Pain is an important warning signal, helping you protect your body from damage. That’s why we can view acute pain as an asset. Chronic pain, though, can be debilitating. In this episode, a pain psychologist offers a roadmap for managing chronic pain. 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, June 13, 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 15, 2026. Managing Chronic Pain Nobody likes feeling pain. Joe remembers that as a child, he would ask the doctors and nurses if the procedure was going to hurt. They always lied and told him it would not. As a result, he ended up not trusting them. We often think of pain as located in the body part that hurts (hence, tell me where it hurts). In actuality, though, pain is a complex phenomenon the brain and its interpretation of the situation at least as much as the body. That is why Dr. Rachel Zoffness maintains that pain is biopsychosocial–the result of three overlapping circles in a Venn diagram: biological, psychological and sociological. The biological circle includes our genetics, tissue damage, diet, sleep and movement. Psychological factors are never just psychological. The brain uses the same limbic system to process emotions and pain, so our feelings about our situation have a major impact on our pain experience. In the sociological realm, we find access to care, a history of trauma, and factors like racism or poverty. One result is that pain is incredibly subjective, varying from one individual to another and even from day to day. Another example of the power of the brain to generate pain is phantom limb pain. You may have heard of someone whose foot hurts even though the leg was amputated. Dr. Zoffness tells us about a boy with hand pain after a fireworks accident that resulted in his arm being amputated. The hand wasn’t there, but the pain was real. What Is Your Pain Recipe? In managing chronic pain, it helps to know what your pain recipe is. What factors contribute to a bad pain day? A few common ones are poor sleep, too much junk in the diet, lots of stress, too little movement. Once you have the recipe for a bad pain day, you may be able to turn that around to find the recipe for a low pain day. If you get enough sleep, does that turn down the pain dial? How about diet? We also discuss the power of self-hypnosis and biofeedback. If you can practice warming your hands up, as Dr. Zoffness has learned to do, you can also practice making yourself more comfortable. She shares another story of a teenager who suffered from crippling migraines, social anxiety and generalized body pain. He had not been to school in years, but taking very small steps at first–just standing in the sun on his front porch–he was gradually able to build himself a low-pain recipe. Taking the dog to the dog park helped him move his body and his brain started producing chemicals like dopamine and serotonin. Eventually Sam was able to return to high school, even graduating. Using Pain Medicines in Managing Chronic Pain Physicians have often learned that managing chronic pain is something of a prescription puzzle. Which drug will work best for this patient? A decade or more ago, the answer was frequently opioids. That’s no longer the case. As a result of the overdose epidemic, doctors usually try to prescribe some other type of medication. Two of the most popular are gabapentin and tramadol. When our listeners tell us about their experience with gabapentin, the results range widely. For some people, it seems to be a life-changing medication. For many others, it is lackluster at best, and for some, the side effects of brain fog, dizziness, breathing problems, edema and an increased risk of dementia are too much. Dr. Zoffness has heard similar reports about gabapentin. Her guideline for pain medicine is to try it for three months and see if it makes a (positive) difference. If not, ask the prescriber to help you taper off. Stopping any pain medicine suddenly could be a mistake. For managing chronic pain, people need a healthcare professional who can help them create a personalized pain management plan. For improving sleep, which is often a key ingredient in the pain recipe, she recommends cognitive behavioral therapy for insomnia (CBTI). The sleep hygiene protocol she suggests can also be helpful, dimming lights and gearing down as the day comes to a close. The Roadmap for Managing Chronic Pain The last section of Dr. Zoffness’s book is a detailed pain protocol. She reminds us that there is no quick hack for pain. If trauma is part of the pain recipe, addressing the trauma will be useful. Medications are important tools, but they are not a permanent fix for chronic pain. She wants us all to remember that if the brain can change, pain can change. It is in our power. This Week’s Guest Dr. Rachel Zoffness is a leading global pain expert, pain psychologist, speaker, author, and thought leader in pain medicine. She is faculty at the UCSF School of Medicine, teaches pain science at Stanford, and is a winner of the prestigious Mayday Fellowship. Dr. Zoffness is the author of Tell Me Where It Hurts: The New Science of Pain and How to Heal. Her website is www.zoffness.com Dr. Rachel Zoffness, pain expert at UCSF 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, June 15, 2026, after broadcast on June 13. 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.

You may think of allergies as causing sniffly noses and congestion in the spring or fall. But allergies can go far beyond that. As Dr. Kari Nadeau points out in this episode, allergies can affect us from head to toe, including eyes, nose, throat, lungs, sinuses, skin and gut. In the most dangerous instances, the whole body is threatened with an anaphylactic reaction. That’s a medical emergency! One in three Americans will develop allergies at some point in our lives, so it’s important to know what works to control them. 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, June 6, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. (Welcome, Huntsville, Alabama!) 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 8, 2026. What Are Allergies? We begin our discussion of your allergy survival guide with an explanation of what is happening during an allergic reaction. The immune system perceives some foreign compound, usually a protein, as dangerous even though normally it would not be. So it reacts by trying to flush the invader out by producing extra mucus. The turbinate sinuses can make one to two gallons of mucus a day, and naturally, it has to go somewhere. That’s why you might be congested. Having all that mucus in the sinuses can also encourage bacterial growth, so if the allergic reaction persists, some people have to deal with sinus infections. Emergency Treatment In determining what works, you need to know the nature of the reaction. If you have two or more organs involved, if you are having trouble breathing or if you feel dizzy, you may be in the midst of an anaphylactic reaction. What works for that is an epinephrine injection and immediate medical attention. This is potentially life-threatening, so you will want to figure out what triggered the reaction so you can avoid it in the future. Once someone has suffered one anaphylactic reaction, they should keep epinephrine with them at all times in case of another episode. Epinephrine comes as a self-injector pen or a nasal spray (neffy). Can You Spot Drug Allergies? In the warnings that are rattled off as part of a TV ad for a pricey new drug, we often hear viewers cautioned not to take the medicine if they are allergic to it. That sounds like simple common sense, but it also has a Catch 22 quality. How do you know you are allergic to a medication unless you take it–and experience an allergic reaction for which you might need treatment. Most of these presumably are immune system-mediated reactions, in which the body produces IgE. That is how allergies to penicillin or sulfa drugs work. Some drugs cause a different type of reaction, not IgE-mediated but dangerous nonetheless. Lisinopril is the most commonly prescribed blood pressure medicine in this country. Like other ACE (ACE is short for angiotensin-converting enzyme) inhibitor medications, lisinopril can trigger angioedema. This swelling can affect the face, lips, tongue and throat, where it can compromise breathing. The most insidious aspect of this reaction is that it can occur after the person has been taking the drug without problems for weeks, months or even years. “Red man syndrome” or infusion reactions in people taking vancomycin can likewise occur without warning. The last type of drug reaction is not actually an allergy at all, although people occasionally use that terminology. It is better described as sensitivity. For example, a stomachache is a common reaction to the antibiotic erythromycin. Some people are disabled by this abdominal pain and try to limit their exposure to erythromycin thereafter. What Works and What Doesn’t? Since the immune system is acting inappropriately to cause allergic reactions, treatment should involve immunotherapy. Eye drops can help eyes feel less itchy and irritated. Likewise, OTC nose drops or nasal sprays can often help the nose. The corticosteroid Flonase (fluticasone) and the antihistamine Astepro (azelastine) are good examples. During allergy season, some people find that a daily nasal wash (with a neti pot or NeilMed device) can help reduce the mucus and remove the allergens such as pollen causing the reaction. There are also oral antihistamines and inhalers for asthma. For decades now, allergists have offered their patients shots to help desensitize them to the allergen causing their trouble. Joe had these as a child and teenager and has been largely free of allergies since. Not everyone gets such lasting relief. Complications from Current Therapies Medications have side effects, and that is true of allergy medicines as with other drugs. Antihistamines, especially the older ones like Benadryl (diphenhydramine), are notorious for causing drowsiness. That’s one reason it is often included in nighttime pain relievers as the “PM” in drugs like Advil PM. We worry about regular use of such antihistamines because it has been linked to a greater risk for dementia. A second-generation antihistamine such as Allegra (fexofenadine) is much less likely to make someone feel sleepy. However, Dr. Nadeau has seen patients on antihistamines suffer worse allergies if they stop suddenly. The People’s Pharmacy has received hundreds of reports from people who experienced unbearable itching upon discontinuing Zyrtec (cetirizine) or Xyzal (levocetirizine). This can last for weeks. Doctors don’t usually worry much about steroid nasal sprays like Flonase because they are topical. Presumably, nasal tissues pick up most of the dose. Just the same, using such a nose spray day after day for a long time could result in systemic steroid exposure that is not trivial. Stronger Medicine Dr. Nadeau is enthusiastic about the benefits of two potent prescription medicines. One is Xolair (omalizumab). It was originally developed to prevent asthma, but is now approved for chronic sinusitis, food allergies and chronic hives. Paradoxically, Xolair is one of those medicines that could cause a severe allergic reaction even on the first dose, so the FDA warns that the initial injection should be given in a healthcare setting prepared to treat anaphylaxis. This is uncommon, though, occurring in 0.1 to 0.2% of patients. The other medication Dr. Nadeau is prescribing for allergy patients who don’t respond well to other treatments is Dupixent (dupilumab). The FDA has approved this medicine to treat a wide range of conditions, including eczema, asthma, chronic sinusitis, allergic reactions affecting the esophagus and chronic hives, among other things. Most insurance companies will not cover this pricey injection unless the patient has failed all other therapies. Fighting Air Pollution: What Works Air pollution makes allergy symptoms worse, so using an effective air filter inside the home is a good step. A HEPA (high-efficiency particulate-arresting) filter is ideal, especially as part of the air-handling system. If that’s not possible, utilizing a MERV 13 in the part of the home where you spend the most time is a good second choice. Sonu One new option for treating allergies is acoustic resonance therapy with the SoundHealth Sonu headband. It uses vibration from sound to loosen mucus from the sinuses so that they can clear. The FDA has approved its use for children as well as adults. New research was just published demonstrating its helpfulness in treating children with nasal congestion (Oto-Open, April-June 2026). SoundHealth has underwritten The People’s Pharmacy podcast. Dr. Nadeau has also been compensated for her role in conducting studies of this device (International Forum of Allergy & Rhinology, Dec. 2025). Since it does not employ medications, there are no drug side effects. This Week’s Guest Kari C. Nadeau, M.D., Ph.D., is Dean of the UCLA Fielding School of Public Health ( starting July 1 2026). Until then, she holds many other positions. At Harvard T. H. Chan School of Public Health she is: John Rock Professor of Climate and Population Studies; Chair of the Department of Environmental Health; and Director of the Allergy, Extreme Weather, and Exposomics Lab. Dr. Nadeau is Professor of Medicine at Harvard Medical School and serves in the Division of Allergy and Inflammation at Beth Israel Deaconess Medical Center. She is an Adjunct Professor at Stanford Medical School. Dr. Nadeau is also the co-author of The End of Food Allergy, which provides strategies for treating and preventing food allergies in children. Here is a link to the research underway in her Harvard laboratory. PHOTO CREDIT: STACY GEIKENTaken in April 2017 at Kari Nadeau’s professorship dinner The End of Food Allergy: The Science-Based Plan That Turns Food into Medicine 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, June 8, 2026, after broadcast on June 6. You can stream the show from this site and download the podcast for free. This episode has additional information about Nasalcrom (cromolyn sodium nasal spray) and its effect on mast cells; alpha gal allergy to red meat; and the latest thinking on preventing peanut allergy among young children. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

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.

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.

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

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.

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.

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.

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.

