The People's Pharmacy

This week, our guest discusses how to prevent and treat a surprisingly common condition, chronic kidney disease. One in three Americans faces the risk factors for kidney disease; one in seven is actually living with the condition, although they may not be aware of 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 EDT on your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on December 29, 2025. Could Your Kidneys Be Failing? According to the CDC, 36 million American adults have some form of chronic kidney disease. There are six stages of this condition, with stages 1 and 2 so mild that they don’t warrant treatment. Doctors start paying attention to stages 3a and 3b. Dr. Emily Chang describes how kidney disease is diagnosed and why we need to pay attention. In the earlier stages, kidney disease does not cause symptoms, so doctors rely on blood and urine tests to monitor function. What Do Your Kidneys Do? Most people are aware that the kidneys produce urine, primarily by filtering the blood and removing chemicals that are not needed. However, the kidneys also have numerous other functions that are critical for our health. They are vital to blood pressure control, and they regulate hormones essential to the preservation of bone strength. Main Risk Factors for Kidney Disease: We wondered why the rates of chronic kidney disease are increasing. The answer is fairly simple. More people have one or more of the factors that increase a person’s probability of experiencing kidney problems. These include high blood pressure and diabetes. In addition, there are numerous medications that can contribute to trouble for your kidneys. Just imagine how many of us take an NSAID such as ibuprofen or naproxen multiple times a week. That can put a significant strain on the kidneys. If ibuprofen upsets your stomach–as it could–you might turn to a PPI such as omeprazole (Prilosec) or lansoprazole (Prevacid). These medications can also pose challenges for the kidneys. “Sick Day” Meds: In general, blood pressure medicines are a help to the kidneys, because blood pressure control is so important. But certain blood pressure meds, especially ACE inhibitors like lisinopril or ramipril or ARBs like losartan or irbesartan, are considered “sick day meds.” They should not be taken on days when a person is under the weather and may be dehydrated. Under those circumstances, they might do as much harm as good. Another potential hazard for the kidneys is the contrast medium used in medical imaging. Sometimes this can be tough on the kidneys. That’s especially true for cardiac catheterization where the doses are higher and the exposure longer. Staying Hydrated to Protect Your Kidneys: Besides controlling risk factors, we can all help protect our kidneys by making sure we stay hydrated. What and how much should you drink? Plain water is always great. Caffeinated soft drinks are not particularly helpful, and neither are dark sodas or tonic water. As for how much, that is individual. Most people can rely on thirst, but as we age, thirst may be a less sensitive indicator. Older people may need to make sure they are drinking enough fluid to produce a reasonable amount of light-colored urine. What Diet Is Best for Your Kidneys? According to Dr. Chang, most of us don’t need to obsess about the amount of protein in our diets. Except at the most severe stages of chronic kidney disease, your kidneys can handle the protein you need for good nutrition. She recommends that people follow a DASH diet or a Mediterranean diet. Both are loaded with fresh produce, low in salt and sugar, and rich in whole grains. Scientists have studied the effects of the DASH diet thoroughly, and they know that it can help with blood pressure control. Likewise, following a Mediterranean diet can also promote healthy blood pressure and blood sugar management. New Medications for Kidneys: Doctors are adopting a type of medicine called SGLT-2 inhibitors to treat chronic kidney disease. One example is dapagliflozin (Farxiga), a drug initially developed to treat type 2 diabetes. It may keep kidney disease from worsening. Other drugs in the same category may also prove helpful. Scientists are also looking at GLP-1 agonists like semaglutide (Ozempic, Wegovy) to see if they might also benefit your kidneys. The podcast includes a discussion with Dr. Glenn Preminger of Duke University Health System about a related topic, preventing and managing kidney stones. This Week’s Guests: Emily Chang, MD, is Associate Professor of Medicine in the UNC School of Medicine Division of Nephrology and Hypertension. In addition, she is Co-director of the Kidney Palliative Care Clinic. Her research focuses on the application of ultrasound in all aspects of care for patients with chronic kidney disease. Emily Chang MD Glenn Preminger, MD, is the James F. Glenn, M.D. Distinguished Professor of Urology at Duke Medicine. Listen to the Podcast: The podcast of this program will be available Monday, December 29, 2024, after broadcast on Dec. 27. It was originally broadcast on Dec. 14, 2024. 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 1411: 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 00:01-00:04 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:05-00:14 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Joe 00:15-00:27 How well are your kidneys working? How would you know? Most people with chronic kidney disease are unaware of it. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:45 Diabetes and high blood pressure are important risk factors for kidney problems. Epidemiologists say that one in three of us face such risk factors. Joe 00:45-00:51 Are there common over-the-counter medications that could make kidney function worse? Are you taking one of them? Terry 00:52-00:58 We’re talking with a kidney specialist about what you can do to avoid damaging your kidneys. Joe 00:58-01:06 Coming up on The People’s Pharmacy, could your kidneys be failing you? The hidden epidemic affecting millions. Terry 01:14-02:08 In The People’s Pharmacy Health Headlines: influenza cases continue to spread. Holiday travel and family gatherings will almost assuredly intensify this already worrisome flu season. The CDC has been running behind in reporting this year and won’t publish its next Flu View update until December 30th. Hospitalizations for flu and its complications doubled in the past week. The majority of sick people seem to have some form of influenza A. Despite fears that it would turn out to be a super flu, the BBC reports that subclade K, the new flu variant, is behaving a lot like other influenza A strains in previous years. Experts remind us to stay home when we’re sick, avoid crowds, especially indoors, and wear a well-fitted mask such as an N95 if you must venture out into crowded spaces. Joe 02:09-03:11 Saturated fat has long been public enemy number one. Nutrition experts and cardiologists have warned us that saturated fat clogs coronary and carotid arteries, and that leads to heart attacks and strokes. But two recent studies, one in the Annals of Internal Medicine and the other in the Journal of Neurology, have created consternation in the public health community. An analysis of 17 controlled trials found that people consuming saturated fat from foods like butter or cheese were no more likely to develop cardiovascular disease. The other study followed over 27,000 Swedish people for about 25 years. It found that those who ate the most high-fat cheese were less likely to develop dementia than those consuming the least cheese. The lead author says that eating lots of high-fat cheese may not protect against Alzheimer’s disease, but such foods may not be as dangerous as previously believed. Terry 03:12-04:16 Healers started using French lilac, known by the scientific name Gallego Ficinalis, in the Middle Ages. In the 1920s, researchers discovered that this herb could help control blood glucose levels in animals. Eventually, they developed a pharmaceutical called metformin, with similar activity, to treat type 2 diabetes. A new study published in the journal Precision Clinical Medicine explores the various cellular pathways by which metformin can calm inflammation and reduce the risk of cancer. Certain immune cells become more active in the presence of metformin. Moreover, intestinal flora that has been exposed to metformin is more sensitive to glucose and produces short-chain fatty acids that discourage the development of cancer. One cohort study, including nearly 500,000 participants and a randomized controlled trial of 19,000 volunteers with diabetes, demonstrated a lower incidence of cancer among people taking metformin. Joe 04:16-05:02 A new report from ProPublica reveals a glaring deficiency at the Food and Drug Administration. 