doctors that they could prescribe it for elderly dementia patients who were agitated. Like other antipsychotic drugs, though, Risperdal increases the possibility that such patients will die prematurely from heart problems or infection. The FDA has not approved it for treating dementia-related psychosis. In 2013, J&J agreed to pay $2.2 billion in fines for its marketing of Risperdal and two other drugs. Johnson & Johnson Responds: A spokesperson for the company responded to our request for comment: “We stand behind the safety of our products and are focused on what we do best: delivering medical innovation for patients around the world.” This Week’s Guest: Gardiner Harris previously served as the public health and pharmaceutical reporter for The New York Times and is now a freelance investigative journalist. He also served as a White House, South Asia, and international diplomacy reporter for the Times. Before that, he was a reporter for The Wall Street Journal, covering the pharmaceutical industry. His investigations there led to what was then the largest fine in the history of the Securities and Exchange Commission. He won the Robert Worth Bingham Prize for investigative journalism and the George Polk Award for environmental reporting after revealing that coal companies deliberately and illegally exposed miners to toxic levels of coal dust. Harris’s novel, Hazard, draws on his experience investigating these conditions. His latest book is No More Tears, the Dark Secrets of Johnson & Johnson. 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). Gardiner Harris, author of No More Tears, the Dark Secrets of Johnson & Johnson (c) Erin Champ Listen to the Podcast: The podcast of this program will be available Monday, May 12, 2025, after broadcast on May 10. It contains some additional discussion of the relationships between drug companies and the FDA, specifically with regard to the role of user fees. We also find out about Procrit (EPO) and why it too was a source of controversy. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Transcribed - Published: 8 May 2025

This week, Joe and Terry discuss liver health with two specialists. You may not have spent much time thinking about your liver. It is, however, an absolutely essential organ. When the liver is working properly, every part of the body gets the nutrients it needs and no parts are exposed to damaging toxins. These are among its superpowers. Find out why you should love your liver. 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 on Saturday, April 4, 2026, at 7 am EDT on 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 April 6, 2026. Love Your Liver: Nutrients don’t go directly from the intestines to the rest of the body. Instead, they pass through the liver first. There, this master organ breaks them down into compounds that can be recognized and utilized by individual tissues and cells. Moreover, if it finds nasty chemicals that shouldn’t be there, it utilizes its superpowers to transform them into less damaging compounds that can be more readily excreted. You should also love your liver because it can store nutrients for unanticipated periods of fasting and hold off starvation. This was a tremendous benefit during earlier periods of human evolution. These days, we have less need for a hedge against starvation. In fact, when we overload our livers with alcohol or sugar, even its superpowers may not be adequate. The liver’s response to this kind of insult is fibrosis, a condition in which it stiffens and stores fat. Liver Disease: One of the liver’s superpowers is that it can regenerate itself so long as we remove the source of injury. That’s pretty remarkable! But what if we keep on eating ultra-processed foods (Nutrients, May 10, 2023) and drinking soda or alcohol?  In that case, the liver continues to try to repair itself. That can change the architecture of the tiny blood vessels that run through the liver, raising the pressure within them and ultimately leading to serious complications. Fatty liver disease, correctly termed metabolic-associated steatohepatitis (MASH), is the first step; cirrhosis and ultimately liver failure might follow. How Do You Know If Your Liver Is Healthy? The liver is so effective at maintaining the body in balance that most people don’t develop symptoms of trouble until liver disease is quite advanced. As a result, the best way to keep tabs on liver health is through blood tests. Tests for the liver enzymes called ALT and AST are common and often used to assess liver health. Agents That Can Help or Harm the Liver: If you love your liver, consider drinking a cup or two of black coffee daily. This has been shown to help the liver fight inflammation and overcome early-stage liver fibrosis (Redox Biology, March 