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

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

Every five years, the Departments of Agriculture and of Health and Human Services jointly issue guidelines on what we should eat. The most recent Dietary Guidelines for Americans (2025-2030) have been controversial. [Here is a link: https://www.dietaryguidelines.gov] Among other things, the administration decided to flip the food pyramid upside-down in illustrating its recommendations. Why did that cause such a stir, and what will it mean for you? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, March 14, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on March 16, 2026. Why Flip the Food Pyramid? Nobody has actually explained to us why they decided to flip the food pyramid on its head. The food pyramid itself debuted in 1991 as an illustration of what we should eat, but many people found it confusing. In 2011, it was replaced by a MyPlate graphic. So why return to the food pyramid now, especially upside-down? Our guest, noted nutrition researcher Christopher Gardner, suggest that it might be a way of denoting dramatic changes from previous guidance. Spoiler alert: only a few details are dramatically different. The main changes are a commendable emphasis on eating real food and attention to red meat as a protein source and full-fat rather than low-fat dairy products. Do Americans Need More Protein? If you pay attention at the supermarket, you’ll probably notice that a lot of product tout their protein content. Even things that don’t seem like they’d stand out as sources of protein (granola, pancake mix) are being offered in containers emblazoned with the promise of protein. Surprisingly, though, this is not a response to an urgent need. Most Americans get adequate protein and don’t need to concentrate on increasing their intake. Might it be a marketing tool? Should We Worry About Dairy as We Flip the Food Pyramid? Generally, public health experts recommend that we avoid foods high in saturated fat such as butter or cheese and opt instead for lower fat items, like skim milk. Consuming excessive amounts of saturated fat can raise blood levels of dangerous LDL cholesterol. On the other hand, Dr. Gardner points out that dairy fat differs in some ways from the saturated fats in meat, for instance. We don’t have enough studies to evaluate health consequences of consuming full-fat dairy. Will that raise cholesterol? Might it increase the chance of heart disease? We still need more research to be able to tell. What About Eggs? Speaking of cholesterol, what about eggs? For decades, Americans were warned not to eat eggs. Experts thought these cholesterol-rich foods would raise the level of cholesterol in our blood. But although eggs are high in cholesterol, they are low in saturated fat. Joe describes an astonishing experiment in which a person ate two dozen eggs a day. After a month, his LDL cholesterol was lower than when he started. Dr. Gardner remarks that we need to know not only what we are eating, but also instead of what and with what. Eggs with sausage and cheese are quite different from a veggie frittata. What’s for Breakfast? Let’s consider what people might be eating for breakfast instead of eggs. Quick toaster pastries, sweetened cereal, orange juice and toast with jam are all popular options that are high in refined carbohydrates. At least for some people, such foods may make blood sugar and insulin spike. That could lead to a midmorning crash, which in turn could encourage someone to have a midmorning snack. Is that a bad idea? Maybe it is one reason to flip the food pyramid. If We Flip the Food Pyramid, Will It Help with Weight Loss? Dr. Gardner has run studies comparing the results of healthful low-carb diets to healthful low-fat diets. He and his colleagues found no significant difference in the weight loss people experienced on average. But none of us is an average person. The range of responses to these diets was huge, with some people losing a lot of weight and other losing none or even gaining. How to Lose Weight Based on this research, it seems no single diet will work for everyone. What makes a big difference is satiety. If what you eat makes you feel full and keeps you feeling full, it will help keep you from eating too much. No need to flip the food pyramid in that case. And, says Dr. Gardner, no need to rely on continuous glucose monitors unless your blood sugar is out of range. Just paying attention to how food makes you feel and to the maxim Eat Real Food will be a pretty good guide for most of us. Dietary Guidelines That Flip the Food Pyramid Shape Food for Kids One important way that the Dietary Guidelines for Americans are implemented is school lunch. Institutions receiving funds from the federal government must follow these guidelines. Substituting minimally processed foods for the inexpensive ultraprocessed foods that are currently found on many school menus will probably be more expensive. The new guidelines also recommend that kids not get any foods with added sugar until they are at least ten years old. That would be a big difference in children’s diets, at as big as when we flip the food pyramid. Is it practical? This Week’s Guest Christopher Gardner, PhD, is a nutrition researcher. He is the director of nutrition studies at the Stanford Prevention Research Center and the Rehnborg Farquhar Professor of Medicine at Stanford University. Christopher Gardner, PhD, director of nutrition studies at the Stanford Prevention Research Center and the Rehnborg Farquhar Professor of Medicine at Stanford University Listen to the Podcast The podcast of this program will be available Monday, March 16, 2026, after broadcast on March 14. You can stream the show from this site and download the podcast for free. In this episode, Dr. Gardner discusses the types of fat he uses in his kitchen and why. What oils does he choose for sautés or salad dressing? What is his perspective on olive oil? what does he eat for breakfast, lunch and dinner, and what is he buying at the market? Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1465:  transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:28 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Americans keep flip-flopping on food. For years, experts recommended low-fat diets. Now, the pendulum has swung back. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:44 The new dietary guidelines for Americans prioritize protein, especially animal protein. They also encourage us to eat real food. What does that mean? Joe 00:45-00:52 Our guest today is one of the country’s leading nutrition researchers. He will explain the changes in these new recommendations. Terry 00:53-00:56 Will the new guidelines change the way you eat and feed your family? Joe 00:58-01:06 Coming up on The People’s Pharmacy, learn about the food fight. Should we flip the food pyramid upside down? Terry 01:14-02:47 In The People’s Pharmacy Health Headlines: Many medical professionals are skeptical about the value of multivitamins. A fresh analysis of data from the COSMOS trial of multivitamins and cocoa flavanols now suggests that the multivitamin-multimineral combination used in the study slowed aging. The conclusion is based on almost 1,000 study volunteers with an average age of 70. Compared to those taking placebo tablets, those on the multi for two years aged more slowly according to two markers of biological aging. In addition to slower aging, those in the vitamin supplement arm of the study had lower inflammation and better cognitive function. Epigenetic aging clocks are not perfect, but they do offer some sense of how fast a person is aging relative to chronological age. The slowing was small, between one-tenth and two-tenths of a year. People whose aging was accelerated before the study began got the most noticeable benefit from multivitamin action. The researchers suggest that aging more slowly in this way could translate to a somewhat lower risk of cancer. The author summarized: In conclusion, we provide evidence from a large-scale and long-term randomized controlled trial that a daily multivitamin and mineral combination is a safe, readily accessible, and low-cost intervention that may slow epigenetic aging. Joe 02:48-03:56 There’s something that might make you age faster at the cellular level. If you have difficult people in your life who create problems, they could be aging you at a faster rate than normal. These hasslers seemingly create biological aging in those around them. The study involved 2,345 participants ranging in age from 18 to 103 years old. The researchers measured cumulative biological aging data. Hasslers were defined as people causing problems or making life difficult. The negative interactions could range from everyday irritations and criticism to exclusion, hostility, denunciations, or even violence. The people who participated in the study reported that on average they experienced 8.1% of their network members as hasslers. The more hasslers in your life, the more pronounced the aging effect. People who make you feel bad may add roughly nine months of biological age to your life. The authors suggest avoiding hasslers whenever possible and seeking out people who are supportive. Terry 03:57-04:43 There’s a common perception that getting older means you lose your edge and start to fall apart. But what if we viewed aging as an opportunity for improvement instead? A new study published in the journal Geriatrics suggests that some of us become healthier and more creative as we age. The key seems to be in our attitude. Participants enrolled in the Health and Retirement Study and took tests of cognitive ability and walking speed. Their average age at the start of the study was 68 years. After a follow-up of up to 12 years, researchers repeated the assessment on more than 11,000 people. These volunteers had also recorded their beliefs about the aging process. Joe 04:44-05:07 Almost half, 45% of the participants, showed improvement in either cognitive performance or walking speed, or both. If the investigators also included people who stayed the same after several years, the proportion of those who did not decline with age was over half. Significantly, more of the people who improved had expressed positive views of aging at the outset of the study. Terry 05:08-06:17 Children in North America eat a lot of junk food. A study notes that nearly half of the calories consumed by Canadian preschoolers come from ultra-processed foods. The investigators wanted to know whether such a diet affects emotional and behavioral functioning. They found that ultra-processed food consumption at age 3 is associated with greater anxiety, fearfulness, and depression at age 5. These results parallel those from a British study linking burgers, fried chicken, potato chips, and chocolate to hyperactivity at age 7. The authors suggest that feeding young children less ultra-processed foods could result in better mental health as they grow older. And that’s the health news from the People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:31 And I’m Joe Graedon. Americans have been fighting about food for decades. First, eggs were bad. Now they’re good. Olive oil was too high in saturated fat. Now it’s a cornerstone of the preferred Mediterranean diet. Terry 06:32-06:44 The latest version of Dietary Guidelines for Americans is controversial. It was presented with a graphic that turns the food pyramid upside down. What should you know about healthy eating? Joe 06:45-07:02 To help us answer that question, we turn to Dr. Christopher Gardner. Professor Gardner is a leading nutrition researcher. He’s the Director of Nutrition Studies at the Stanford Prevention Research Center and the Rehnborg Farquhar Professor of Medicine at Stanford University. Terry 07:03-07:07 Welcome back to the People’s Pharmacy, Dr. Christopher Gardner. Dr. Christopher Gardner 07:08-07:10 Joe and Terry, thanks for having me back. Joe 07:10-07:49 Christopher, it is so good to have you back on the People’s Pharmacy. It’s been far too long and so much has happened in the world of food. So let’s just start at the beginning. There’s a lot of confusion and emotion around food in general. It’s so complicated. Our grandparents, they had it so simple. They went out to the garden. They cooked what was available. There was no controversy about good foods and bad foods. So we’re going to start right off with the dietary guidelines. Who sets them up? Dr. Christopher Gardner 07:50-08:10 Oh, yeah. So the secretaries of Agriculture and Health and Human Services have shared that responsibility since the beginning, which is a little odd because it seems like it should be Health and Human Services, given that the agricultural community has an obvious conflict of interest. But that’s the short answer. Terry 08:11-08:19 That definitely makes it more complicated, I think, for them to be able to collaborate on these guidelines. What are the guidelines supposed to do? Joe 08:19-08:23 Terry, before that, why do they have a conflict of interest? Terry 08:23-08:23 Okay. Dr. Christopher Gardner 08:25-08:52 Right. So you can’t, let’s say you represent the cattleman’s industry, and the pork industry, and the egg industry, and the scientists say you should eat less of something. Wow, that would work against your interest to tell somebody that you represent that the whole American public should eat less of you. But if you’re a vegetable and fruit growing type person and the scientists say eat more veggies and fruits, well, it’s easy to suggest eating more of someone you represent, but not less. Terry 08:54-08:55 Keep going. Joe 08:55-09:02 I just wanted to know why it was [a] conflict. Back to your question. Terry 09:02-09:19 Well, it sounds as though this dietary guideline project has been complicated right from the beginning if they’ve had to collaborate from the beginning. What is the function of the guidelines? What’s the big idea? Dr. Christopher Gardner 09:19-10:36 Yeah, so great question. So there’s a whole story that Marion Nestle is the best at explaining of why they originated in 1980. But when they did originate in 1980, they made a deal, or it was part of their write-up, that every five years, just in case there was new science, they would update them. And so there have been updates every five years since 1980. And the way they’ve gone about this over the last 20 years or so, not necessarily in the beginning, was they would get together a group of scientists and refer to them as the Dietary Guidelines Advisory Committee. And for two years, that group would review any new papers that came out since the last time they were issued. And the group would submit an advisory report to the secretaries of ag and health and human services. And as an advisory, they didn’t have to take the advice. And over time, there’s many times they did not take the advice, but many times they did take the advice. And then it was really USDA and HHS that issued those guidelines sometime the next year after they got this report. And I have lots of details to share with you about what happened this time, but that’s the short answer. Joe 10:36-10:48 Well, before we get to what happened, what’s the point? I mean, why do we even have dietary guidelines and what are they supposed to do for American health? Dr. Christopher Gardner 10:48-12:47 I’m really glad that you started there. So it is kind of interesting that when you read these, every time they’ve been reissued, the very beginning says these particular guidelines are really not for the American public to read. A lot of scientific work went into this, a lot of the language is rather technical. So this is really for health professionals and policymakers. It’s a really long, boring document. But at its best, what it does is it informs federal safety net programs. So if you’re thinking school lunch, school breakfast, women, infants, and children, there’s really about 20 to 25 federal safety net programs to help people who don’t have enough to eat. And so when you’re trying to provide more food for those in need, there’s some