90% of the medicines we take are generic, and most are made abroad. The FDA does almost no testing to verify foreign drugs meet quality standards. ProPublica tested several versions of widely prescribed generic drugs and found two samples that did not dissolve at the same rate as their brand-name counterparts. One sample of the antidepressant bupropion failed to dissolve properly. So did a sample of the heart drug metoprolol. When generic medications don’t dissolve appropriately, patient safety may be compromised. Terry 05:02-05:49 The FDA has just approved a new version of Wegovy for weight loss. Until now, this GLP-1 agonist was available only as a once-a-week injection. Now it will be available in a pill. Some people are squeamish about shots, so the idea of a pill to help with weight loss could seem much more appealing. The top dose will be 25 milligrams. In a study published in the New England Journal of Medicine, the average weight loss over more than a year was 14%. The new Wegovy pill may be challenging for some people to take. It must be swallowed on an empty stomach, and patients need to wait at least 30 minutes before eating or drinking anything. And that’s the Health News from the People’s Pharmacy this week. Joe 06:15-06:17 Welcome to The People’s Pharmacy. I’m Joe Graedon. Terry 06:17-06:32 And I’m Terry Graedon. According to the CDC, more than one in seven American adults could have chronic kidney disease. The overwhelming majority of these people are unaware that there’s anything wrong with their kidney function. Joe 06:33-06:50 Unless people undergo testing, they may not realize their kidneys are starting to fail. By the time symptoms develop, significant damage may have been done. The CDC estimates that 360 people begin treatment for kidney failure every day. Terry 06:50-07:06 Why has kidney disease become so common? Although one in seven of us could already have kidney disease, one in three may have risk factors for this common condition. What can be done to protect the kidneys from a downward spiral? Joe 07:07-07:33 To help us get answers to those questions, we turn to Dr. Emily Chang. She’s Associate Professor of Medicine in the Division of Nephrology and Hypertension at the University of North Carolina School of Medicine. In addition, she’s co-director of the Kidney Palliative Care Clinic. Her research focuses on the application of ultrasound in all aspects of care for patients with chronic kidney disease. Terry 07:35-07:38 Welcome to the People’s Pharmacy, Dr. Emily Chang. Dr. Emily Chang 07:39-07:41 Thank you so much. I’m delighted to be here with you today. Joe 07:42-07:49 Dr. Chang, are kidneys essential for good health? How do they work? Dr. Emily Chang 07:50-08:06 Well, the number one thing that they do that most people know about is that they filter your blood, meaning they clean the bad stuff out and get rid of it through your urine. But they do a lot of other things, too. But that’s kind of the big essential thing that keeps you alive. Joe 08:07-08:11 I want to know about some of those other things. What else do they do? A lot. Dr. Emily Chang 08:11-08:46 So let’s start. People are always surprised when I ask them, you know, all the other things I’m talking about because they say, “Oh, kidneys do that too?” So they participate in control of your blood pressure, maintaining how much water your body needs to hold on to and how much it needs to get rid of, controlling your electrolytes so you have the right pH balance in your blood for all your organs to work, control of your blood counts. They make a hormone that tells your bone marrow how much blood cells to make. And then the big surprise is the bone health. They’re very involved in your bone health as well. Terry 08:47-08:51 Oh, that is definitely something I did not know. Dr. Emily Chang 08:52-08:53 Most people don’t. Terry 08:53-08:55 There you go. How do they affect bone health? Dr. Emily Chang 08:56-09:16 There is a complicated pathway of communication that involves the gut, the bones, these four glands in your neck, and the kidney. And they all talk to each other in this very complicated back and forth way to regulate the calcium, the phosphorus, and other lesser known hormones to keep your bones healthy. Joe 09:17-09:29 Well, we’re going to talk about parathyroid in a bit and calcium and phosphorus because I don’t think people realize how important they are. But first, Terry, you have a question for Dr. Chang. Terry 09:29-09:49 You know, when we talk about what’s important for being healthy, if you talk to a French person, they’re going to say, oh, the liver, it’s so important. And if you talk to Americans, mostly they say, it’s your heart. So is there someplace, a group of people who really focus on the kidney? Dr. Emily Chang 09:50-10:04 Oh, definitely. Absolutely. If you ask a nephrologist, we’ll say the kidney because we make sure all those other things can work appropriately. But I wouldn’t say geographically there’s a place. Joe 10:06-10:16 So, Dr. Chang, why has kidney disease become so common, not just in the United States, but in other countries as well? Dr. Emily Chang 10:17-10:48 So part of the reason is that it is very hard to detect. There are no symptoms until very late. And people don’t realize they need to go get it checked out, what risk factors they might have. So people could prevent it, but they just don’t know. So that’s one thing. Another thing is that we’re getting better at detecting it. So it may have been that people who didn’t know before they have kidney disease now know. And we’re getting better and better. We still have quite a ways to go on that. Terry 10:48-10:53 Can you tell us a little bit about those risk factors? What should people be paying attention to? Dr. Emily Chang 10:53-11:40 Yeah, there’s quite a few. So first of all, the two most common causes of kidney disease are high blood pressure and diabetes. So if you have either of those, you absolutely need to have your kidney function checked periodically. And your regular doctor knows how to do that. If you have any family history of kidney disease, that is also a risk factor. As you age, aging is a risk factor. It doesn’t mean that everyone who’s aging will necessarily have kidney disease that’s severe, but it is certainly a risk factor. The older you get, the more likely you are to have it. And then obesity, the more obese you are, the higher your risk of kidney disease. And then there’s certain medications that if you use, for example, non-steroidal. Joe 11:41-12:04 Okay, we’re going to get to those drugs in a minute. But first, how common is kidney disease? You said that nephrologists like yourself and your colleagues think that the kidneys is number one. You’ve got to really pay attention to them. But if we were to start looking at some of the statistics, what’s the deal? Dr. Emily Chang 12:05-12:13 Well, the most common one that I like to tell you is that one in three people is at risk of kidney disease. Joe 12:14-12:14 Whoa. Terry 12:15-12:16 That is very common. Joe 12:16-12:17 That’s scary. Dr. Emily Chang 12:17-12:30 So if I’m looking, if I’m talking to a crowd, I say, look to your left, look to your right. One of you is going to be at risk. It doesn’t mean you’ll have it, but you’re at risk if you don’t get it checked out, if you don’t get to see a doctor regularly and get it treated. Joe 12:31-12:32 So it is increasing. Dr. Emily Chang 12:33-12:45 It is increasing. And we have the increasing epidemic of diabetes, high blood pressure, obesity. And with all those risk factors, yes, they’re contributing to an increasing risk of kidney disease. Terry 12:45-12:50 How would you know if your kidneys were starting to not work as well as they should? Joe 12:50-12:51 Yeah, what symptoms? Dr. Emily Chang 12:52-13:18 So that is, unfortunately, you really don’t have symptoms till you’re in the severe stage. And that’s one of the difficult parts about it. When you get to very severe, you start to feel nauseous, vomiting. You might have extreme itching, dry skin, a funny taste in your mouth, like it’s sort of a metallic taste. But if you get to that point and you haven’t had kidney care, it’s… Joe 13:18-13:19 You’re in trouble. Dr. Emily Chang 13:20-13:21 Yeah. It’s not a good thing. Joe 13:22-13:35 So let’s talk about testing because I’ve heard that, as you just said, that the diagnosis often doesn’t occur until somebody’s already at stage four. And there are four stages, if I’m not mistaken. Dr. Emily Chang 13:35-13:36 Actually, six. Joe 13:36-14:01 Six. Oh, my goodness. Okay. Well, we’ll get you to describe those six stages in a moment. But if you go to your doctor for an annual checkup, there’s a very good chance that you’re going to have your cholesterol measured, LDL in particular, and you’ll have your blood pressure monitored. And you might get a blood test. Terry 14:01-14:03 They’ll probably put you on the scale first. Joe 14:04-14:17 Yeah. But what about that blood test? What should be tested and what should you be asking for perhaps in addition to the quote unquote standard stuff? Dr. Emily Chang 14:18-15:18 All right. So, yes, those things are usually checked. And the kidney, the kidney, the way we check the kidneys, there’s two ways. One is with a blood test and one is with a urine test. The blood test is on a basic panel. It’s called like a chemistry panel. It’s not always drawn. The older you get, the more likely your doctor is to check it. But that’s one thing. And the test we’re looking at on that panel is called a creatinine. And we use that creatinine to… putting it through a calculation, a formula. We get what’s called an estimated GFR. And we like to explain that as a percentage of kidney function. And then your question about what test should you ask for, it’s the urine test. So a lot of times primary doctors forget to get the urine test because they’re so focused on the creatinine. And so we often remind people one of the things we’re out there telling people who may be at risk, ask for the urine test. Joe 15:18-15:21 So what are you looking for in the urine test? Dr. Emily Chang 15:22-15:42 The most important thing we’re looking for is protein in the urine. It should not be there. And so we’re looking for hopefully absence of protein. We’re also sometimes looking for blood in the urine. But the protein in the urine for your standard chronic kidney disease is very important as far as predicting your risk of getting worse over time. Joe 15:42-15:57 Now, you mentioned calculating the glomerular filtration rate. I’ve heard from someone in the biz who says, yeah, you should do that glomerular filtration rate. Terry 15:57-15:59 Just use the abbreviation, Joe. Joe 15:59-16:04 GFR, GFR with Cystatin C. What’s that about? Dr. Emily Chang 16:05-17:31 Okay, so this is an evolving area in our field and really quite interesting. So historically, it’s been done with creatinine, and there have been a number of calculations and formulas over time that have evolved as we’ve learned more. And just a few years ago, I want to say in 2021, there was a big change in the field where we used a new equation because it used to be race based. And we’ve now moved, there was a big task force, a lot of very smart people who got together to figure out how to remove that