2025). Another precaution to take: avoid excess acetaminophen. This is the pain-relieving ingredient in Tylenol and hundreds of other over-the-counter medications. Doctors consider it safe for occasional use at doses under 4,000 mg in a day. Chronic use might call for lower doses yet. Because it is so widespread, people may mistakenly take several different medicines containing acetaminophen (paracetamol in the rest of the world) and end up exceeding the maximum dose by accident. Liver experts like our guest Dr. Ahmad treat such emergencies with a medicine called N-acetylcysteine. Other pain relievers, such as NSAIDs, are less likely than acetaminophen to damage the liver. Dangerous reactions to such drugs are unpredictable, however, which can make them harder to manage. Fluoroquinolone antibiotics such as Levaquin and corticosteroids like methylprednisolone also fall into this category. Oral antifungal drugs can also be very hard on the liver. Herbs That Can Challenge the Liver: Pharmaceuticals are not the only compounds that may test the liver’s detoxifying superpowers. Botanical medicines can also cause challenges. Dr. Ahmad has treated people whose liver injuries were caused by green tea extract, turmeric, kratom or ashwagandha. Most people taking such supplements are attempting to improve their health, so discovering that instead they have developed liver damage is a nasty surprise. If you love your liver, stick with drinking green tea and eating curry rather than taking pills with concentrated extracts. This Week’s Guests: Meena Bansal, MD, is Professor of Medicine, specializing in liver diseases, at the Icahn School of Medicine at Mount Sinai. She is System Chief of the Division of Liver Diseases and Director of the MASH/NASH Center of Excellence at Mount Sinai. Meena Bansal, MD, Professor of Medicine Mt. Sinai, photo courtesy of Mt. Sinai Jawad Ahmad, MD, is a professor of liver diseases at the Mount Sinai School of Medicine. He is co Primary Investigator on the NIH/NIDDK research initiative to study cases of severe liver injury caused by prescription drugs, over-the-counter drugs, and alternative medicines, such as herbal products and supplements. For more information on the Drug-Induced Liver Injury Network (DILIN) visit: https://researchfunding.duke.edu/drug-induced-liver-injury-network-dilin-clinical-centers-u01-clinical-trial-optional Jawad Ahmad, MD, Professor of Medicine at Mount Sinai, photo courtesy of Mt. Sinai Listen to the Podcast: The podcast of this program will be available Monday, April 6, 2026, after broadcast on April 4. You can stream the show from this site and download the podcast for free.  

Transcribed - Published: 2 May 2025

In this episode, a renowned neurosurgeon shares what he has learned in decades of working to restore ailing brains. His new book covers a vast range of neuroscience. Our dilemma was what to pay attention to in all those options. In a sense, that is always the human situation. We are capable of conscious processing of approximately 200 bits per second (bps) of information. Our unconscious brain deals with as much as 11 million bps. 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 Saturday, May 16, 2026, at 7 am EDT on 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 May 18, 2026. (This show originally aired April 25, 2025.) The Power of the Unconscious Brain Our senses feed us a tremendous amount of information all the time, but we don’t have the bandwidth to pay attention to more than a small fraction of it. That’s where the unconscious brain is so valuable, juggling millions of bits of information while we focus our conscious attention on what seems important. One surprising outcome of the research on how our brains function is a re-assessment of what is going on when people are unconscious. For centuries, doctors thought there was really no brain activity while a person was comatose. Then, a few decades ago, a scientist was recording the brain waves of a patient in a coma. The activity was very peculiar, as if the person were watching a ball being lobbed back and forth across a tennis court. In actuality, a television set in the room was broadcasting a world championship match between Roger Federer and Rafael Nadal. The neuroscientist recognized that this individual was following the match and was not nearly as deeply unconscious as had been thought. Further research showed that this kind of unconscious brain activity is not uncommon. It may hold keys to determining who has the best potential for recovering from their coma. Freud and the Unconscious Brain If you hear the term the unconscious mind, you may think of Sigmund Freud. He really popularized the concept that some very important brain activity takes place outside of our