guidelines that say, well, you should make sure you emphasize this and try to avoid that because we would like these people getting federal assistance to get healthy choices. So the biggest impact of those dietary guidelines is actually on like kids getting school lunch and school breakfast, not so much the general public. And it’s well known that if you look at what’s been stated in the dietary guidelines, because this is actually part of the advisory group’s responsibility every five years to get a hint of how America is eating. And that’s done by looking at something called the healthy eating index. And actually people go through group by group, the veggies, then the fruits, then the grains, then the meat, then the dairy. And Americans for a long time have not followed the dietary guidelines, which is a super interesting part because quite often some social influencers have said, “Oh my God, the dietary guidelines as written are killing us. We have an obesity epidemic, a diabetes epidemic. Oh my God, we better change them.” And the typical response among those who made them is, well, people aren’t following them. Terry 12:47-12:48 Aha. Dr. Christopher Gardner 12:48-12:59 It’s not following them that made them sick. We have them available, but most people don’t follow them. So that would be an interesting experiment if we check their health after they did. Terry 12:59-13:13 So you can have good advice to look both ways before you cross the street. And if you fail to look both ways, you just ignore that and look at your phone instead while you’re crossing the street and you get run over. You can’t really blame the guidelines, right? Dr. Christopher Gardner 13:14-13:23 Exactly. That’s been a very frustrating point to try to deal with with social influencers lately, and it’s actually just led to more confusion than is necessary. Terry 13:24-13:46 Well, Dr. Gardner, you mentioned that these guidelines traditionally are long, boring documents. Long, I mean, 100 pages or so. And apparently, the most recent ones are a lot shorter, like maybe 10 pages. Can you tell us how they have changed the advice from the previous set of guidelines? Joe 13:46-13:49 And why are they so controversial? Dr. Christopher Gardner 13:52-14:52 Yep. Okay, so picture the last guidelines were 164 pages from 2020. But actually, the government put together all kinds of short versions of those, depending on who the audience was. There’s a five and a 10-page version. And if you look at all the marketers and the communicators, they set up different length documents depending who they were targeting. And this particular one, I honestly thought it was 12, but maybe it’s 10 pages. I think the one I have is 12 pages long. That sounds much shorter, but there’s a 90-page document that goes with it. And there’s also a 400-page document that goes with it. If you want even more detail and to put that in perspective, I worked on the 2025 Dietary Guidelines Advisory Committee. We generated a 421-page report with a 1,000-page supplement that went into the details. And I could probably pretty quickly explain why it’s so long if you want me to go there. Joe 14:52-15:25 Well, you know, I think everybody has heard by now about the food pyramid. And so I think the food pyramid kind of boils down the dietary guidelines to something that doctors and patients and just the rest of us can kind of make sense of. But this new food pyramid has got everybody all excited. Why? What’s the big deal? Dr. Christopher Gardner 15:25-17:27 Excited in both directions, like super happy and super sad. So interestingly, the original food pyramid that came about in 1991, if you look into the history of it, nobody actually really liked the food pyramid from the beginning. And one of the reasons they didn’t like it is there were tiers to this pyramid. The base of it said six to 11 servings of grains, just as one obvious example. And people thought that was bewildering. And so when you actually read the details behind the graphic, it said, well, if you’re a small, inactive person, you might need six servings. And if you’re a large, super active person, you might need 11. And so after quite a few years, they actually got rid of the standard food pyramid and then made mypyramid.gov. And you got to go online for that one and say how big and how active you are. And then instead of getting a huge range, it said, oh, you should get six and you should get eight and you should get 10. And so that was a little bit better. But at the end of the day, a lot of people didn’t understand the pyramid and they thought, oh, the tip of the pyramid, that’s the top. That must be the most important thing. So I’m going to go straight to the top and have the most of that. And the original intent had been that’s the smallest part of the pyramid is the tip. And that’s the thing you’re supposed to have the least of. So in 2011, after 20 years, they completely abandoned the pyramid and came up with myplate.gov. And they said, oh, half your plate should be veggies and fruits. And the other half can be grains and protein sources and a little circular thing of dairy on the side. And they said, these are simpler. Interestingly, if you clicked on either the pyramid or myplate.gov, there’s a mind-numbing amount of detail, and the architecture never changed. It talked about lots of different things in very specific language. Joe 17:28-17:48 Well, I have to tell you, Dr. Gardner, we have a break. We’re going to stop for just a few seconds. But when we come back, we’re going to talk about the new food pyramid and why are people so excited. So get ready. We’re going to talk food pyramid 2026. Terry 17:50-18:06 You’re listening to Dr. Christopher Gardner, Director of Nutrition Studies at the Stanford Prevention Research Center. He’s the Rehnborg Farquhar Professor of Medicine at Stanford University. Dr. Gardner has studied the effects of popular weight loss diets comparing low-fat to low-carb eating patterns. Joe 18:07-18:12 After the break, we’ll find out more about the new food pyramid and why they got rid of my plate. Terry 18:12-18:17 What does it mean that the new guidelines tip the food pyramid upside down? Joe 18:17-18:21 The new guidelines put a stronger focus on protein, especially animal protein. Terry 18:22-18:24 Is protein in short supply in the American diet? Joe 18:24-18:27 We’ll also talk about breakfast. What’s your favorite? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:54-19:11 And I’m Terry Graedon. Joe 19:11-19:24 The new dietary guidelines for Americans from 2025 to 2030 emphasize protein, especially animal protein. Are Americans really deficient in protein? Terry 19:25-19:32 The theme of the guidelines is that we should eat real food. That’s something we’ve been advocating here at the People’s Pharmacy for decades. Joe 19:32-19:45 Our guest is one of the country’s leading nutrition experts. He’s studied vegetarian diets, garlic, ginkgo biloba, fish oil, and other omega-3 fats, as well as a range of weight loss diets. Terry 19:45-19:57 We’re talking with Dr. Christopher Gardner, Director of Nutrition Studies at the Stanford Prevention Research Center. He’s the Rehnborg Farquhar Professor of Medicine at Stanford University. Joe 19:58-20:09 Dr. Gardner, food pyramid, 2026. Why is everybody so excited? What’s the deal on meat and dairy and… Terry 20:10-20:12 And why did they give up on the plate? Dr. Christopher Gardner 20:13-21:06 Yep. So I have an opinion about that. It’s my personal opinion. So I don’t have any data to support this. Interestingly, this administration has been really gung-ho for getting at ultra-processed food. They ended up calling it highly-processed food. At the end of the day, it’s basically junk food that Americans have been eating too much for a really long time. And they said, you know, we are on a mission here and we’re going to take this more seriously than any administration before us. We are going to make the most dramatic changes that have ever been witnessed in rewriting and shortening these guidelines. And to show you how revolutionary this is, let us show you the new graphic. So this is the pyramid on its head. We have flipped the entire thing upside down. Terry 21:06-21:09 So it’s teetering on the point of the triangle, right? Dr. Christopher Gardner 21:10-22:49 And I think it was meant to show that this is a really, really dramatic shift. And you should take note, we are super proud that we are taking this on for the first time. So the challenge there is if you really look through all the details, most of it hasn’t changed. So the very first recommendation is to not eat too many calories and to balance those out to watch your weight. That’s the same. The second one, let’s come back to, it has to do with prioritizing protein every day. That is the one that has the most people curiously looking into the details. But then it says eat veggies and fruits, eat four servings of whole grains, don’t eat too much added sugar, eat healthy fats. They added a cool thing about the gut for the microbiome. And most of the recommendations are really carried over from the past. The red meat and the prioritizing protein are two of the big changes. And the other one was for dairy, it very specifically said whole fat dairy and three servings a day. And for so, so long, the dairy part recommended low fat dairy. So those are the big changes. And I think there’s about 12 different points if you go through each one, one at a time. Most of them are actually the same. It’s not very radical. So my opinion of the flipped pyramid is it’s sensationalist. It’s to show how radically different things are. If you read through it, it’s not really that different except for the protein and the whole fat dairy and kind of focusing on ultra-processed food. But that’s a separate topic. Keep going. Terry 22:50-23:11 Let’s talk about that protein focus, because my recollection is and, you know, my memory’s not perfect, but my recollection is that a long time ago when we talked to you before, you said most Americans are getting already plenty of protein and don’t really need to focus on getting more. A, was that true? And B, is it still true? Dr. Christopher Gardner 23:12-25:13 Was true, still is true, but it would be hard to know that going in any grocery store or crawling out from any rock and looking around right now because everything says high protein. There’s protein water, there’s protein Pop-Tarts, there’s protein cereal, there’s protein soup. You would think as you go through the grocery store, I mean, tell me if you have experienced the same thing. I’ve seen so many foods in font 12. This is yogurt. This is grain. This is something else. But protein is in twice the size font of whatever the food is. Like it seems to be more important that they tell you it has protein than they tell you what the food is actually itself. It’s turned out to be an incredibly effective marketing tool. And so after seeing all the protein powder, all the protein bars, the David bar, which crammed more protein in a bar than anybody’s ever managed to do before, only because of this bizarre undigestible fat that they added to it, which is super processed, they put all this protein in it. And then I think because they’re saying, oh, you know what? The new target range is no longer, okay, now sorry for these units here, 0.8 grams of protein per kilogram of body weight. I don’t know if you want to stop and explain that, but that’s just the general way they refer to it. It’s no longer 0.8. It’s 1.2 to 1.6, which kind of sounds like double. And my frustration as a public health person and a nutrition scientist is somebody’s going to look at that and say, that’s why there’s protein in everything at the grocery store. Oh my God, for all these years, it’s been wrong. They’ve only been telling us to get half the amount we need. And thank God they’re labeling all that food in the grocery store. And thank God they brought red meat back. Because as an American, for most Americans, when they think of protein, they think of meat. They don’t really think of beans, legumes, peas, lentils, and… Terry 25:13-25:14 Peanut butter. Dr. Christopher Gardner 25:15-26:51 Joe and Terry, yeah, that’s been my push for years is everything has protein in it. The dietary guidelines have always pointed out what the nutrients of concern are, and those have typically been fiber and calcium and vitamin D, and for infants and young kids, iron. Protein has never been a nutrient of concern that Americans aren’t getting enough of, and so it is bizarre that they chose to do that. By the way, the National Academies is the one who comes up with the DRIs, the Dietary Reference Intakes, where they actually list amounts of nutrients that you get. The Dietary Guidelines for Americans is separate. It’s the USDA and Health and Human Services. And their main job is supposed to show you what servings of what foods would get those numbers for you. So technically [it] isn’t their purview to be putting numbers in with their recommendations. So weird that they put numbers, weird that the numbers are double what they were when there isn’t a protein problem. Weird that they brought red meat back in their new flipped pyramid. It is at the very top in the upper left. And when Americans read top to bottom and left to right, that is the first thing that they see is this big thing of red meat followed by a huge turkey and some other meat, and whole fat dairy thing. So that’s what has people questioning WTF. What happened? Was the science all wrong for all those years? Terry 26:51-26:58 And of course, Americans have a hard time with the metric system. So trying to figure out grams per kilogram is a challenge. Dr. Christopher Gardner 26:58-27:57 And so they just look for the big font. Oh, okay. All I really know is it’s protein. So I’m going to get my protein pop tarts and my protein soup and my protein candy bar. And if somebody says, no, no, no, they said eat whole food. Oh, wait, no more junk food. Okay. And I personally, Joe and Terry, I do like the no junk food, less highly processed, less ultra-processed food. But I think if they recognize how many of those high protein foods are junk foods, then they’ll say, oh, well, thank God you clarified that. Now I know to get my meat. No, no, for the last 20 years, the Dietary Guidelines advisory committees have always said less meat, less red meat and processed meat in particular. And after handing it off to the Secretary of Ag, that was transferred to choose lean sources of meat instead of eating less red meat. So that went counter. Joe 27:57-28:39 So, Dr. Gardner, let’s move on to fat. Because for years, we were told low fat, no fat, that’s the answer to good health. And there were all these dairy products. I mean, you had low fat yogurt, no fat yogurt, no fat cottage cheese. Oh, and milk, it’s got to be low fat. Or skim. Skim milk is so much healthier than whole milk. And now they’ve turned that upside down. Did they get that right? Did they get that wrong? What does Dr. Christopher Gardner think about dairy? Dr. Christopher Gardner 28:41-31:28 Okay. Well, take one step back because the fat thing was an oversimplification. They always meant saturated fat. And that seemed to be too much for the American public to handle. So the marketer said, let’s just be more simplistic. Let’s say less fat. And then quite immediately, the health community pushed back and said, no, no, no, that was supposed to be less meat and lard and butter and things like that. It was supposed to be less saturated fat, but olive oil, avocados, nuts and seeds, the unsaturated fats are okay. So let’s just differentiate saturated from unsaturated. But Joe and Terry, dairy fat is a little different. So all the different fats have different lengths of carbon chains. And part of the reason butter smells like butter is butyric acid only has four carbons. It’s a saturated fat. But there honestly aren’t that many studies that are well done of something as super practical as whole milk versus skim milk in our school kids. So this is one of the main places where the battlegrounds lies, because one