race variable because it wasn’t we found it wasn’t accurate. So all of that goes to say we do all those formulas currently with creatinine. But there are problems with the creatinine. Creatinine is based on muscle mass. People who have abnormally high or abnormally low muscle mass, it’s not very accurate. Children, it’s difficult. So in comes Cystatin C, the new guy. And Cystatin C is not based on muscle mass. It’s not quite ready for prime time because a lot of labs aren’t equipped for it. But when you’re not sure, you don’t believe the creatinine, or there’s reasons to not believe it, we do like to check a Cystatin C. And we are moving the field slowly towards doing a formula that includes both of them. Terry 17:31-17:52 You’re listening to Dr. Emily Chang, Associate Professor of Medicine in the Division of Nephrology and Hypertension at UNC School of Medicine. In addition, she’s co-director of the Kidney Palliative Care Clinic. Her research focuses on the application of ultrasound for the treatment of patients with chronic kidney disease. Joe 17:53-18:00 We need to take a short break. When we return, we’ll learn about the different stages of kidney disease. Terry 18:00-18:06 You might have seen a number called GFR on a lab report. What does it mean? Joe 18:07-18:13 Nonsteroidal anti-inflammatory drugs like diclofenac, ibuprofen, and naproxen may not be kind to the kidneys. Terry 18:14-18:18 Do the heartburn medicines we call PPIs also harm the kidneys? Joe 18:19-18:32 ACE inhibitors and ARBs are blood pressure pills that are thought to help the kidneys, but can they also cause damage? How can you make sure to stay hydrated? Just how much should people drink every day? What’s the best beverage? 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 18:54-19:16 And I’m Joe Graedon. Terry 19:17-19:32 Today, we’re talking about the hidden epidemic of kidney disease. The CDC estimates that 36 million Americans have this condition, but most of them are unaware that their kidneys are not functioning as they should. Joe 19:32-19:43 There are numerous stages of kidney disease. What should we know about them? What should you ask your doctor to test in order to track your kidney function? Terry 19:43-20:00 Many popular medicines can have an impact on the kidneys, for better or for worse. Tens of millions of people take non-steroidal anti-inflammatory drugs like ibuprofen or naproxen daily to ease inflammation and pain. How do such medicines affect kidney function? Joe 20:00-20:24 Our guest today is Dr. Emily Chang, Associate Professor of Medicine in the Division of Nephrology and Hypertension at UNC School of Medicine. In addition, she’s co-director of the Kidney Palliative Care Clinic. Her research focuses on the application of ultrasound in all aspects of care for patients with chronic kidney disease. Terry 20:24-20:34 Dr. Chang, I hope that you’ll be able to tell us about the different stages of kidney disease. And then I have a follow-up question. Dr. Emily Chang 20:34-21:26 All right. So stages one and two, we don’t really… they’re very hard to detect, partly because that GFR formula we talked about before, it doesn’t calculate that well at very high levels of GFR. So one and two, you’re pretty healthy. Three and four is when you start worrying, depending on your age and your risk factors, you might start to see a kidney doctor like myself. And three is actually split into two stages. So technically there’s seven, but there’s 3A and 3B. And they’re all based on your GFR, what we talked about before, the glomerular filtration rate. And then five is when you’re pretty much needing dialysis, but you’re not yet on dialysis. And then stage six is when you’re on dialysis. Joe 21:26-21:34 So let’s go back to that GFR thing, glomerular filtration rate. What does it mean? Dr. Emily Chang 21:34-22:07 So at the beginning, I had said that the kidney’s primary job that everyone knows it for is filtering. And that’s that filtration, the F in the glomerular filtration rate. And the glomerulus is the name of the part of the kidney. It’s a very small structure in the kidney where the filtering happens. So essentially, it’s filtering at the glomerulus and the rate at which it happens. So if you’re filtering at a higher rate, that’s good. If you’re filtering at a lower rate, your kidneys have slowed down and they’re not doing well. Joe 22:07-22:41 So let me ask you one other question before Terry follows up. I had a test in the middle of the summer, and it was just part of the regular panel, and it suggested, I think it was my BUN was elevated. And I asked my doctor, oh, are my kidneys going bad? What’s going on? He said, “Oh, don’t worry. You’re probably dehydrated. Drink more water.” It worked. Terry 22:37-22:27 Amazing, hunh? Joe 22: 38-22:41 So what’s the BUN anyway? And what does that have to do with your kidneys? Dr. Emily Chang 22:42-23:27 So we do look at the BUN as well. We don’t look at it as hard and as chronically as the creatinine because the BUN can be affected by a number of things, including medicines you’re on, other diseases. If you’re taking steroids, there’s things that are not necessarily related to the kidneys. But when the story fits with the dehydration, so you’re at the beach, you were probably out in the sun sweating a lot, and you notice that the BUN is elevated. Sometimes the creatinine goes up a little with it. Sometimes it doesn’t. But you’re kind of looking at the ratio between the two, you get a hint that dehydration is the issue. So you have to put the labs together with the story the patient gives you and understand what’s going on with them. But it is a piece of the puzzle. Terry 23:28-23:46 So you have just described the six or seven different stages of kidney problems. Is it possible to reverse if you’re at, say, stage 3B, can you go back to stage 3A or stage 2? Dr. Emily Chang 23:46-24:52 I love that question because I get it all the time because everybody wants to get better. Yeah. Yeah. So it’s complicated. So in addition to what we’ve been talking about, which is chronic kidney disease, there is also something called acute kidney injury. And when you look at the labs, you don’t necessarily know which one you have. You need the whole picture and you need people like me to look at the whole picture and decide whether we think it’s acute or chronic. If it’s acute, there is a chance you will reverse. So you might assign it a GFR number and a stage, but that’s not accurate. If it’s acute, you can’t really assign that, but the creatinine can improve. If it’s chronic, true chronic, only chronic disease, the chances of it reversing are basically none. Sometimes there is an acute component, so it’s partially acute and partially chronic. So you can improve a little the acute part, but the chronic part cannot. And the reason is the chronic kidney disease is scarring, so you can’t reverse scarring. Joe 24:53-25:40 So we’ll talk about the things that you should and should not be doing in a minute. But I do want to go back to the medication issue. There are a lot of drugs that can be nasty to the kidneys. And let’s just start with, I think, America’s number one favorite over-the-counter medication, the non-steroidal anti-inflammatory drugs. You knew the question was coming. Ibuprofen, naproxen, the rheumatologists, your colleagues, they love these drugs. They prescribe them in pretty high doses. If you’ve got a pain in your knee or your back hurts or your shoulder’s giving you trouble. And people think, oh, well, if it’s over-the-counter, no worries. If one’s good, two’s better. If two’s working, I need four. Tell us about NSAIDs. Dr. Emily Chang 25:41-26:21 Yes, this is a big area in our field, and they are really good medicines. I mean, they reduce inflammation. They’re good for a lot of things. The problem for the kidneys comes when you use high doses for long periods of time. And we’ve sort of swung the pendulum from one end to the other. We used to say, no, don’t use them at all. But we’re now moving more towards depending on your kidney function, you may be able to use some or sporadically here and there and not super high doses. But they can hurt your kidneys in high doses and taken for long periods of time in a number of ways. And they can also raise your blood pressure, which then hurts your kidneys. Joe 26:21-27:07 Number two in the popularity, and they kind of go together because the NSAIDs like ibuprofen and naproxen and their whole bunch of prescriptions often damage the digestive tract. So you get a little, you know, heartburn. You might even get an ulcer. And then what you do is you go to the pharmacy and you buy what is now available over the counter, PPIs, proton pump inhibitors. And of course, we’re talking brand names like Nexium and Prilosec and Lansoprazole, which is Prevacid. So all of a sudden in the last couple of years, we’ve been seeing articles about kidney damage and PPIs. What’s the deal? Dr. Emily Chang 27:08-27:41 So those can also damage your kidneys in a couple different ways. We don’t fully understand all of them. But one is you can get an allergic reaction to the kidneys. I mean, sorry, to those medicines. And that can cause kidney problems because the allergic reactions happens in your kidneys. And then there’s some signal that they can just contribute to chronic kidney disease. It’s a small signal, and not everyone is convinced. But if a patient doesn’t need it, I try to get them off of them unless they’re truly indicated. Terry 27:42-28:05 Are there any other medications that we should be thinking about when it comes to kidneys? For example, I know that some people are told that they need to take an ACE inhibitor for their blood pressure because that will benefit their kidneys. But I have also heard that for some people, sometimes the ACE inhibitor is not good for kidneys. What’s going on? Dr. Emily Chang 28:05-28:13 Yes. I also love that question because I have to deal with that a lot. ACE inhibitors and ARBs, they’re two groups that are closely related. Joe 28:13-28:15 