conscious awareness. It still has a powerful influence on our behavior. By the way, if we recognize that our conscious attention is indeed a limited resource (200 bps, remember), we won’t try to multitask. Humans actually aren’t very good at multitasking; instead, we switch our attention from one thing to another. Some people can do that fairly easily, but for most of us, it is less effective than staying focused. Three Stages of Brain Development Evolution likes to build on what it’s already got in place, so it shouldn’t surprise us that we can track three different evolutionary stages to our human brains. The reptilian brain came first, of course, and is there as a base, operating mostly on reflex. It’s definitely an important part of the unconscious brain. The mammalian brain brings in emotions. The hormone oxytocin is relevant for this discussion. It is critical for birthing and nursing young. As it turns out, oxytocin can also be put to other uses, such as bonding mates together and creating friends. Finally, we have the primate part of our brain. We humans, like other primates, can exercise empathy because our mirror neurons allow us to relate to another creature’s experience. In fact, mirror neurons were discovered by scientists studying macaques and eating gelato. Listen for a great story! Speaking of empathy, we wondered about empathy fatigue. We started hearing about empathy fatigue during the COVID pandemic, when healthcare providers were overwhelmed by extreme demands with inadequate support. Research shows that “constant, repetitive exposure to the pain of others leads to empathy fatigue.” Lack of empathy can lead people to do terrible things. Wonders of the Unconscious Brain Our brains are full of clocks. To some extent, these are shaped by how we use them. Musicians who play percussion instruments can perceive time differences of just a few hundredths of a second. All of us are entrained to a 24-hour a day cycle, whether we observe sunrise and sunset or not. But if we are deprived of connection with that cycle, our internal clocks can’t keep good time, and our brains may get far off track. What About Premonitions? Some people think premonitions are a fantasy. Yet this is another area where our unconscious brain may be more capable than we imagine. Dr. Hamilton describes an experience in the Swiss Alps where he and his wife had a choice of which path to take down from the summit. One appeared to be a shortcut, and they did have some time constraints. But as soon as they had taken a few steps that direction, he had a premonition of something terrible. They took the other path and learned later that there had been a landslide on the shortcut that would have swept them helplessly down the mountain. According to Dr. Hamilton, some people have the ability to influence the output of random number generators. Those of us who can’t may wish to reject that idea, but it has been documented. The Princeton Engineering Anomalies Research lab has run many studies demonstrating an impact on random number generations, not to mention remote viewing. In this way, some of the hidden power of the unconscious brain appear as cerebral entanglements, analogous to quantum entanglements at the sub-atomic level of matter. This Week’s Guest Dr. Allan Hamilton, MD, FACS, is a neurosurgeon who has specialized in treating brain tumors. His extraordinary journey from janitor to Harvard-trained neurosurgeon is just the beginning of his remarkable story. A decorated Army veteran, he now holds four professorships at the University of Arizona and has been recognized as “One of the Leading Intellects of the Twenty-First Century.” As the only American honored with the Lars Leksell Award for pioneering scientific discovery in stereotactic neurosurgery, Dr. Hamilton’s groundbreaking work has revolutionized the field. He has had a life-long interest in the application of computer technologies to enhance surgical care and reduce avoidable medical adverse events. In addition, he has served on two White House Advisory Committees under two presidential administrations. Allan Hamilton, MD, FACS His expertise extends beyond medicine, having studied creative writing under Rod Serling and serving as a senior medical consultant for Grey’s Anatomy for nearly two decades. Dr. Hamilton’s seven non-fiction books have garnered numerous awards and international translations, offering insights that have inspired leaders across various fields. Dr. Hamilton’s 7th non-fiction book is Cerebral Entanglements: How the Brain Shapes Our Public and Private Lives. 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, April 28, 2025, after broadcast on April 26. 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.

Transcribed - Published: 24 April 2025