of those places where it really is having an impact is not, Terry, as you were saying, going to the street and looking both ways before you cross. This is like, what are schools allowed to buy? And it says schools can’t buy whole fat dairy. Interestingly, schools could buy low fat dairy that was chocolate and full of sugar. And that’s actually appalled many of us in the health community for many years. But let’s say you got rid of the chocolate and the sugar and just had low-fat milk versus whole-fat milk, believe it or not, there’s almost no studies on that. But think about this. One of the main issues of saturated fat is cholesterol in the blood, which leads to heart disease. How many 12-year-olds have heart attacks? None. How many 15-year-olds? Okay, maybe one or two. But the main way to look at that outcome of switching your saturated fat source for adults has been a quick blood draw to see what your LDL and HDL cholesterol are like. And nobody wants to let their kids go in for blood draws for drinking different kinds of milk. So I’m actually working with a group right now that’s doing a really interesting low fat versus whole fat milk study in kids. But it’s not cholesterol that is the main outcome. It’s lots of other possible health outcomes. And so the people who are pushing back on the whole fat dairy and saying it’s okay are kind of within their right to do that cause there is not a strong evidence base against whole fat dairy and kids. Terry 31:28-31:46 So they’re saying it’s okay, but what you’re saying is we don’t have the evidence to say it is or it isn’t okay. And there are some people who worry that a very low-fat diet, if you’re very young, you know, two, three, four, might not be good for your brain. Dr. Christopher Gardner 31:47-32:03 Yes. And that’s actually what our Dietary Guidelines Advisory Committee found out, that some of that whole-fat dairy was better, especially for really young kids. So the idea is, what about middle school and high school? At what point does it switch over, if it switches over? Joe 32:03-32:09 You’ve used that bad word, LDL cholesterol. Dr. Christopher Gardner 32:10-32:11 Yeah, Ok. Joe 32:11-33:07 With regard to whole fat dairy. Now I want to switch for a moment because we seem to demonize foods. There are good foods and there are bad foods. And for a long time, eggs were bad foods because they had cholesterol and because they would therefore cause heart attacks. Well, there is this rather interesting fellow, Dr. Nick Norwitz, MD, PhD. You may have heard of him at Harvard. I think he was at Harvard. But in any event, he started eating an enormous number of eggs, 24 eggs a day, two cartons of eggs for 30 days. That’s a lot of eggs. 720 eggs, 133,200 milligrams of cholesterol over the course of a month. Terry 33:07-33:10 And most of us would never want to see another egg after we’d done that. Joe 33:11-33:16 But he measured his LDL cholesterol. It went down. How could that be? Dr. Christopher Gardner 33:17-34:59 Oh, because they probably got less saturated fat in their diet. So the saturated fat in the diet has a more direct impact on the LDL cholesterol in your blood than the dietary cholesterol. And that’s been known for decades. The liver actually makes a lot of cholesterol on a day-to-day basis. And all the cholesterol that you eat goes to the liver in your body before it goes anywhere else. And for most people, and maybe for Nick in particular, he’s probably just a super efficient compensator. He says, “Oh, I don’t need to make any liver cholesterol today. I ate 24 eggs today. So I’m just not going to make any internal cholesterol.” And it’s kind of a wash. So to be honest, Gerald Reaven, who’s a Stanford professor and who is the godfather or the father, whatever you want to call it, of insulin resistance as it relates to things like LDL cholesterol and triglyceride. And he has passed away, bless his heart. He did one of the oldest studies where people had 900, 600, 300, or zero grams, milligrams of cholesterol a day, and it didn’t impact their blood cholesterol. And you can add that to a dozen other studies that showed it’s really not the cholesterol in your diet. It’s the saturated fat, but it’s kind of a moot point, Joe and Terry, because most things that have cholesterol also have saturated fat with two exceptions. Are you ready? Drum roll, eggs and shellfish have a ton of cholesterol, but they don’t have much saturated fat. So they kind of got a bad rap from that whole saturated fat LDL cholesterol thing. Joe 35:00-35:03 Well, I remember when we weren’t supposed to eat shrimp. Dr. Christopher Gardner 35:04-35:49 Yeah, because of that. And so they’re kind of off the hook. Now picture, so I don’t know if you know this, Joe and Terry, but maybe when I was talking to you last, which was a while ago, my two favorite terms now are “instead of what” and “with what?” And eggs are my favorite example. So picture scrambled eggs or picture egg McMuffin or picture eggs with sausage and bacon versus an omelet with veggies in it and sauce on top. Picture cheesy eggs with sausage and bacon. So is it really just the eggs or is it that you had eggs with cheese, with bacon, with sausage… Terry 35:46-36:08 Or, Dr. Christopher Gardner, our favorite, Joe’s favorite breakfast specifically, is refried beans. I sauté some onions in a little olive oil, and then I put in the refried beans. And then when the refried beans are all nice and warm, I cook an egg on top. And that’s how we have our eggs. Joe 36:08-36:11 And I like peppers as well. Terry 36:11-36:11 Oh, yeah. Joe 36:11-36:36 It’s like it gets me through at least half a day or longer. It’s wonderful. Well, we do need to take another break. When we come back, we want to talk about weight loss. We want to talk about Christopher Gardner’s favorite foods. We want to talk about the future of the food industry. So keep those thoughts. We’ll be right back. Terry 36:37-36:50 You’re listening to Dr. Christopher Gardner, Director of Nutrition Studies at the Stanford Prevention Research Center. He is the Rehnborg Farquhar Professor of Medicine at Stanford University. Joe 36:51-36:59 After the break, we’ll talk about the obesity epidemic. Are there some dietary patterns that make it easier to lose weight? Terry 36:59-37:06 Dr. Gardner’s research has shown that lots of different diets can contribute to good health throughout the lifespan. Joe 37:07-37:11 How can people find out which diet works best for them? Terry 37:12-37:22 The new dietary guidelines suggest that kids should not have any food with added sugar until they’re 10 years old. That would be a big change. Joe 37:22-37:27 Find out about the risks and the benefits of the new food pyramid. Terry 37:39-37:56 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to the People’s Pharmacy. I’m Terry Graedon. Joe 37:54-38:10 And I’m Joe Graedon. Joe 38:21-38:41 Have you ever tried to lose weight by focusing on a particular dietary approach? Did it work? Some people embrace the low-carb Atkins approach, while others sing the praises of the Dean Ornish low-fat strategy. Is there one best diet for everyone? Terry 38:41-38:51 Today, we’re talking about the food fight over dietary guidelines for Americans. The food pyramid was flipped upside down. How will that affect your food choices? Joe 38:52-39:07 We are talking with Dr. Christopher Gardner, a leading nutrition researcher. He’s the Director of Nutrition Studies at the Stanford Prevention Research Center and the Rehnborg Farquhar Professor of Medicine at Stanford University. Terry 39:08-39:37 Dr. Gardner, it is no secret that one of the biggest problems for Americans in terms of diet and health is that there’s too much obesity. People are too fat. People are eating too much or else they’re eating the wrong things. So are there dietary patterns that make it easier to lose weight? We know you have done some research in this regard. Dr. Christopher Gardner 39:38-42:45 Oh, I did a lot. Yeah, so we’ve had 1,000 people across two different studies where we did a lot of focus on low-fat and low-carb. And we compared them head to head and drum roll, pretty much a wash. They both on average lead to about the same amount of weight loss and almost everybody loses weight on them, especially if they’re healthy. So our second of the two studies was one where we had a healthy low fat and a healthy low carb and the average weight loss was the same. But Joe and Terry, what was stunning was always the range of response to that. So some of the participants gained weight and some lost a lot of weight on both diets. And so a lot of people have been looking for personalization of diets. So is there, oh, maybe insulin resistant people do better on low carb and insulin sensitive people do better on low fat. That was our main hypothesis in the study. And it failed when it was a healthy low carb and a healthy low fat. At one point, we thought genetic predisposition might be part of this. And so we got what we thought were low-carb predisposed people and low-fat predisposed people, and that also failed. So everybody’s been looking sort of for this magic bullet. Is it the carbs, fats, and protein? Let me just go to protein for a second. We never focused on the protein. But I will say that I looked at our two studies and several other studies, and I know protein is a huge craze and in theory protein is satiating and helping people out. But when we looked at a bunch of studies a year or two years out, almost every group, no matter how good they were at getting lower in carb or lower in fat, ended up almost exactly at 20% protein. Even the most famous study out there called POUNDS Lost that had a 15% protein diet and a 25% protein diet. In the beginning, when they were excited about it, they did that. But a year or two out, they were both at 20%. So you could talk about whether high or low protein has a difference. But when you actually watch people over time, it kind of nullifies. They end up at the same level of protein. So I don’t think it’s a macronutrient thing. I think you can do pretty much any of the popular diets out there and find that it works for someone. And sadly, I wish the health professionals had better advice, but you’re kind of going to have to biohack and figure out which one works the best for you. A lot of health professionals say the best diet to be on is the one that you can maintain for a really long time. So if this is culturally adapted to your preferences, you like the taste, it works in social settings, it works with your family. All those are probably, I think, more important than low-carb or low-fat or high-protein. Terry 42:45-43:33 We just saw a study published in Science Advances that looked at five different types of healthful, presumably healthful diet, and found that actually people who did well on any of these diets were likely to live longer. So it looks as though there’s quite a range of diets that can be healthful, that can contribute to good health into your later years. And that kind of makes sense if you think about human evolution, I mean, humans around the world have eaten a pretty wide range of diets and done well on them until, of course, we got to the junk food. Dr. Christopher Gardner 43:34-45:58 Absolutely. And really, that’s the key. It’s not, it really isn’t low carb or low fat or high protein. It’s how much, I mean, this is my biggest concern always, added sugar and refined grain–the carbs that have a lot of calories and very little fiber to no fiber, and not very many nutrients that come with it. So one of my favorite publications is from the Harvard group that looked at NHANES, the National Health and Nutrition Examination Survey, over a course of 20 years to see if there were any trends, not just in protein, carbs, and fats, but type of protein, type of carb, and type of fat. And over 20 years, there were some very, very modest differences in all of those. But what’s most stunning about the graphic that they show of this is when they say three types of fat, saturated mono and poly, is like 10% of calories from each one of those. It’s about 10% of calories from animal protein and maybe five to eight of plant protein. We’re still in the 10 range. About 10% of calories from good quality carbohydrates that have fiber in them. Okay, that’s 10, 10, 10, 10, 10. Oh, that adds up to 60. 40% of calories from added sugar and refined grains! That is the problem. And that’s why low carb sounds very popular. If the low carb is getting rid of the added sugars and the refined grains, everybody wins. The question is, what do you replace that 40% calories with? Hopefully you don’t replace them all. Then you’ll be in calorie deficit. That will help you lose weight. But let’s say you replaced 30 of the 40… here’s my biohack to it: I think somebody can do that in a healthy way and have 10 come from more carbs. 10 come from more protein, and 10 come from more fat. Or 30 from fat or 30 from carbs (as long as it’s healthy carbs or healthy fat). So that actually gives you a whole bunch of different ways to go lower carb, but replace it all with healthy foods that are healthy sources of carbs, healthy sources of fat, and healthy sources of protein, which for me is beans, peas, and lentils, which bring fiber along with the protein. Joe 45:58-46:50 We know that you are a peas, beans, and greens kind of guy, and we love that about you. I’m interested in how people can biohack their way to success. How do you find out what’s going to be best for you? You talked a little earlier about insulin sensitivity and insulin resistance, and that’s a really big deal in metabolism these days. But how do you know what works best for you? There’s got to be some kind of a process. Some people are wearing CGMs, continuous glucose monitors to try and figure out what works. And what I discovered, by the way, is that when I have oatmeal for breakfast, my blood glucose goes pretty high pretty fast. Terry 46:50-46:56 And that’s even though I’m cooking steel-cut oats. It’s not like instant sugary oatmeal. Joe 46:56-47:18 And we had a diabetes expert who said, don’t worry about it. That’s fine. Just eat your oats and you’ll be great. But if I have those refried beans with an egg, onions, and peppers, my blood glucose doesn’t go anywhere. It just stays rock solid. So help us figure out how to biohack our way to good health. Dr. Christopher Gardner 47:19-47:23 And you sauteed those onions, right, and peppers in oil. Joe 47:24-47:25 Yeah, olive oil. Dr. Christopher Gardner 47:25-47:33 So you had fat. And if you had a fatty oatmeal breakfast, so what if you put a whole bunch of walnuts and nuts in there? Terry 47:34-47:35 Actually, I do that sometimes. Dr. Christopher Gardner 47:36-47:46 Right? And so the idea is it isn’t really just the one thing. First of all, so actually, Joe, let me just ask, do you have an issue with glucose? Joe 47:47-47:47 Nope. Dr. Christopher Gardner 47:47-47:48 Are you? Okay. Joe 47:49-48:06 I mean, my glucose is usually pretty under control, like in the 90s to 100 range. And after breakfast, if I have my refried beans and egg, it may go up to 105 or 110. But if I have that oatmeal, it’ll go up to 130 or 140. Dr. Christopher Gardner 48:07-49:53 So I’m worried that a lot of people who actually don’t have glucose problems are playing with the CGMs and taking it too seriously. And they’re trying to completely blunt any response, any glucose spike, which is ridiculous because your body is prepared to have carbs and fats and proteins. And when you have carbs, you will get a glucose spike. You will make insulin. You’ll put it away. And then the insulin gets broken down and the glucose is out of your blood. If you try too hard to have no glucose spike at all, you’re going overboard. That’s too much. But when you’re just talking about how do you biohack, you know, in theory, you could make sure you don’t get a really high peak. I actually think the bigger thing that we should try to biohack right now, Joe and Terry, is satiety. What makes you full? I actually asked this at a couple of conferences and I said, what would make you the most full and keep you full for