And give us a couple examples. Dr. Emily Chang 28:15-28:27 So ACE inhibitors: lisinopril, enalapril, ramipril. ARBs: losartan, irbesartan, telmisartan. You see they sound a little similar. Terry 28:27-28:28 They do. They do. Dr. Emily Chang 28:29-29:04 So long-term, very good for the kidneys. We have decades and decades of data, especially in patients who have diabetes or that nasty protein in the urine. However, in the short term, on sick days, let’s say you have diarrhea or you have a pneumonia, then it can be harmful. And so they have to come off temporarily. And that’s when they can hurt the kidneys when you’re sick. So we’ve evolved to calling them sick day medicines. And the more we actually have more and more of those, the more medicines we’re using these days that are sick day medicines. Terry 29:04-29:07 So they’re sick day medicines that you should not take on your sick day. Dr. Emily Chang 29:08-29:20 Correct. And so we sometimes will advise our patient, if you get sick, you can call me, but you also can just temporarily hold X, Y, and Z medicines because we know they’re not going to be good for you. You don’t need them in the short term. Joe 29:21-29:52 Let’s talk about another category of medications. More often than not, people have to go in and get a scan. So it might be a CT scan. It might be an MRI. It might be some other kind of imaging to diagnose something that might be quite serious. And the doctor orders contrast. And that contrast is often iodine. But there are other contrast materials as well. Terry 29:53-29:54 Gadolinium. Joe 29:55-30:03 So tell us a little bit about what happens to the kidney when it gets a big dose of iodine or one of these other materials. Dr. Emily Chang 30:04-30:51 We have a long history with these contrast agents, and it, again, has evolved over time. So we do worry most about the super high doses, like the doses you get when you do a cardiac catheterization. We worry less about the doses you get with a CT scan of your abdomen or of your brain. But if you get a really large dose and you’re already having an acute kidney injury or have bad chronic kidney disease, it does put you at risk of things getting worse. But if you’re only mild or moderate kidney disease, the risk is low and we have ways, which is basically hydration, to try and reduce that risk. And if the indication or the reason to do the test is high, we recommend to do it. Joe 30:51-30:54 So what do they usually use for cardiac cath? Dr. Emily Chang 30:55-30:58 The contrast agent, you mean? It’s an iodinated contrast. Joe 30:59-31:38 And is there something that the patient can say in advance like, oh, I’ve got some issues with my kidneys? Because, you know, we kind of all live in silos today, and that’s especially true in medicine. So the cardiologist may not be thinking kidneys. And the nephrologist may not think to warn the patient who has chronic kidney disease. If you need a cardiac cath, you may need to talk to your cardiologist about how to prepare. Are there alternatives that are safer, for example, than iodine? Or is just the fluid intake the key factor? Dr. Emily Chang 31:39-32:18 We definitely like to do the fluids before and after. Cardiologists also have other tools that aren’t as good. So the best thing about the catheterization, it’s direct visualization and you can intervene. You can do something while you’re there. But they do have other tools if you’re lower risk that they can use to diagnose the heart disease without using contrast. But if someone shows up at the ER with chest pain and they’re having an active heart attack, it is helpful if the patient or family member tells the doctor, I do have kidney disease. They can try and hydrate as they’re running you down to the cath lab. But you will die if you don’t get that catheterization. Joe 32:18-32:28 Sure. One other quick question. I’m sure there are other medications. It’s a fairly long list. What about a diabetes drug called metformin? Dr. Emily Chang 32:29-33:10 I wrote that down to talk about it. I love talking about metformin. So I often hear the false statement from patients, whether they heard it wrong or was told wrong, I often hear metformin hurt my kidneys, so I had to stop it. And that is not true. I have had my whole career to try and dispel that myth. It doesn’t hurt the kidneys. What happens is when your kidneys deteriorate, when that GFR gets lower, you have to either lower the dose or stop it at some point because it can cause a buildup of something called lactic acid in your blood, which can cause problems. Terry 33:10-33:16 And there you get into that lactic acidosis, which is the most serious complication of metformin. Dr. Emily Chang 33:15-33:33 Yes, right, exactly. And so that’s why you have to stop it, not because it hurt the kidneys. We really like metformin because it’s very good for diabetes, and controlling the diabetes is really good for the kidneys. It’s just that at certain levels, you can’t use it anymore. Terry 33:33-33:49 There’s something else that’s very common and over-the-counter, but that when you have kidney function problems, you probably shouldn’t take it. And that would be milk of magnesia. Can you tell us anything about that? Dr. Emily Chang 33:49-34:11 It’s the… so the milk of magnesia is the buildup of magnesium that can happen when you have chronic kidney disease. And it’s just you can’t, you shouldn’t take a lot of it. The other thing is that it has calcium and the whole bone issue. You don’t want to take too much milk too sometimes when you have advanced kidney disease. Terry 34:11-34:26 Well, that brings us up to diet, and what should we be looking at in terms of diet as we’re trying to find the best diet for our kidney disease? Dr. Emily Chang 34:27-35:04 The number one thing, number one thing, almost all my patients can adhere to is low salt. Americans eat way too much salt. So just about everyone can lower the salt in their diet. And then most people, hydration. And then beyond that, it’s very individualized. So I try not, I mean, there’s general kidney things, but you should really talk to your doctor about what’s best for you. Because what applies to your friend who has CKD-3, when you have CKD-3, may not apply to you. Joe 35:05-35:13 So when you say hydration, I’m assuming that some beverages are better than others, like maybe water is number one. Dr. Emily Chang 35:13-35:16 Water is number one. Water is absolutely the best. Joe 35:17-35:21 And soft drinks with artificial sweeteners? Dr. Emily Chang 35:22-35:43 Soft drinks with caffeine I don’t like. Dark sodas for advanced kidney disease I don’t like. And sweetened [sodas] for diabetics I don’t like. So when it comes to sodas, my favorite would be ginger ales and diet ginger ales or the lighter colored sodas without caffeine. Joe 35:43-35:45 Or water. Dr. Emily Chang 35:45-35:49 Or water. And the seltzer water I prefer to the sodas, too. Joe 35:49-35:53 Okay. And what about quinine, tonic water? Is that a problem? Dr. Emily Chang 35:53-35:59 It is with interaction with certain medicines, but not usually until you get to more complicated medicines. Joe 35:59-36:05 And how much should people be drinking? I mean, we hear all the time, oh, you need to drink eight glasses of water a day. Terry 36:06-36:06 Eight eight ounce glasses. Joe 36:07-36:17 Right. And then other people say, no, no, no, that’s not nonsense. You don’t need eight. And then other people say, no, no, you need 10. So is there any goal that you should strive for? Dr. Emily Chang 36:19-36:34 Just for the basic person, it’s make sure you listen to yourself and drink when you’re thirsty. Sometimes my older patients need more guidance because they won’t listen to themselves. But your basic is just make sure you’re listening to your body. Terry 36:35-36:57 You’re listening to Dr. Emily Chang, Associate Professor of Medicine in the Division of Nephrology and Hypertension at UNC School of Medicine. In addition, she is co-director of the Kidney Palliative Care Clinic. Her research focuses on the application of ultrasound for the treatment of patients with chronic kidney disease. Joe 36:58-37:14 It’s time for a short break. After that, we’ll find out if a keto diet puts too much strain on the kidneys. What kind of diet is especially healthful for the kidneys? Parathyroid hormone is important and under-appreciated. Terry 37:14-37:18 How does that hormone interact with phosphorus to affect kidney health? Joe 37:19-37:23 We’ll also hear about Farxiga and other medicines that might be helpful to the kidneys. Terry 37:24-37:29 These pricey drugs were originally developed for another purpose, but they appear to support the kidneys as well. Joe 37:30-37:32 What is the future for kidney disease? Terry 37:39-37:54 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 37:54-38:13 And I’m Joe Graedon. Terry 38:14-38:33 There is a hidden epidemic of kidney disease that affects tens of millions of Americans. We are looking at ways to keep our kidneys healthy. How does diet affect kidney function? Are there some dietary patterns you should avoid if you want to keep your kidneys healthy? Is the Mediterranean diet beneficial? Joe 38:34-38:59 And what role does baking soda, sodium bicarbonate, play in kidney health? Why is the parathyroid gland important when it comes to kidney health? We’ll get answers to those questions from our guest today, kidney specialist Dr. Emily Chang. She is Associate Professor of Medicine in the Division of Nephrology and Hypertension at the University of North Carolina School of Medicine. Terry 39:01-39:37 Dr. Chang, earlier we were talking about what doctors look for when they’re trying to figure out if your kidneys are functioning. And you mentioned a urine test in which you’re trying to make sure that there is no protein in the urine. Does that have any implications for what people are eating? In other words, if I say I know that obesity is bad for my kidneys, so I’m going to try to lose weight and I’m going to go on a keto diet. Is that a bad idea? Dr. Emily Chang 39:38-40:04 So for the kidneys, we do think a lot about protein. Keto diet is not necessarily my favorite, but I don’t have a big problem with it. But the tie-in to the urine protein is really interesting because this is another very common question because it’s natural to think if I’m looking for the protein in the urine, does that mean I need to eat less? Terry 40:04-40:12 And sometimes we do hear that. People say, oh, I’ve been told I shouldn’t be eating any protein because I have kidney problems. Dr. Emily Chang 40:12-41:00 So right now, we do not believe that’s true. So right now, our thinking is eat the same protein requirements as for not patients without kidney disease. So there’s no benefit to lowering the protein. And in fact, there can be risks if you become malnourished. Now, when you get to your later, very late stages, I’ve had a patient who was trying to stay off of dialysis in time for family to come visit. And for that reason, he kept his protein intake low to not need dialysis. And then he went on to hospice. So, you know, in your very late stages, you can do some things with it. But in general, protein requirements, just like non-patients without kidney disease. Joe 41:01-41:33 Do you have a kidney healthy diet that you recommend? Because, you know, we hear so much now about ultra processed foods and we hear a lot. You’ve already mentioned sodium, but there are all kinds of other artificial ingredients. So if you were going to come up with a dietary program for someone who has the beginning stages of kidney disease before they reach the four or five level. So maybe they could prevent things from getting worse. What would that look like? Dr. Emily Chang 41:33-42:14 So we have, you know, for patients looking up diets, there’s two diets that we like the most and they are proven to benefit patients with kidney disease, high blood pressure, heart disease. And that’s the DASH diet and the Mediterranean diet. And the Mediterranean diet, I know you’ve talked about this on your show before I’ve heard it, has lots of good things for your heart, your kidneys, your blood pressure, everything. And we tend to just give those general recommendations. I like to tell patients in general, shop from the outside of the grocery store, try to avoid too much from the inside. Lots of fruits and vegetables, unprocessed meats, things that you make fresh. Terry 42:15-42:23 And of course, the differences between the DASH diet and the Mediterranean diet are pretty small. They resemble each other quite a lot. Dr. Emily Chang 42:23-42:26 Yes. And low salt is a part of both of them. Joe 42:27-42:56 So we have heard from some functional doctors that restoring alkali reserves are important for kidney function. And they’re talking about sodium bicarbonate and calcium carbonate to reduce phosphorus. What are your thoughts about this alkali issue with sodium bicarbonate, baking soda, and calcium carbonate to reduce phosphorus? Dr. Emily Chang 42:56-43:39 So I’ll start with the sodium bicarbonate. There was thought that keeping your blood less acidic, meaning more alkali, was helpful towards preventing kidney disease. And there was good indication that was so. But in some large trials recently done in the last three years or so, that’s not borne out to be as true as initially predicted. So we have recently changed our guidelines to being a little bit less aggressive towards using sodium bicarbonate. Basically gave patients a little more leeway. And it means for some patients less medicines, which is nice. Joe 43:39-43:41 And what about calcium carbonate? Dr. Emily Chang 43:42-44:03 So that’s of a group that is among these other things that we call the phos binders [phosphate binders]. We have other ones too. There’s other prescription ones, and they’re all to lower the phosphorus. And it’s not entirely clear for early… We don’t use them in early kidney disease. They’re more from moderate to severe to lower your phosphorus, which is a very important thing to do. Joe 44:03-44:16 And the parathyroid. We talked earlier about how important it is to have those glands working. What can you do to normalize parathyroid hormone levels? Dr. Emily Chang 44:17-45:00 So most of the parathyroid issues come in later kidney disease. So for early kidney disease, it’s less of an issue, but we do check it to track its trajectory. When you get to the later stages, what happens is the parathyroids get too active because they’re trying to do too much to make up for what the kidneys unable to do as far as the phosphorus. And when they get too active, they can cause problems in your bones. And that’s where you can get the bone disease. So our job is to try and quiet them down by getting rid of the phosphorus other ways by not having you absorb it so your kidney doesn’t have to deal with it. And we have other tricks in our tool belt, too. Terry 45:01-45:11 Dr. Chang, is there anything else that we need to keep in mind as we’re thinking about the parathyroid hormone and the phosphorus? Dr. Emily Chang 45:12-45:38 Yes. In addition to the bone health, they also contribute to cardiovascular health. Because when you have too much phosphorus, it binds with the calcium. And you can get deposits on all your vessels, which can put you at increased risk of heart attack and strokes. They can also deposit on your vessels in the skin and cause very bad skin conditions. So this phosphorus PTH axis is really important because it can cause problems throughout your body. Joe 45:39-45:40 And what can you do about that? Dr. Emily Chang 45:41-45:54 The most important thing is lowering the phosphorus and then all the other little tricks we have to help keep the PTH down. But lowering your phosphorus by a low phosphorus diet and the binders that we talked about. Joe 45:54-45:56 And the binders being calcium carbonate primarily? Dr. Emily Chang 45:56-46:08 Calcium carbonate is kind of the early one. We have calcium acetate, which is Foslo. We have Renvela. Now newer ones are Eryxia… I’m leaving one out. Terry 46:08-46:20 I would like to ask you about the new drugs that you are using now for people with kidney problems. Can you tell us about, for example, Farxiga and maybe some others? Joe 46:20-46:28 And please spell Farxiga because it’s being advertised quite commonly on television, but it’s not exactly spelled the way it sounds. Dr. Emily Chang 46:29-46:42 It’s F-A-R-X-I-G-A. And that is probably the one I see the most ads for now. There’s also Invokana and Jardiance. And then Brenzavvy, too. Joe 46:43-46:45 And what are they, and why would they be good for the kidneys? Terry 46:46-46:49 They’re called SGLT2 inhibitors. Joe 46:49-46:51 Oh, that’s a mouthful. Terry 46:51-46:57 And I’m glad we’re abbreviating it, because if we weren’t abbreviating it, it would take us the rest of the time. Dr. Emily Chang 46:57-47:24 Yes. So they were originally found as diabetes medicines because the way they work is you pee out sugar. And that makes sense. Lower your sugar. But it turns out that we found that they were protective to the kidneys and very much in the same way that the ACE inhibitors and ARBs were, and maybe even more so. And we found that patients who were put on them had a lower risk of progression of kidney disease over time. Joe 47:26-47:27 They’re pricey. Dr. Emily Chang 47:27-47:52 They are, but there are more and more insurances that are covering them. And the nice thing is, beyond diabetes now, we’ve even found that they’re beneficial to patients who have kidney disease and protein in their urine, but no diabetes. So we’re learning more and more about them. And we’re now looking into whether they can be beneficial for patients with kidney disease who don’t have diabetes or protein in their urine. Terry 47:52-47:59 Are there any risks that people should be aware of with these medications? I mean, most medicines do have side effects. Dr. Emily Chang 47:59-48:11 Yes. So the biggest side effect of these are that it makes you pee. And so just like the ACE inhibitors and the ARBs, they are sick day medicines. So when you are sick, we ask people to hold them. Joe 48:11-48:18 Any other medications that might be beneficial to the kidney when you’re up around that chronic kidney disease 4 or 5? Dr. Emily Chang 48:19-48:36 So one of the other ones that we, newer ones that we’re thinking about when you get the ACE inhibitors and the ARBs on and the SGLT2 is called a finerenone or the brand name is Kerendia. And that is a non-steroidal mineralocorticoids receptor antagonist. Terry 48:37-48:37 Woo! Dr. Emily Chang 48:39-48:47 And it’s the only one of its class. And it also has been shown to reduce the progression of kidney disease currently only for diabetics. Joe 48:47-48:54 Now, what about the hottest drugs in the pharmacy these days? These are the drugs that are… Terry 48:54-48:56 GLP-1 agonists. Joe 48:56-49:08 Yes. And of course, people are more familiar with the brand names than semaglutide, which is the generic name, Ozempic and Wegovy. We’re hearing some rumors they might be helpful. Dr. Emily Chang 49:09-49:30 Yes. The rumors are starting to come out and they’re being looked at more and more, but there was a large trial done recently called the FLOW trial that showed a benefit to patients with kidney disease who were taking these medicines. So the list of the benefits from these medicines just keeps growing. So more to come on that, but it looks to be promising. Joe 49:32-49:51 When everything fails and you’ve done everything you possibly can to prevent kidney disease from getting worse, the next stage is dialysis and the possibility of a kidney transplant. Tell us a little bit about that and also about kidney donation. Dr. Emily Chang 49:54-50:50 So dialysis is the dreaded D word. And just about every new patient I have, first thing they want to hear from me is, do I need dialysis? And it’s basically where we’re trying to replace the work of the kidneys. We can’t do it nearly as good as the organ that was developed in your body, but it’s our best attempt