the next hour or two? First, I’m going to tell you oatmeal with some fresh fruit and some nuts and maybe some whole fat yogurt on there and a bunch of people raised their hand versus eggs. That’s an omelet with some salsa and some veggies in there and a whole bunch of people raised their hand. I said, “Isn’t there one breakfast that makes everybody full?” And I gave a couple options. And no, different people, different things are satiating for different people. And so there’s two aspects of the satiety. One is when do you stop eating because you’re full? And when you eat again next, because you’re hungry again. So there are some things that because of bulk fill you up, but then an hour later, you’re hungry again. Joe 49:53-49:57 I’m guessing you would not recommend Pop-Tarts for breakfast. Dr. Christopher Gardner 49:57-50:40 The American breakfast for how many years has been carb on carb on carb. We have a sugary cereal, we have a piece of white bread, we put jelly on it with a glass of orange juice. That’s just simple carbs. So yes, as soon as you switch from that to your beans and eggs, or to your cheesy eggs with bacon and sausage, you would be more full. But I would say switch from that American sugary breakfast to your beans and eggs, not the cheesy eggs with bacon and sausage. But you’ll have to biohack that out for yourself and look at your numbers with your doctor for your cholesterol and your blood pressure and the things that we measure typically. Terry 50:41-51:18 Dr. Gardner, I would like to go back to the new dietary guidelines for just a moment. It is related to what you’re talking about. We know that a lot of kids eat those Pop-Tarts and sugary cereals and so forth. And my understanding is that the new dietary guidelines suggest that kids should not be eating any foods with added sugar until they’re at least 10 years old. A, have I got it wrong? And B, is that a good idea? And is it practical? Dr. Christopher Gardner 51:19-53:37 So it’s a great idea. The challenge is going to be, and this is what I’d really like to see. So I really admire the new administration for putting greater emphasis on this. It’s just obscene and obscene how much added sugar kids are eating and adults as well. And also, you know, the deal with ultra-processed food and cosmetic additives and things like red color dye. And so I know the administration said, all right, no more of these dyes. And as far as I know, M&Ms and Skittles are still colored the same way. And if they say no sugary things in schools, I have a feeling that if they recommend that, schools are going to need more money to buy more whole foods. And so part of the reason those are there, Joe and Terry, is because they’re inexpensive. They have a long shelf life for people with limited resources or for places like schools. They buy them because that’s what they have the budget for. So I totally applaud this idea of getting rid of as many added sugars as we can. But it will really take some regulatory force that I haven’t seen yet to have more, for example, farm-to-table food. I know that the administration took away a billion dollars of farm-to-school money recently, where it was going to come fresh from the farm. I know that some of the other safety net food money has been taken away. So you’d have to say, yes, get rid of the sugars. And there’s going to be some regulations so that the food industry has its feet held to the fire and they can’t make these anymore. They can’t sell these. And the immediate response, as has always been the case, is going to be: this is capitalism. We can make what we want and sell what we want, as long as people will buy it. That’s where the tension will be, not on the recommendation, not on the recommendation to avoid them, but on the power to change the food environment we all live in. That’s a, hey, if you come up with something clever and can sell it, that’s the way capitalism works. That’s a big lift. Joe 53:39-54:22 Dr. Gardner, one of the most controversial areas in your field these days is fat. And I think a lot of people were told for a very long time, no fat, low fat is the answer. And so we saw all kinds of products that were marketed as low-fat, no-fat. And that has changed. And so you now will see all kinds of products out there that will say, okay, we make our ice cream with avocado oil. It’s like, okay, instead of dairy, it’s avocado. Interesting. Terry 54:23-54:24 It’s good. Joe 54:24-54:51 But I want to get your feedback. What kind of oils are you cooking with? What do you put on your salad dressings? And what’s the deal on olive oil? Because I think everybody goes, yeah, yeah, yeah, olive oil is the greatest, but it does have some saturated fat in it. So help us understand the Christopher Gardner perspective on oils and fat. Dr. Christopher Gardner 54:52-56:42 Sure. I have very fatty foods. I put lots of avocado, lots of nuts and seeds. I drench my salads in olive oil or some kind of vinaigrette made with olive oil. Olive oil is pretty expensive, the good quality olive oil. So is avocado oil. And so to be honest, canola, sunflower, safflower, there’s this whole bizarre seed oil debacle that’s just wrong. But it would take me more than 10 seconds to tell you why it’s wrong. All those unsaturated cooking, seasoning, salad dressing oils are fine, but please keep in mind that all of them have higher and lower quality, and the higher quality oils cost more. So when you’re like, there’s this thing about seed oils that’s been going around and it’s true as you take a seed and you crush it in different ways you get the oil out, and if it’s a first press or if it’s a cold press, that’s the best quality. At some level, somebody goes along at the end of the day and squeezes the last little bit out of those seeds and puts in hexane and charcoal and bleaching to squeeze the last bit out. And that’s a lower quality oil and it will cost less. And so all of those oils have higher and lower qualities and it’s pretty snooty to say only buy the high quality oils. So there’s a lot of things you can have that have unsaturated fat, like avocados and nuts and seeds. Those are not cheap either if you buy good quality avocados and nuts and seeds. But, you know, I do a lot with the American Heart, and the American Heart for decades has embraced a high, unsaturated fat, Mediterranean-type diet that includes fatty fish, too. Joe 56:44-57:14 If we were to sit down at your table invisibly and just watch what is Christopher Gardner eating on a regular basis, walk us through breakfast, lunch, and dinner, or perhaps just breakfast and lunch. But just tell us, what are the foods that you’re putting into your groceries bag and taking home, and what are you making most often? What are your favorites? Dr. Christopher Gardner 57:16-57:23 Okay, yeah. And did you know I actually have a book coming out soon, and I put all my favorite recipes in the book. Joe 57:21-57:35 Oh well you’ve got to put us on your list because we would love to talk and and see that book. So make sure we get a hold of that book as soon as it’s available, but tell us the good stuff. Dr. Christopher Gardner 57:35-58:44 Okay, coming out in October, you’ll see that I have a couple of very basic breakfasts. One is steel-cut oats with berries, and nuts, and soy milk, and a little shaved dried coconut, and cacao beans. And then another one is I make this scrambled tofu dish. So I put in onions and bell peppers, and I put some greens in there like kale or chard. And then I mash up some tofu. And even though I’m not trying to fool myself, I put turmeric in there and nutritional yeast. So it looks kind of like scrambled eggs with veggies in it. Another one is an avocado toast with kimchi on it, because I actually study the microbiome now. And that’s one of the ways I get fermented food into my breakfast is to have avocado toast with kimchi. So those are three of my standard breakfasts. Joe 58:27-58:29 Wait, tell me about the toast. Dr. Christopher Gardner 58:29-58:44 And the toast is a whole grain bread, whatever the most whole grain thing that I can find is, which is way more expensive than the wheat bread in the grocery store that’s not really whole wheat bread. It’s just wheat. Joe 58:44-58:49 Terry is taking to baking bread and her whole wheat bread is phenomenal. Terry 58:49-59:06 And I’ve now, speaking of not inexpensive, I like to buy stone ground flour from a local miller at the farmer’s market. So I’m paying extra for my flour, but I’m putting the labor in myself. Dr. Christopher Gardner 59:06-01:00:04 Yeah. Yeah, yeah, yeah. See, so that labor or that time or that money… it all costs. If you want to talk about lunches, I’m looking at my favorite lunch. So salad. Oh, because salad is anything. There’s a grain based salad. I make a really good wheat berry salad. Today, downstairs, I went and got the regular lettuce salad. I’m just looking right now what I have. I have shaved almonds. I have garbanzo beans. I have edamame. I have tofu. I have bell pepper, carrots, red bell pepper. I have beets in it. I have cucumber in it. Just a lot of veggies and nuts and seeds and crunch and color. My salads are really beautiful. I make a really good squash eggplant tempeh dish that has a pomegranate glaze. That’s one of my favorites that I make at home. So those are some of the favorite kind of things that I make. Is that enough for now? Terry 01:00:04-01:00:05 That’s great. Thank you. Joe 01:00:04-01:00:10 That’s perfect. And when that cookbook is available, we’d love to talk to you about it. Dr. Christopher Gardner 01:00:10-01:00:21 And it’s not a cookbook. It’s called Food Sense. And actually, it’s got a chapter on protein, a chapter on seed oil, a chapter on organic, [and] my journey as a food scientist. And at the end are my favorite recipes. Joe 01:00:21-01:00:36 Christopher, we’ve got one minute left. And so I need you to summarize the benefits and risks of the new food pyramid and what you would like to see for the future. Dr. Christopher Gardner 01:00:37-01:01:20 Yeah, I love the eat real food. So if everybody would eat real food, let’s do that. I think they really, one of our strongest recommendations from the Dietary Guidelines Advisory Committee was eat more legumes, beans, peas, and lentils, and less red meat. I think they really got that one wrong. And for the dairy, I think we should all recognize that three quarters of the world is lactose intolerant. And so I don’t think the issue is whole fat versus skim. I think it’s that most of the world can’t handle dairy. And it’s pretty insensitive to suggest that everybody get three servings of dairy a day. Fall back on more veggies and fruits, more whole grains, more beans, peas, lentils, more nuts and seeds, and we’ll be okay. Terry 01:01:20-01:01:26 Dr. Christopher Gardner, thank you so much for talking with us on The People’s Pharmacy today. Dr. Christopher Gardner 01:01:27-01:01:29 Pleasure to be back. Thanks for having me. Terry 01:01:30-01:02:07 You’ve been listening to Dr. Christopher Gardner. He’s a nutrition researcher and the Director of Nutrition Studies at the Stanford Prevention Research Center. Dr. Gardner is the Rehnborg Farquhar Professor of Medicine at Stanford University. He’s focused his research on the potential health benefits of various dietary components or food patterns using randomized controlled trials. The interventions have involved vegetarian diets, soy, garlic, omega-3 fats or fish oil, antioxidants, ginkgo biloba, and popular weight loss diets. Joe 01:02:07-01:02:16 Lyn Siegel produced today’s show, Al Wodarski engineered, Dave Graedon edits our interviews, BJ Leiderman composed our theme music. Terry 01:02:16-01:02:24 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 01:02:24-01:02:39 Today’s show is number 1,465. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 01:02:39-01:03:08 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. This week’s podcast also has information on the controversy over fats. Which oils does Dr. Gardner use for cooking or salad dressing? We’ll get hints on his favorite foods for breakfast, lunch, and dinner. You could also watch the interview on YouTube. Look for The People’s Pharmacy. Joe 01:03:08-01:03:38 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We would be grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics interesting, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 01:03:38-01:04:12 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:04:12-01:04:22 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:04:22-01:04:27 All you have to do is go to peoplespharmacy.com/donate. 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According to the Alzheimer’s Association, nearly seven million Americans currently suffer from that type of dementia. Experts expect that more will be burdened with it in the future, as baby boomers continue to reach advanced ages. Many people are eager to protect the brain from deterioration. In this episode, we discuss an unexpected approach to lowering your risk for Alzheimer disease (AD) and other dementias–get a shingles shot! At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, March 7, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on March 9, 2026. How to Protect the Brain with Vaccination Our guest, Dr. Pascal Geldsetzer, has led three impressive studies that took advantage of natural experiments to see if vaccination against shingles could protect the brain from dementia. The results were remarkably consistent and encouraging. What Is a Natural Experiment? In Wales, when the Zostavax shot against shingles first became available, public health authorities established eligibility criteria to get it through the national health system. Welsh citizens had to be born on or after September 2, 1933, to get the shot. This created a situation in which two groups of people differed only by birth date and by whether or not they were immunized. (Most people who were eligible for the shot got it.) This mimics a randomized clinical trial in which the only difference between two groups is the intervention. The absolute risk reduction over 7 years was 3.5%, which means that people who got the shot were 20% less likely (relative risk) to be diagnosed with dementia. That big difference is statistically significant (Nature, April 2, 2025). Wales is not the only country that set up eligibility requirements. Australia did, too. In Australia, everyone between 70 and 79 years old as of Nov. 1, 2016, could get a free shingles shot and many people did. Here, too, you have a group of senior citizens who differ from each other only by whether they got vaccinated and whether their birthdays were slightly earlier or later. In this case, the absolute reduction in risk of dementia over 7 years was 1.8% (JAMA, April 23, 2025).  This difference was also significant. One More Experiment Suggests Vaccination Can Protect the Brain Another natural experiment comes not from a nation, but from a province of our norther neighbor, Canada. The province of Ontario decided that people born on or after Jan. 1, 1946, could get a shingles vaccination. People just slightly older were not eligible. Do you recognize a pattern? When the investigators analyzed health records from 1990 to 2022, they found that people eligible for the vaccine based on their date of birth were 2% less likely to get a dementia diagnosis. In other provinces of Canada that had different rules for vaccination eligibility, people don’t show a significant difference in dementia risk based on their birthday. (Lancet Neurology, Feb. 2026). Which Vaccine Were Scientists Studying? The original shingles vaccine, Zostavax, was the one available for all these natural experiments. For the most part it has now been replaced by a newer version called Shingrix, which uses different technology. Studies show that Shingrix is better at preventing shingles outbreaks and post-herpetic neuralgia, the lingering pain after shingles (Vaccines, April 28, 2025).  