at it. We can do it through your blood or through your belly. You can do it at home or at a clinic. It’s not something people like to do, but it does keep you alive. Transplant is a great option if you are healthy enough to get one and if you are lucky enough to get one. And most people have to wait years on the waiting list if they are healthy enough to get one, which is why donation is so important. And we are constantly asking kidney transplant potential recipients if they have living donors because most people have two kidneys and you only need one. Terry 50:51-51:24 So if you had someone in your family, your extended family, who was in a position to need a transplanted kidney, and you say to yourself, I’ve got two kidneys and I only need one, what are the considerations that a potential donor might make? What should they be looking at in terms of their own health to see whether they’re healthy enough to donate a kidney? And what are the consequences after they donate a kidney? Dr. Emily Chang 51:25-52:24 There have been lots of studies looking at health of kidney donors because we certainly want to protect these people who are so generous to give their kidneys. And there really has not shown a detriment as far as lifespan or mortality. There is an increasing rate of high blood pressure, but it’s not affected the mortality. And people who give living donations, if they end up on the very small chance having kidney failure later in life, they are prioritized on the list. And then consideration. So it is important for the donor to be healthy, not be at risk of kidney disease. So if you have difficult to control blood pressure or diabetes, you may be excluded. If you have a family history of kidney disease, that may or may not exclude you. It will depend on the center where you’re evaluated, what they take. But most every center goes through a very stringent evaluation process to make sure the donors are healthy enough. Joe 52:25-52:34 Dr. Chang, your crystal ball: what is it telling you? What is the future for kidney disease and how can we better prevent it? Dr. Emily Chang 52:36-53:08 I don’t think there’s one. I think there’s many different ones. And one is prevention. Well, detection and prevention. And then another is treatment for progression. And that’s what all these new drugs are. But then there’s the newer stuff we haven’t talked about, like artificial wearable kidneys or potentially transplants from non-human animals. And these are all things that are way down the line. But if we hit it from all these different directions, we really can make inroads into this devastating disease that hits so many people. Joe 53:08-53:27 Tell us again, if you would, what symptoms people should be alert for, recognizing that in the early stages it may not be very apparent, and what tests people should specifically be asking their primary care provider that they should undergo to prevent or be aware of kidney function. Dr. Emily Chang 53:27-53:54 The late-stage symptoms are nausea, vomiting, itching, funny taste in your mouth. Those are kind of some of the early signs. If you stop making so much urine, that’s not good either. And then the tests you want to ask for are, of course, the usual blood pressure check, weight, those kind of things. But then the urine test for protein and then a creatinine to calculate your GFR. Terry 53:57-54:09 Dr. Chang, you mentioned that prevention might be the first thing that all of us are looking for. What should we be thinking about in terms of preventing kidney disease, keeping our kidneys as healthy as possible? Dr. Emily Chang 54:10-54:24 I think the best ways to prevent are to control your blood pressure and monitor for and control diabetes because those are our two biggest causes. And if we can get those things under control, we would make big headway. Joe 54:24-54:40 And I’m assuming good night’s sleep, exercise, drinking a reasonable amount of water, not too little, not too much, and also being thoughtful about what kinds of sweets we are putting in our body. Dr. Emily Chang 54:41-54:43 Absolutely. Definitely. All those things you said. Terry 54:44-54:48 Dr. Emily Chang, thank you so much for talking with us on The People’s Pharmacy today. Dr. Emily Chang 54:49-54:51 You’re welcome. It was a pleasure to be here. Terry 54:51-55:11 You’ve been listening to Dr. Emily Chang, Associate Professor of Medicine in the Division of Nephrology and Hypertension at UNC School of Medicine. In addition, she is co-director of the Kidney Palliative Care Clinic, which provides specialized palliative care services for patients with kidney disease. Joe 55:11-55:25 We have also spoken with Dr. Glenn Preminger, professor of urological surgery and director of Duke’s Comprehensive Kidney Stone Center. He has information on kidney stones. Terry 55:27-55:30 Welcome back to the People’s Pharmacy, Dr. Glenn Preminger. Dr. Glenn Preminger 55:31-55:33 Terry, thank you. It’s great to be here again. Joe 55:34-56:14 Dr. Preminger, when I think about the body, you know, the organs that get all kinds of attention the heart, the brain, the stomach. But our livers and our kidneys, they don’t seem to get the respect that they deserve. We kind of take those organs for granted, and yet they’re absolutely essential for good health. You’re a kidney expert. Can you please give us a little perspective on how the kidneys work, why they’re so important, and why we don’t want them to go bad. Dr. Glenn Preminger 56:15-57:07 Well, I share the opinion that kidneys are important. And in fact, my children will smile when I say that to pee is to live. And it’s because the kidneys have a tremendous responsibility to regulate our bodies, to get rid of waste, get rid of excess electrolytes that we might eat, like salt or calcium, for example. And they also, the kidneys supply enzymes to increase the blood count. And so they’re essential to what we do and how we maintain a normal homeostasis or regulation within the body. Terry 57:07-57:19 Obviously, occasionally, things go wrong with the kidneys. What are the most common problems that you as a kidney specialist would see? Dr. Glenn Preminger 57:19-58:02 Well, most people, when they think about problems in the kidney, they think about renal failure and its varying degrees, whether people might be told that they have renal insufficiency where the kidneys are not working or filtering as well as they normally do, going all the way to chronic renal failure, where the patient might need to be placed on dialysis or even have a renal transplant if the kidneys have failed. This can be a common problem in patients that have diabetes or other issues. Terry 58:02-58:10 How would you know that you were developing, let us say, renal insufficiency, which is a term you just used? Dr. Glenn Preminger 58:11-59:24 Well, the basic blood tests that we all get if you go see your primary care doctor or go up, go for a follow-up visit, we call it a basic metabolic panel. It has different names at different institutions, but basically it’s measuring the electrolytes within the body in addition to a substance called creatinine. And creatinine is probably the most sensitive blood test to suggest that a patient might have a damage to the kidney. Creatinine is a breakdown product of muscle. And as this creatinine gets filtered by the kidney, the creatinine level in the body is maintained at hopefully at a certain level. And if the creatinine value in the blood in the serum goes up, then further investigation needs to be done to assess what’s called the glomerular filtration rate or the GFR. This is the actual way that the nephrologist or the internist can assess the kidney function. Joe 59:26-01:00:11 Now, I’m curious about fluids because this seems to be an ongoing controversy in medicine. Eight glasses of water a day, two liters or three liters or half. I mean, we hear all the time, you’re supposed to drink a lot of water. And if you’re dehydrated, your GFR, your glomerular filtration rate may actually go up because your kidneys aren’t getting enough fluid. Help us understand what this whole business of how much fluid you’re supposed to be consuming in a day and why that affects the kidneys. Dr. Glenn Preminger 01:00:11-01:00:51 Well, there’s no doubt that having an adequate amount of fluid per day will keep you well hydrated and also helps to protect the kidney, as you suggest. If we’re talking about kidney stones, we recommend that our patients take at least 100 ounces a day of fluid. And it doesn’t have to be only water. It can be mainly everything that you like to drink unless you’re found to have a specific problem from a kidney stone standpoint. There are certain beverages that might increase the risk of kidney stone. Joe 01:00:51-01:00:51 Such as? Dr. Glenn Preminger 01:00:52-01:01:03 Such as foods [and beverages] that contain a high amount of oxalate, such as spinach, tea, nuts, some other leafy green vegetables. Joe 01:01:03-01:01:11 And I’m assuming alcohol would be problematic if you were relying on it as one of those important sources of liquids. Dr. Glenn Preminger 01:01:12-01:01:36 Well, my patients always ask me, can I drink alcohol as part of the 100 ounces? And I said, of course you can, but I don’t think I’d make it the 80% of your 100 ounces a day. So in moderation, I think alcohol is absolutely fine. But we don’t rely on alcoholic beverages as our main source of hydration. Joe 01:01:36-01:02:04 Dr. Preminger, how would somebody begin to sense that there’s a problem? I mean, you mentioned that a metabolic panel that a doctor could order, a blood test, would be really important. But a lot of people don’t go in for an annual physical. Let’s just be honest about that. Or they may not get a blood test on a regular basis. How would they detect that their kidneys are not functioning optimally? Dr. Glenn Preminger 01:02:07-01:02:30 One of the top symptoms is being thirsty all the time, or some patients will notice that they have an increased frequency of urination or perhaps making more urine than they normally do. In addition, the color of the urine can change, as well as… Joe 01:02:30-01:02:31 From what to what? Dr. Glenn Preminger 01:02:32-01:03:05 [It] usually will get darker because they’re over-concentrating the urine, trying to absorb more fluid and leaving less fluid available to come out as urine. And some people might see blood in the urine. Uh, [it] could be another factor that might indicate renal damage, not necessarily renal failure, but it could be a sign of some other problems within the kidney. Terry 01:03:05-01:03:13 I’m assuming that if you see blood in your urine, it doesn’t belong there, and you should get in touch with your primary care provider. Dr. Glenn Preminger 01:03:14-01:04:15 Definitely. And also, when you see your primary care provider, normally, in addition to getting basic blood work like a basic metabolic panel and perhaps a CBC or a complete blood count, a urinalysis will be performed. And during the urinalysis, in most cases, a microscopic examination of the urine is performed to look at the number of red blood cells and white blood cells in the urine. And so some of our patients, we see them in our urology office because they’ve been found to have what we call microscopic hematuria. And this is meaning that it’s blood in the urine that can only be seen under the microscope as opposed to the patient coming in and saying, oh, I’ve noticed blood in the toilet the last time I’ve urinated. That is what we call gross hematuria. Terry 01:04:15-01:04:27 Now, what would that signal if you saw blood in the toilet? As I said, obviously, it doesn’t belong there. Something’s wrong. What sorts of things might be wrong? Dr. Glenn Preminger 01:04:28-01:05:15 Well, the American Urological Association has very specific guidelines [for] what to do if you see gross, or if a patient has microscopic hematuria. And basically what we need to do at that point is to rule out bad things going on, bad things such as cancer of the kidney, cancer of the bladder, or perhaps a benign growth either in the kidney or the bladder. Or it could be due to a kidney stone could be one of the first identification, identifying factors of someone who has formed a kidney stone, the blood in the urine. Terry 01:05:16-01:05:26 Now, when we talk about kidney stones, what I think about is pain. But you’re saying even before the pain shows up, there might be another symptom or two. Dr. Glenn Preminger 01:05:27-01:06:04 No doubt. And in fact, we have many patients who will present with either vague discomfort in the back or no symptoms at all. And it’s picked up that the patient has blood in the urine or the patient is found to have a urinary tract infection. And then during imaging, which is part of our protocol to assess why the patient is having blood in the urine, we notice that there’s a stone or a number of stones in the kidney. Terry 01:06:05-01:06:06 So what is a kidney stone? Dr. Glenn Preminger 01:06:07-01:07:01 So a kidney stone is when minerals within the urine come together and crystallize and come together to form a stone. So it’s the crystallization of various minerals, calcium oxalate or calcium phosphate. There are also stones that are based on whether the urine is too acidic, such as uric acid stones. And occasionally patients can form stones because of persistent infection. And these are usually called struvite stones. So stones come in different flavors, different sizes, but really depends on what the irregularity or abnormality is within the urine that’s causing the stone. Joe 01:07:01-01:07:20 Let’s talk a little bit about diet. You were talking before about the risk of having a kidney stone from certain kinds of foods. And tell us what those foods are, why they pose a problem, and what to avoid. Dr. Glenn Preminger 01:07:20-01:08:08 So like most other dietary recommendations, we recommend moderation for a number of foods. Salty foods are probably the biggest. Foods that contain calcium, dairy products, milk, yogurt, cheese, and ice cream. We do want patients to take two or three dairy servings per day to maintain normal calcium levels in the body, and especially in women, postmenopausal women, and even older men need calcium to maintain bone strength and bone density. And we also try to limit the foods that are high in oxalate, as we mentioned earlier. Joe 01:08:08-01:08:11 Give me a list, please. What are some of the worst offenders? Dr. Glenn Preminger 01:08:12-01:09:30 The three biggest offenders are spinach, tea, and nuts. These are specific foods that people will eat routinely, especially if you live in our part of the world here in the Southeast, a lot of iced tea, which can cause a problem with urinary oxalate and higher oxalate in the urine can increase the risk for kidney stones. Joe 1:08:41-1:08:43 What about lemonade? Dr. Glenn Preminger 1:08:43-1:09:30 Now, lemonade, on the other hand, has been demonstrated to increase citrate excretion. And citrate is one of the factors that we examine when we do a 24-hour urine looking at the patient’s risk factors for stones. And studies have demonstrated that either a homemade mixture of lemonade with two ounces of reconstituted lemon juice with water, and we usually recommend sweetened to taste with an artificial sweetener, or things like crystal light lemonade or other over-the-counter lemonades have been shown to raise the citrate level and to potentially decrease the risk of kidney stones. Terry 01:09:31-01:09:34 It sounds as though if you like iced tea, you might want to put lemon in your tea. Dr. Glenn Preminger 01:09:36-01:09:46 Lemon juice is actually a great thing to put not only in your iced tea, but in just plain water or make your own lemonade. Terry 01:09:49-01:10:03 Dr. Preminger, when someone has a kidney stone, we mentioned there might be blood in the urine. There might be pain, actually quite significant pain. What do you do if you have an attack? Dr. Glenn Preminger 01:10:05-01:11:26 So, Terry, the patient that has the acute onset of flank pain, that’s what we call renal colic. And renal colic occurs when usually a small stone that’s trying to pass from the kidney into the bladder gets stuck in the ureter and causes an acute obstruction of the kidney. When that happens, the kidney continues to make urine, but the urine can’t get by the stone into the bladder. And so the kidney actually becomes dilated. And there are a set of nerves that cover the outside lining of the kidney that gets stretched. And this stretching of these nerves causes what we call renal colic. And patients usually not only will have severe pain, but sweating, nausea. Many times you can tell that a patient’s having colic because they’re the ones that are writhing on the ground, on the floor. And so we can make the diagnosis from across the room in an emergency room in someone that we think has colic. But of course, we need to document this with imaging. Joe 01:11:26-01:11:58 Dr. Preminger, we’ve heard people say the pain of a kidney stone is worse than having a baby, than being in labor, which sounds pretty awful, to be honest with you. So what do you do? What kind of treatments can a medical center like Duke or any other medical center, how do you help people who are in that kind of pain deal with a kidney stone that’s stuck? Dr. Glenn Preminger 01:12:00-01:12:27 So the main treatment option would be pain medication to try to get the pain under control and make sure that the individual can take in fluid. And if they can’t, we would start an intravenous fluids. And perhaps some anti-emetics or anti-nausea medication would be the three main things that we would do acutely. Joe 01:12:27-01:12:54 Well, let me hit the pause button there because it’s my memory that this pain is so acute, so powerful, that it wasn’t unusual for urologists to prescribe opioids. These days, opioids have gotten a pretty bad rap. What do you do to control that kind of pain in 2024? Dr. Glenn Preminger 01:12:55-01:12:57 We prescribe opioids. Joe 01:12:58-01:12:58 Okay. Terry 01:12:58-01:12:59 There you go. Dr. Glenn Preminger 01:12:59-01:13:11 And the reason is because opioids, for most people, are very effective in trying to manage that acute pain. Terry 01:13:11-01:13:15 This is a short-term situation, so it would make sense. Dr. Glenn Preminger 01:13:15-01:13:16 Exactly. Terry 01:13:16-01:13:30 Now, one other question. I’m thinking there’s a stone sitting in a little teeny tube somewhere in your body, and it’s stuck there. Can you get it unstuck? Dr. Glenn Preminger 01:13:31-01:14:42 So, in fact, Terry, there is a class of medications that have been proven to facilitate the passage of stones that are stuck in the ureter. These are called alpha blockers. The most common, the one that we use most commonly is Tamsulosin or Flomax. And this class of medication was originally developed to help men pass their urine. It’s been shown to relax the prostate, if you will, and men can therefore more easily empty their bladder. But studies have been shown that these alpha receptors, which are in the prostate, also are found in the ureter, that kidney tube that connects the kidney to the bladder. And by giving an alpha blocker such as Tamsulosin, that will relax the ureter and actually facilitate its passage. And studies have shown that you can increase the rate of passage by 40 to 50 percent by taking an alpha blocker. Joe 01:14:43-01:14:44 What happens if it doesn’t work? Dr. Glenn Preminger 01:14:45-01:15:40 Well, if it doesn’t work, so our routine is after we start someone on an alpha blocker, we want to make sure that, A, they’re feeling better, and we would get follow-up imaging to make sure that the stone is passed. So a follow-up with the physician, with the urologist, is essential to make sure that you’re out of the woods, that the stone is at least progressing, if it’s not already passed. So we will instruct the patient, call us if you continue to have pain, or we give them some medication to take home. Perhaps a non-opioid like tramadol or ketorolac has been shown to, again, provide