It is unclear whether it would also work better to protect the brain from Alzheimer disease. At least one study suggests it works quite well in reducing the risk of dementia (Vaccine, Feb. 5, 2025). Was the Single-Minded Pursuit of Amyloid Misguided? For decades, the pharmaceutical industry has focused its anti-Alzheimer efforts on amyloid plaques that are a pathological feature of brains afflicted with Alzheimer disease. They were apparent in the very first brain described by Alois Alzheimer at the turn of the 20th century. But the assumption that getting rid of amyloid plaque would solve the problem has not borne fruit. The FDA has approved three compounds that are quite effective at reducing amyloid plaque in the brain. Two, lecanemab (Leqembi) and donanemab (Kisunla), are still on the market. Their impact on cognitive decline and functionality of AD patients is unimpressive. Other Infections That May Harm the Brain It seems odd that neurologists might be resistant to the idea of an infection such as chickenpox (the virus behind shingles) or herpes (which causes cold sores and genital lesions) changing brain function. More than a hundred years ago, before the development of effective antibiotics, doctors were quite aware that tertiary syphilis could lead to dementia. Other infections such as Chlamydia pneumoniae may also interfere with brain function. The COVID pandemic demonstrated that the SARS CoV-2 virus can cause brain fog, and we worry that people with long COVID may be at higher risk for dementia. Can the Shingles Vaccine Help with Treatment? One immunization outcome that Dr. Geldsetzer’s team uncovered may help with treatment. In Wales, people with dementia who got the shingles vaccine had a slower progression of their cognitive decline. (Cell, Dec. 11, 2025).  This suggests that whatever it is doing to protect the brain may extend into the disease process itself. This definitely deserves more research. Dr. Geldsetzer would like to conduct a true randomized clinical trial to explore this possibility and to tease the differences, if any, between Zostavax and Shingrix with respect to their effects on dementia prevention. This Week’s Guest: Pascal Geldsetzer, MD, PhD, MPH is an Assistant Professor of Medicine at Stanford University and a Biohub Investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. In 2026, he was named one of the 100 most influential people in health and medicine globally by TIME Magazine (The TIME100 Health list) for his work on the link between shingles vaccination and dementia. He is currently trying to raise funds from philanthropy for a large-scale clinical trial of shingles vaccination for dementia prevention. You can contact him by email: pgeldsetzer@gmail.com Pascal Geldsetzer, MDCourtesy Stanford Medicine Listen to the Podcast: The podcast of this program will be available Monday, March 9, 2026, after broadcast on March 7. You can stream the show from this site and download the podcast for free. You can also listen to our previous interview with Dr. Geldsetzer. It is Show 1394: Viruses, Vaccines and Alzheimer Disease. Download the mp3 of this show, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1464: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:25 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Alzheimer disease is one of the cruelest conditions. It robs people of their memories and their personalities. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:42 For decades, drug companies have focused almost exclusively on removing amyloid plaque from the brain. That hasn’t worked very well. Joe 00:43-00:55 Research has been accumulating that pathogens might be contributing to dementia. There’s growing evidence that the shingles vaccine might be able to reduce the risk of developing dementia. Terry 00:55-01:03 Today, we’ll speak with Dr. Pascal Geldsetzer, the lead investigator behind that research. He’ll explain these natural experiments. Joe 01:03-01:09 Coming up on The People’s Pharmacy, can vaccines protect the brain from dementia? Terry 01:14-02:05 In The People’s Pharmacy Health Headlines: Measles cases continue to climb. The CDC reported 160 new cases during the last week of February. The total in just two months is 1,136 confirmed cases from 27 states. That’s way more than last year at this time, and it may be an underestimate. According to the Johns Hopkins University Center for Outbreak Response, the total is actually 1,189. Many measles cases go unreported. We are likely to beat last year’s record of 2,281 cases by spring and shoot way past it. States that have been hardest hit include South Carolina, Florida, and Texas. Utah, Arizona, and Ohio are also reporting new cases. Joe 02:06-02:46 Many older adults maintain that measles is not that big a deal because they remember catching this highly infectious disease as children. But the CDC points out that one in five unvaccinated youngsters will be hospitalized. One out of every 10 children with measles will get an ear infection. One in 20 will develop pneumonia and one in a thousand will develop brain encephalitis. Because measles is considered the most contagious virus known to man, it’s likely that this disease will continue to accelerate unless people begin to follow Dr. Mehmet Oz’s advice from last month: “Take the vaccine, please.” Terry 02:48-03:45 GLP-1 drugs such as Ozempic and Wegovy have clear benefits in that they help control blood sugar and enable people to lose weight. Other possible outcomes include reduced cravings for alcohol, improved kidney and heart health, and reduced fatty liver disease. But there are a number of gastrointestinal side effects that can be quite distressing. Now, two new studies suggest that GLP-1 drugs may also increase the risk for osteoporosis or bone fracture. An Israeli study included records for more than 46,000 older adults with type 2 diabetes. Those on GLP-1 drugs were 11% more likely to experience a fragility fracture. Whether it’s caused indirectly by weight loss or directly from the medicines remains to be determined. Previous research has shown that exercise can help moderate the risk of bone loss. Joe 03:46-04:28 Just as GLP-1 drugs have some unexpected side effects, such as osteoporosis, they may also have some unanticipated benefits. Researchers from Thomas Jefferson University in Philadelphia conducted an analysis of medical records. People with chronic migraine were 10% less likely to visit the ER if they started taking a prescribed GLP-1 medication. The comparison group was people with chronic migraine taking topiramate, an anticonvulsant used to prevent migraine. In addition, those on GLP-1 medicines were 14% less likely to be hospitalized and 13% less likely to get a new triptan prescription for treating migraine. Terry 04:28-05:16 A research letter in JAMA this week reports that American teenagers are not getting enough sleep. The study looked at trends from 2007 to 2023. The percentage of students reporting insufficient sleep increased from 68.9% in 2007 to 76.8% in 2023, the investigators write. The number of adolescents who sleep five hours or less a night increased dramatically. An accompanying editorial notes that inadequate sleep is linked to academic struggles, cognitive difficulties, and depression. It recommends changes in school start times and reduced use of phones and tablets in the evening. Joe 05:17-06:03 People have been paying increasing attention to the microbiome of their digestive tracts. To find out what bacteria and other microorganisms they’re hosting, some people turn to testing laboratories. How reliable are the results? A study recently found a serious lack of quality control among direct-to-consumer testing services. The authors conclude that their rigorous assessment of seven microbiome testing companies has spotlighted the systemic issue of poor comparability that plagues the industry. They blame methodological variability. Until this problem can be rectified, health care providers and patients can’t trust stool testing data to give them reliable results. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:25 And I’m Joe Graedon. The Alzheimer’s Association states that there are more than 7 million Americans currently dealing with dementia. Terry 06:26-06:38 The problem is likely to get worse, as the baby boomers age. The impact on families and society is daunting. Is there anything we can do to reduce the likelihood of developing dementia? Joe 06:39-07:10 To help us answer that question, we turn to Dr. Pascal Geldsetzer. He’s an assistant professor of medicine at Stanford University and a Biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. In 2026, Time magazine named him one of the 100 most influential people in health and medicine globally for his work on the link between shingles vaccination and dementia. Terry 07:12-07:15 Welcome back to The People’s Pharmacy, Dr. Pascal Geldsetzer. Dr. Pascal Geldsetzer 07:16-07:17 Thanks a lot for having me. Joe 07:18-07:51 Dr. Geldsetzer, it’s great to have you back. And since we last talked with you, you are now in the realm of superstardom because of your third study. We’ll get to your studies in a moment with vaccines against dementia. But first, I’d really like to find out, how did you come up with this idea in the first place? The notion that there was a natural experiment just waiting to be tested. How did that get hatched? Dr. Pascal Geldsetzer 07:52-08:30 Yeah, well, I had this NIH New Innovator Award to look at using this method that we’re using here in our natural experiments. And we came upon the Shingles vaccination program in the UK as this beautiful textbook example of this approach that we could use. And then, of course, we knew about this growing literature around herpes viruses that preferentially target your nervous system and a potential link to dementia. And in this older age group, we thought the natural outcome to look at for us would be dementia. And that’s really how it all started. Terry 08:31-08:41 Dr. Geldsetzer, do explain to us the natural experiment. You mentioned the UK. I think it was in Wales. What constitutes a natural experiment? Dr. Pascal Geldsetzer 08:42-11:33 So it’s essentially a different approach than we usually use in epidemiology and analyses of electronic health record data sets, medical claims data. Usually what we do in these studies is that we compare those who get a certain medication or a vaccine to those who don’t. And the basic problem and why often these studies are only considered to be at best hypothesis generating or suggestive but can’t get at cause and effect is that these individuals, those who decide to get vaccinated to those who don’t get vaccinated, are often very different in terms of their health motivations, health behaviors. And we have very little information on these variables, right? Like your dietary behavior, your physical activity levels. So it’s very hard to adjust for all of these differences. And we never really know whether what we’re looking at is an actual cause and effect or just that those who happen to live a healthier lifestyle of some sort or be healthier in general are the ones who decide to get vaccinated as well and therefore have a lower risk of dementia or other health outcomes. What we do in this natural experiment is that we’re using different comparison groups where we don’t rely on having perfect information on your diet and physical activity levels. Instead, we’re trying to find comparison groups that must be similar to each other in all respects. And here we have this beautiful situation in the UK and in some other countries as well in the way in which they rolled out the shingles vaccine. So specifically, for example, in the UK, they said, you are ineligible if you had your 80th birthday just prior to the start date of the shingles vaccination program, which happened to be September 1st, 2013. And you were eligible if you had it just after. So we have these beautiful comparison groups where all that’s different about them is whether they were born just a week earlier or a week later. And we know if I take a thousand people born one week, a thousand people born a week later, there shouldn’t be anything different about them in their physical activity levels, diets, etc. So we have beautiful comparison groups. And all that’s different about them is this massive difference in their probability of ever getting the shingles vaccine. And then we can look at health outcomes very similar to a situation in a clinical trial where you throw a coin and you assign people to control or intervention. And here, essentially, by random chance, just like the coin, people are born just a little bit earlier or a little bit later. So that’s why we are so excited about this research and why we really think we’re much more plausibly able to get at cause and effect rather than just correlation. Terry 11:35-11:43 And what you found was that there was a difference in the likelihood that people would develop dementia after they were 80, right? Dr. Pascal Geldsetzer 11:44-13:05 Absolutely. So we see these strong protective signals. So that was our first paper published in Nature last year, where we show that shingles vaccination appears to avert one in five new dementia diagnoses over seven years. Then we show a similarly large protective effect in Australia using primary care data from Australia. That was published just a few weeks after in JAMA. And most recently, we show this also in Canada, where Ontario was the one Canadian province that rolled out the vaccine using these date-of-birth cut-offs. Other Canadian provinces didn’t, and we only see this effect as expected in Ontario. We have got many other analyses, publications in the works. We seem to be seeing these strong protective patterns in data set after data set from different countries that rolled out the vaccine using these specific date of birth cutoffs. And it just together provides, I think, a uniquely compelling body of evidence that we’ve never had really for an intervention from observational data because we usually never have these beautiful natural experiments that we can exploit like we’re doing here with shingles vaccination. Joe 13:05-13:32 So Dr. Geldsetzer, you are three for three. You’re batting a thousand. It’s an amazing accomplishment. And you have other studies in the works. So can you just give us some sense of how they compare to one another? Are the results similar or substantially different? Dr. Pascal Geldsetzer 13:33-13:54 No, they are similar. Of course, the data sources are always a bit different. There are advantages and disadvantages. So what exactly we can look at and how [it] differs a little bit between data sets. But generally speaking, they all show the same strong protective signals that we have shown in our published studies so far. Joe 13:54-14:07 Now, one of the things that’s sort of fascinating about your research is that it used what we’ll call an old shingles vaccine. I think it was called Zostavax? Dr. Pascal Geldsetzer 14:08-14:09 Yes, correct. Joe 14:10-14:22 And that has now disappeared. We now have a, quote unquote, new and more effective shingles vaccine called Shingrix. It requires two shots. Terry 14:23-14:30 We know it’s more effective against shingles. We don’t know if it would be more effective against dementia. Joe 14:30-14:57 Well, we don’t know if it’ll even work against dementia. So that’s the big question. But we know that the old shingles vaccine was surprisingly effective at preventing an onset of dementia after several years. What is your thinking when it comes to the new, high-powered, more effective shingles vaccine called Shingrix? Dr. Pascal Geldsetzer 14:58-16:29 Yeah, that’s a very important question. I think it really comes down to what we think the effect mechanism is. If we think what links shingles vaccination to dementia is a reduction in reactivations of the chickenpox virus. So we know the chickenpox virus remains with you for life, hibernated in your nervous system after you contract chickenpox, usually in childhood. And it’s in this constant interplay with the immune system. It presumably causes some inflammatory processes. We know inflammation is a key process, a bad thing in many chronic diseases. So reducing these reactivations through shingles vaccination may well have benefits. If that is the mechanism, then we would think the newer vaccine should have at least the same protective effects for dementia because it’s more efficacious at reducing these reactivations than the old shingles vaccine. However, if we think that the effect mechanism might be through a potentially virus-independent, broader effect on the immune system, a boost to the immune system, if you like, which we know exists for many vaccines and particularly for these live-attenuated vaccines, which is the Zostavax, the old shingles vaccine, is a live-attenuated vaccine, while the newer one is not, then it’s an open question whether the newer vaccine has similar benefits or larger or smaller benefits. Terry 16:31-16:36 Dr. Geldsetzer, how have your colleagues responded to your research? Joe 16:36-16:52 And I’d like to follow up on that question because for decades, we have put all our chips on the anti-amyloid approach. This is completely new, and you have about a minute to finish that before the break. Dr. Pascal Geldsetzer 16:53-17:35 Yeah, so it’s actually been a very positive and encouraging reaction. People really, I think, understand that what we are generating here is a body of evidence from observational data that is very different and much more compelling than what we usually have for vaccines, other interventions when we do these observational data analyses. People understand this basic intuition that our comparison groups here are virtually perfect comparison groups because all that’s different about them is this tiny difference in each. And so there’s a lot of excitement now in the dementia research community around this. Terry 17:37-17:50 You’re listening to Dr. Pascal Geldsetzer, Assistant Professor of Medicine at Stanford University and a Biohub investigator. His research focuses on evaluating interventions for improving the health of older individuals. Joe 17:51-17:54 After the break, we’ll find out about the reaction to Dr. Geldsetzer’s research. Terry 17:55-18:04 Has it spurred a new way of thinking about the development of Alzheimer’s disease? It certainly is a different path from the pharmaceutical focus on amyloid plaques. Joe 18:04-18:11 The infection connection with dementia is not as new as it might seem. A hundred years ago, doctors knew syphilis caused dementia. Terry 18:11-18:18 It seems that a range of microbes might be making trouble in the brain, from herpes and chickenpox to Chlamydia pneumoniae. Joe 18:18-18:23 Will anti-vaccination sentiment have an impact on Dr. Geldsetzer’s work? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:51-20:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:54-21:09 And I’m Terry Graedon. Terry 21:23-21:51 Today, we’re talking about novel natural experiments that unexpectedly revealed a connection between infection and dementia. Policies that set arbitrary cutoffs on eligibility for vaccination with the first shingles vaccine, Zostavax, allowed researchers to compare people who were vaccinated with those who were not. This situation resembled a gold standard randomized controlled trial. Joe 21:51-22:24 This natural experiment was conducted in at least three different countries, Wales, Australia, and Canada. In all of them, vaccinated individuals did better than unvaccinated people when it came to developing dementia. Would the newer Shingrix vaccine be even more effective? Research just published in Nature Communications suggests that people who received this recombinant shingles vaccine were 51% less likely to be diagnosed with dementia. Terry 22:24-22:42 Our guest today is Dr. Pascal Geldsetzer, an assistant professor of medicine at Stanford University and a biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. Joe 22:43-23:42 Dr. Geldsetzer, I would assume that the pharmaceutical industry would be incredibly excited about your research because up until now, they’ve spent billions, perhaps tens of billions of dollars down the anti-amyloid… I won’t say exactly what I think, but down that path that has not led to much in the way of real improvement or prevention of Alzheimer’s or dementia. So along comes Dr. Geldsetzer and his colleagues, and they show that a vaccine might be effective and it might be some sort of infectious process. I mean, we’re talking about the virus that causes chickenpox. So how has the pharmaceutical industry responded to your research? And is it spurring a whole new way of thinking about Alzheimer’s disease and dementia? Dr. Pascal Geldsetzer 23:43-25:47 I do think that it is playing into, but I think generally in the dementia research community, including in the pharmaceutical industry, there’s increasing openness, I think, to other hypotheses of dementia, of Alzheimer’s disease, than the amyloid cascade. Because so far, as you’re saying, some of the large investments really have provided relatively modest output. And there’s increasing evidence that other pathways seem to also play an important role. And this year, of course, is one of these. There’s also increasing awareness of chronic disease consequences of infectious diseases more generally, for example, due to the COVID pandemic and some of the links between the SARS-CoV-2 virus and neurological consequences. So it’s certainly, I think, further opening up the openness to these possibilities. And I think, you know, for us, the next step is really trying to generate funds to run a true clinical trial on this question to be able to more conclusively test this research question. But of course, we want to use the old live-attenuated vaccine, which is off-patent, because that is the vaccine for which we have all this evidence from our natural experiments. But I think if we can provide this proof of concept that what we’re seeing in our natural experiments are true cause and effect relationships, it would be of such important implications for population health, for dementia research, that we must run this trial. And because it’s an off-patent vaccine, we are really hoping for philanthropy, private foundations to support us in getting this done. Terry 25:50-26:38 I would like to point out that the infection connection with dementia is actually not quite as new as we are imagining. A hundred years ago, or more than a hundred years ago, doctors treating patients with dementia knew that one of the possible causes of dementia was tertiary syphilis. Now, we think of syphilis as a sexually transmitted disease, which it is. It was, and it still is. But back in those days, before antibiotics, it could get to a state where it gets into the brain and actually causes pretty severe dementia. How did we forget that? Dr. Pascal Geldsetzer 26:39-27:52 Well, I think it’s always been a hypothesis in the field. But generally, it’s always been very niche because we haven’t, well, the focus was on other hypotheses, particularly the amyloid cascade. And the evidence around infectious diseases and dementia was always just in the correlational realm. So it was always comparing individuals who [were], you know, who fell sick from a certain infection or contracted a certain pathogen versus those who didn’t. And as I was saying earlier, these are always very different, usually, comparison groups, right? People who get a certain condition may have other differences to those who don’t in the immune system, in their exposure to other things in life. So we’ve never had the evidence that we have now where we have natural experiment evidence and beautiful comparison groups to show this link potentially between here an infectious agent and dementia. Joe 27:54-30:02 Dr. Geldsetzer, I’m fascinated by the idea that infections, a variety of infections, might in some way be causing dementia. So Terry mentioned neurosyphilis going way back over 100 years. But not that long ago, 30, 40 years ago, there was some suggestion that herpes simplex virus, HSV-1 and 2, might somehow get into the brain. And, you know, we know that cold sores, for example, it’s the virus traveling down the nerve to manifest itself. And, of course, sexually transmitted disease, herpes, too, can also do that. But it can also maybe go up into the brain. And so this idea that there were herpes infections, and by the way, chickenpox, varicella zoster, that causes shingles is also a herpes virus. So there were these viral infections. And more recently, there have been some studies suggesting that bacterial infections, something called C. pneumoniae, Chlamydia pneumoniae, which is not a sexually transmitted disease. It’s a respiratory disease that affects the nasal passages in the lungs. So you have C. pneumoniae, which is also easily transmitted. And then you have some other bacterial infections. I think there may be some other germs that are bad for our brains. And Dr. Geldsetzer may have a better sense of what they are. But the idea that there are a bunch of, we’ll call them pathogens, that might trigger inflammatory reactions in the brain, the neuroscience community has been somewhat resistant to that, even though it’s been out there for decades. Your thoughts? Dr. Pascal Geldsetzer 30:05-31:52 True, but in the neuroscience community’s defense as well, um we’ve never had really strong evidence on the link between these infectious agents and dementia. But you can argue easily that we should have this evidence. We should have invested by now in clinical trials for example, that treat some of these pathogens that you’re mentioning and see whether it reduces your risk of dementia. I will say, though, as well, that for the virus that causes shingles, we have a special pathogen, I think, in the sense that we know it preferentially targets your nervous system. And we know that it is in this constant interplay with the immune system and that these reactivations of the virus become more common with age. And so the idea that it may sort of act as a chronic stressor to the immune system over life and accelerate some of these chronic inflammatory pathways, the weakening of the immune system with old age, and that this may be bad for dementia disease development, maybe potentially other conditions in the nervous system, is, I think, not far-fetched. It’s highly biologically plausible. And that is a case that we don’t have for many other pathogens. So, yeah, I do think there’s something special to be said about the biological plausibility of the virus that causes shingles. Terry 31:52-32:31 Dr. Geldsetzer, we have seen over the last five or six years or perhaps a little bit longer, the development of a great deal of polarization. We have political polarization, and it’s spilled over into public health so that we have some individuals with a fair amount of prominence who have become anti-vaccination. How do you think this will affect both your research and any potential intervention that we might develop from your research? Dr. Pascal Geldsetzer 32:33-33:23 It’s hard to say. So for me really, you know I’m focused on generating the most rigorous research evidence that I can. That is everything that that I’m focused on. And I, as I was saying I’m turning particularly to to private foundations and philanthropy to hopefully be able to get a true clinical trial on this question of shingles vaccination and dementia off the ground. Because I think this would be such an important finding that we need this trial. And that’s really what I’m focused on. And I don’t think it’s my place to comment on broader societal and political issues. Joe 33:23-34:25 One of the things that distresses me is that the pharmaceutical industry has poured, as I mentioned, billions of dollars into the development of anti-amyloid drugs. And we had the great honor to interview Dr. Moir at Harvard, who had come up with the idea that amyloid might be an immune reaction to infection. In other words, it was the body’s natural immune system trying to fight off some kind of infectious agent. And unfortunately, he has died. But there are some researchers who sort of agree with him that maybe the amyloid hypothesis that if we could just get rid of amyloid, we could solve the problem, which doesn’t seem to have been the case, may have been somewhat counterproductive. Your thoughts about that original research and where it stands today? Dr. Pascal Geldsetzer 34:26-35:28 Yeah, I think it’s a very exciting line of research. And there has been more evidence generated in that line since Dr. Moir’s pioneering work on that front. So, for example, recently, there has been a team around William Eimer and Rudy Tanzi at Harvard who have shown that P-tau, so the other hallmark of Alzheimer’s disease, are these tau protein tangles. That they also appear to be produced or generated at least partially in response to herpes virus infection. So I think there is an increasing body of evidence that this antimicrobial hypothesis, as it’s called, of dementia, of Alzheimer’s disease, may well be an important line of evidence. Joe 35:28-36:23 So as I’ve mentioned, billions of dollars have been spent to try and get rid of amyloid in the body. And you would think, I mean, I would think that the pharmaceutical industry would be knocking down your door saying, Dr. Geldsetzer, please take our money. We want you to do this extraordinarily important research on vaccinations. So we’d like you to go back and look at that old vaccine that we have seen disappear from the marketplace. And, oh, by the way, we’d like you to test the new vaccine, the Shingrix vaccine, not so new anymore. But, you know, here’s $50 billion. Do this research immediately and gather your colleagues together. Why aren’t they knocking down your door? Dr. Pascal Geldsetzer 36:24-37:22 Well, it is a large investment to run a clinical trial. And in fairness, we don’t fully understand the mechanism that links Shingles vaccination to dementia or Alzheimer’s disease. That’s, of course, important. It could lead to many new insights that could lead to other potential treatments, therapeutics, preventative tools. And of course, one obstacle as well here is that the evidence from our natural experiments is for this old live-attenuated vaccine, which is an off-patent vaccine. It’s not used very widely anymore in most countries. And yeah, that’s really the main reason, I think, why I’m turning to hoping for philanthropy and private foundations to support the clinical trial. Joe 37:22-37:48 You know, there is an old vaccine, a really old vaccine called BCG. It’s a vaccine that was developed primarily against tuberculosis. There’s a little bit of data that suggests that maybe BCG would have some, we’ll call it anti-dementia benefits. In the minute we have before the break, your thoughts about BCG and the data that’s been created? Dr. Pascal Geldsetzer 37:49-38:21 Yeah, so BCG is known. It’s also a live-attenuated vaccine, just like the old shingles vaccine. And it’s known to have strong indirect effects on the immune system that appear to be important for a variety of health outcomes. So I don’t think it’s, you know, far-fetched to think that BCG may have effects on dementia disease development as well, particularly in older age. Terry 38:22-38:40 You’re listening to Dr. Pascal Geldsetzer, an assistant professor of medicine at Stanford University and a biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. Joe 38:41-38:48 After the break, we’ll consider whether antibiotics could play a role in reducing the risk of dementia. Terry 38:49-38:57 Given Dr. Geldsetzer’s research, it seems that the shingles vaccine might be a therapeutic tool in addition to helping with prevention. Joe 38:58-39:09 Scientists once thought that the brain was sterile, no bacteria, no viruses. But now it seems that it has a distinct microbiome of its own. Terry 39:09-39:17 Well, one thing we worry about is the possibility that COVID could increase the risk for dementia. How will we find out? Joe 39:17-39:24 What can we all do to reduce our chances of developing dementia? We’ll get Dr. Geldsetzer’s recommendations. Terry 39:24-39:28 He’ll also tell us about the research he hopes to conduct going forward. Joe 39:28-39:33 How does he plan to study the infection connection with Alzheimer’s disease? Terry 39:38-39:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 39:50-39:53 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 39:53-40:07 And I’m Terry Graedon. Terry 40:22-40:56 Our topic today is the infection connection with dementia. If vaccines could help delay or prevent the onset of Alzheimer’s disease or other dementias, might other anti-infective approaches also be valuable? Could vaccines help fight off dementia even after cognitive decline has begun? Dr. Geldsetzer’s research focused on the first-generation shingles vaccine called Zostavax. A new study suggests that the Shingrix vaccination might also provide protection. What about antibiotics? Joe 40:57-41:16 If bacteria like Chlamydia pneumoniae are contributing to brain problems, is it possible that treating people for infection would be helpful? Are there other bacteria or possibly even fungi that might make brain function worse? What else can we do to reduce our risk of dementia? Terry 41:17-41:35 We’re talking today with Dr. Pascal Geldsetzer, an assistant professor of medicine at Stanford University and a Biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. Joe 41:37-43:18 Dr. Geldsetzer, your research is really compelling when it comes to the issue of vaccines, especially the older vaccine, against the possibility of developing dementia, kind of what we’ll call a preventive strategy. And of course, there are literally 6 million Americans who would like to know, well, what can I do now about treatment? And there was a fascinating study in Nature Communications just recently in which the authors quoted a study from Taiwan. And they said, and I’m going to read, notably, a recent nationwide cohort study in Taiwan demonstrated that the antibiotic treatment targeting Chlamydia pneumoniae significantly reduced the risk of Alzheimer’s disease onset. These findings suggest that Chlamydia pneumoniae infection may exacerbate Alzheimer’s disease pathology and that therapeutic strategies targeting Chlamydia pneumoniae could potentially slow or mitigate AD progression. And the antibiotic in particular that they were looking at was something called a macrolide, azithromycin, Z-Pak. And I’m curious if you’ve thought at all about antibiotics as a treatment or a preventive when it comes to dementia for people who may be infected with a bacteria such as C. pneumoniae? Dr. Pascal Geldsetzer 43:21-45:10 Yeah, so I think it’s a very interesting study. Of course, as I was saying earlier, it also has this fundamental limitation that we always have in these observational data analyses usually, that patients who get this infection or patients who get this infection and then are treated versus those who don’t get the treatment for whatever reason. You know, it’s hard to know whether these are good comparison groups and whether we can really say what we’re seeing here as correlation, or actually reflect cause and effect. So that is why I think this evidence to really show a cause and effect relationship would require a clinical trial. I’m not saying that this is not true. I’m just saying that really to provide rigorous evidence that there does appear to be a link would require, in this case, a clinical trial, because there’s no opportunity here to run a natural experiment on this particular question. That is very different for Shingles vaccination, as I was saying earlier, of course. I would also say that for shingles vaccination, as you’re talking about therapeutics for dementia, we have shown in our paper in Cell in December that there are also benefits, it appears, from shingles vaccination for those who already have dementia at the time of getting vaccinated. So we see large reductions in your probability of dying from dementia in the future, which suggests that really the shingles vaccine isn’t just a preventative tool, but potentially also a therapeutic tool for dementia. Joe 45:11-45:14 Whoa. Say that again. That’s incredible. Terry 45:15-45:16 Yes, I think that’s really important. Joe 45:17-45:21 So it’s not just preventing dementia over the next five… Terry 45:21-45:24 Which in itself is a great thing. Joe 45:24-45:33 That’s huge, but the idea that it could actually be beneficial in what we’ll call a treatment situation, that’s astonishing. Dr. Pascal Geldsetzer 45:34-46:29 Yes. So I think it was for us a very important question to look at using our natural experiment approach. So we’re using the same data and same approach as we have for our first study in Wales, where we show this reduction in dementia diagnosis. And we show that there appear to be benefits across the disease spectrum as far as we can ascertain it from electronic health record data. So we show that among those without any record of cognitive impairment in the electronic health records, there is a reduction in your diagnosis of mild cognitive impairment, sort of a pre-dementia stage, if you like. And we show that among those who already have dementia, there is this large reduction in your probability of dying from dementia, really suggesting that the Shingles vaccine appears to act across the disease spectrum and not just for this prevention of dementia. Joe 46:29-46:56 Now, there are some people who may have tuned in late and they keep hearing you say this natural experiment. Could you very quickly summarize what made this a natural experiment and why it’s so critical because it’s not just one country. It’s not just the UK, Wales, but it’s also Australia and now Canada. So you’re, like I said earlier, you’re hitting a thousand, three for three. Just give us that synopsis, please. Dr. Pascal Geldsetzer 46:58-48:22 Yes. So to show in clinical medicine that a new medication or a vaccine works for a certain indication, what we always need is a clinical trial. So we throw a coin and assign participants that way to a control group or an intervention group. And the power of this approach is that we know these comparison groups must be similar to each other on average, because all that’s different about them is whether the coin landed on heads or tails. In our natural experiment, we are using the same approach. And so we are using or looking at individuals who were born just a little bit earlier and were therefore ineligible for the shingles vaccine in a number of countries. And very few people of these groups got vaccinated versus those who were born just a little bit later were eligible and a high proportion of them were vaccinated. And so just like with a coin toss, we now have two beautiful comparison groups where essentially by random chance, people were born just a little bit earlier or a little bit later. And that’s why we’re able to generate evidence that’s not just correlational in nature like we usually have with observational data analysis, but actually likely reflect cause and effect. Terry 48:22-48:56 Dr. Geldsetzer, I’d like to perhaps state the obvious. Sometimes that’s my position. But not all that long ago, we could talk to people who know a lot about the human body, and they would tell us, well, the brain is sterile, does not have a microbiome. And I think what we’re seeing with your research and some of the other related research we’ve been talking about this hour, there appears to be a microbiome in the brain. What do you say? Dr. Pascal Geldsetzer 48:59-49:56 Yes, so there’s definitely an increasing body of evidence that appears to show what you’re saying, that the brain is not sterile. But it’s also important to realize that what may link the virus that causes shingles to dementia may not be a direct invasion of the brain by the virus, but could be through chronic inflammatory processes. There’s lots of intertalk between different parts of the body and certainly between the peripheral nervous system, where we know the virus hibernates and your central nervous system, so the brain, and that these inflammatory processes may play a role in many chronic diseases. I think there’s increasing evidence, convincing evidence that this is a key process. Joe 49:57-50:43 Dr. Geldsetzer, I’m curious what you think about COVID. Here is the SARS-CoV-2 virus that has invaded the bodies of hundreds of millions of people all around the world, billions by now. And for some people, it does produce brain fog as one of the symptoms. Is it possible that some of the people who have been infected with COVID will be at higher risk in future years? And when I say higher risk, I’m talking about cognitive issues. Dr. Pascal Geldsetzer 50:44-51:23 Right. It certainly is possible. I think we still don’t understand long COVID very well from a research perspective. But I think it’s a very important area of research, as you’re saying, because it’s such a widespread infection. And, you know, even if it’s a small proportion of individuals in absolute numbers, it’s still a very important population health issue. And, yeah, certainly further investments in that area could provide really, really important insights for population health and not just for individual patients. Joe 51:22-51:28 We here at The People’s Pharmacy like to give people news that they can use. Terry 51:28-51:29 When we can. Joe 51:29-52:28 Whenever that’s possible. And so if you were to look into your crystal ball to the future, but also what people can do here and now to reduce their risk of coming down with dementia. First of all, your thoughts about shingles vaccine, even though your research was with the prior vaccine, which is no longer available, do you think the current vaccine, which is more effective, the Shingrix vaccine, is something that people should consider if they’re of a certain age? And what about other strategies? I mean, we always hear that exercise, yes, of course, that’s very, very valuable in preventing dementia. And Terry, there are some other strategies as well. But what are your recommendations these days, Dr. Geldsetzer, to prevent this debilitating, horrific condition called dementia? Dr. Pascal Geldsetzer 52:30-53:45 Right. So the shingles vaccine is a recommended vaccine for older adults in the United States because it prevents shingles. And so, you know, the evidence that it may also have benefits for cognitive health in older age, for dementia disease development, I think only provides additional motivation to get vaccinated. And yes, as you’re saying, you know, lifestyle interventions are also an important tool to reduce your risk of dementia in the future. But I think, you know, the beauty about the shingles vaccine is that it’s a one-off, relatively inexpensive, readily available, readily scalable and safe intervention. It’s not a lifestyle regimen that we know is hard to adhere to, that you have to maintain for decades. It’s not a monoclonal antibody therapy, which is what we currently have in the Alzheimer’s disease space, that has important risks as well for patients. We know this vaccine is a safe vaccine. So I think that’s what makes this particularly exciting about shingles vaccination. Joe 53:46-54:06 If we were to put you in charge of the National Institutes of Health and give you a huge pot of money and say, okay, Dr. Geldsetzer, what else should we be doing to try and reduce this risk of dementia and Alzheimer’s disease? What kinds of research would you like to fund? Dr. Pascal Geldsetzer 54:08-54:37 I would certainly like to fund a large-scale clinical trial on shingles vaccination and dementia, as I was saying before, because it would have such important implications for population health and dementia research. And if there’s anyone out there, philanthropists who think this would be an exciting project and would help us get this off the ground, I’d be incredibly grateful. Joe 54:37-54:39 How do they get in touch with you? Dr. Pascal Geldsetzer 54:37-54:55 So you can, probably email is the easiest. If you Google me, you’ll find my profile and my email. And, you know, I’ve been very excited to talk about our research, our plans, what we have in the works, et cetera. Joe 54:56-55:18 Well, we will make sure that your email address at the university is on the show notes for today. Dr. Pascal Geldsetzer 55:04-55:06 Great. Thank you. Joe 55:06-55:18 Are there any other areas, if you were to look into your crystal ball, when it comes to the infection connection with Alzheimer’s disease, that you would like to see pursued going forward? Dr. Pascal Geldsetzer 55:21-56:17 Certainly more mechanistic research would be really important here for us to try to understand particularly how shingles vaccination appears to be reducing your risk of dementia, and this dementia disease development. I don’t think I take the position that we must fully understand the mechanism before we run a clinical trial, because that’s something that will take a lot of money and a lot of time and will never have certainty. I think to me, having this proof of concept, and we don’t need to fully understand the mechanism to use this tool for reducing the risk of dementia. So to me, you know, my priority is getting this clinical trial off the ground of the old, off-patent live-attenuated vaccine for dementia. But having said that, of course, mechanistic research is an important area of investment as well. Terry 56:18-56:23 Dr. Pascal Geldsetzer, thank you so much for talking with us on The People’s Pharmacy today. Dr. Pascal Geldsetzer 56:25-56:27 Thank you for having me. Had a lot of fun. Terry 56:29-57:22 You’ve been listening to Dr. Pascal Geldsetzer. He is an assistant professor of medicine at Stanford University and a biohub investigator. His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. In 2026, Time Magazine named him one of the 100 most influential people in health and medicine globally for his work on the link between shingles vaccination and dementia. He is currently trying to raise funds from philanthropy for a large-scale clinical trial of shingles vaccination for dementia prevention. You’ll find links to the research that we’ve been discussing in the show notes. That’s at www.peoplespharmacy.com. Joe 57:23-57:33 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 57:33-57:42 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 57:42-58:14 Today’s show is number 1,464. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email. It’s radio at peoplespharmacy.com. We would be very grateful to hear from you. Has anyone in your family dealt with dementia? What was it like? If there were a vaccine that lowered your odds, would you get the vaccine? Terry 58:14-58:24 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Joe 58:24-58:51 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We would be grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics interesting, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 58:51-59:27 And I’m Terry Graedon. Thanks for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 59:27-59:37 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 59:37-59:42 All you have to do is go to peoplespharmacy.com/donate. Joe 59:42-59:55 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

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

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

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

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. 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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.

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.

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.

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.

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. Joe 01:00:50-01:00:59 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 01:01:00-01:01:04 All you have to do is go to peoplespharmacy.com/donate. Joe 01:01:05-01:01:18 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.

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. Joe 01:03:27-01:03:36 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 01:03:37-01:03:41 All you have to do is go to peoplespharmacy.com/donate. Joe 01:03:41-01:03:55 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

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.