pain relief as not an opioid. Joe 01:15:40-01:15:54 But what happens if it won’t pass? In other words, you’ve done everything you can think of. You’ve given the Flomax. You’ve given the fluids. You’ve given the other medications. Terry 01:15:54-01:15:55 Pain relief. Joe 01:15:56-01:16:13 Everything that you’re – and the person is still in egregious pain. You know, it’s, “Ah, I’m in pain, doctor.” The opioids aren’t working or they’re not working adequately. And you take a look and that image shows, uh, that stone is stuck. Now what? Dr. Glenn Preminger 01:16:14-01:18:12 So then if we’re fairly sure that the stone is not progressing, we would recommend removal. And there are a number of different minimally invasive ways to remove stones, such as shockwave lithotripsy, which is the kidney stone machine that people might be aware of. And this is a device that sends sound waves into the body through the skin. And the sound waves are focused on the stone, causing it to break up into sand. And then people need to pass those fragments. More commonly now, in 2024, we have minimally invasive endoscopic modalities, such as ureteroscopy, which are very small telescopes that we can pass through the bladder and up the ureter and even up into the kidney if that’s where the stone is stuck. And we can use very small laser fibers to break up the stone into small pieces. One of the real innovations in ureteroscopy over the past couple of years has been the addition of suction during ureteroscopy because in the past, we would break up the stone into small pieces and then expect the patient to pass those fragments by themselves, similar to the treatment with shockwave lithotripsy. The problem is that not all the stone fragments pass. And even if you break the stone up into smaller pieces, they can’t, those smaller pieces could even get stuck. But having suction incorporated into this device actually allows you to suck out all the fragments more easily than using a small basket or a grasper to pull out the individual pieces of stone that have been fragmented. Joe 01:18:12-01:18:25 Now I’m guessing after stone removal, people do not want to experience this again. You know, once was enough. What are your recommendations post stone removal? Dr. Glenn Preminger 01:18:26-01:19:28 So we see every patient that we see that comes through the emergency department or gets referred from an outside physician to our kidney stone center at Duke. We offer the patient ways that we can prevent stones from coming back. And basically, there’s two different roads. One is to just recommend some… what we term conservative measures, dietary recommendations, as we’ve already talked about, increasing your fluid intake, avoiding an excessive intake of animal protein, salty foods, or calcium. And if people are able to adhere to these recommendations, change their lifestyle, change their diet, that will go a long way and reduce their chance of forming another stone by about 40 to 50 percent. Terry 01:19:28-01:19:40 Dr. Preminger, do stones run in families? And if they do, is there anything on the horizon that would help doctors help their patients prevent them. Dr. Glenn Preminger 01:19:41-01:21:49 Well, Terry, yes, stones do run in families. And if we use this information, assessing risk factors for people that have had their first stone. So if I see an individual who says their father and their uncle and their brother or sister all form stones as well, then they’re at a really high risk for forming another stone. The issue we have right now is we’re just scratching the surface on looking at the genetic implications of kidney stone disease. There are certain stones where we’ve identified a gene that if you can turn that gene off, you can reduce the risk of kidney stones, for example, cystine stones. But the most perhaps impressive example has been in a condition that’s called hyperoxaluria or primary hyperoxaluria. And this is a problem usually found in children who start forming stones at an early age. And it’s due to the fact that their liver does not make the enzyme necessary to break down oxalate in the urine. And investigators have identified the gene for this problem, which in the past would result in not only kidney stones for young children and even adults, but renal failure. But by turning off the gene with a class of drugs called SI mRNAs or specific inhibitor mRNAs, they can turn off the gene and normalize the oxalate in the urine. So there are some very exciting therapeutics that are out there. And I look forward to the time over the next 10 to 15 years when we see genetic manipulation or medications that can manipulate the genes that will cause either calcium or other types of stones. Terry 01:21:51-01:21:56 Dr. Glenn Preminger, thank you very much for talking with us on The People’s Pharmacy today. Dr. Glenn Preminger 01:21:56-01:21:59 Thank you, Terry. I appreciate the invitation. Joe 01:21:59-01:22:08 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:22:08-01:22:14 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Terry 01:22:35-01:22:54 Today’s show is number 1,411. You could find it online at peoplespharmacy.com. That’s where you can share your comments about today’s interview. You can also reach us through email, radio at peoplespharmacy.com. Joe 01:22:54-01:23:11 Our interviews are available through your favorite podcast provider, including YouTube Music. You’ll find the podcast on our website on Monday morning. This week, the podcast contains some extra information on kidney stones from Dr. Glenn Preminger of Duke University. Terry 01:23:12-01:23:32 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. That way, you can find out ahead of time what topics we’ll be covering. Joe 01:23:32-01:23:35 In Durham, North Carolina, I’m Joe Graedon. Terry 01:23:35-01:24:16 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 01:24:16-01:24:25 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 01:24:26-01:24:31 All you have to do is go to peoplespharmacy.com/donate. Joe 01:24:31-01:24:44 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.

This week our guest is gastroenterologist Robynne Chutkan. She explains how keeping our digestive microbiota in good health can help our immune systems fight off pathogens from the inside out. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Nov. 29, 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 December 1, 2025. You will find this show well worth your time! What Determines Host Health? During the COVID-19 pandemic, we could all see big differences in who got sick and who seemed more resilient. Our immune systems are critical in determining just how susceptible we may be to infectious viruses like SARS-CoV-2. But what shapes our immune response? What we need is an immune system that reacts just the right amount. This “Goldilocks immune system” meets both internal and external threats without becoming overly exuberant. If the immune system fails to react adequately to external threats, like germs, we come down with an infection. Conversely, if it overreacts, we end up with allergies, sometimes very severe allergic reactions. In the case of internal threats, an overreaction leads to autoimmune conditions like Crohn’s disease. Lax response to an internal threat could allow a tumor to get out of hand. A hefty proportion of the immune system is localized in the vicinity of the digestive tract. As it turns out, the balance of microbes inside the gut has a significant impact on how the immune cells just outside the gut behave. Keeping the microbes balanced can help the immune system control pathogens from the inside out. Tackling Pathogens from the Inside Out: Even before the pandemic, lots of people wanted to know how to optimize their immune systems. That desire is only stronger now. Surprisingly, we can make a lot of progress with some very simple steps. Check the Medicine Chest: To start with, we should all be considering the medications we take. Quite a few common medicines can disrupt the gut microbiota. Proton pump inhibitors like omeprazole (Prilosec) or esomeprazole (Nexium) are not kind to digestive microbes. Neither are pain relievers like ibuprofen or naproxen. Besides disrupting the microbes, NSAIDs like these can irritate the lining of the gastrointestinal tract. Sometimes they are necessary. When they are not, they should be avoided. We could say the same for antibiotics. Our guest is a gastroenterologist. She understands the impact of pharmaceuticals on our digestive tracts better than most other physicians we have talked to. You will not want to miss her insights! Feed Them Fiber: Feeding our microbes what they need is crucial to keeping them healthy so that they can signal our immune systems properly. What microbes like is fiber, so a diet that leans heavily on plants is best. They also like variety. According to Dr. Chutkan, one study found that people who consume foods containing at least 30 different types of plants each week have the healthiest balance of microbes. She gives an example of oatmeal (one plant) with blueberries, coconut and walnuts (three more plants), served with almond milk (one more plant) and cinnamon (another plant). That brings the total up to six types of plants in one bowl. (Adding maple syrup gives one extra!) Other Essentials: There are some other practices that are crucial for keeping our immune systems in tune so they can manage pathogens from the inside out. Getting enough sleep helps reboot the immune system. So does physical activity, especially when it takes you into nature. Exposure to dirt sounds counterintuitive, but it can really help your immune system hum. Moreover, being outside is often a good way to address your stress. Dr. Chutkan cited the Japanese practice of “forest bathing” as a good way of de-stressing and helping the immune system. Healthy and Delicious: Finally, Dr. Chutkan shares some of her favorite recipes with us. There are lots more in her wonderful book, The Antiviral Gut, with its detailed plan for improving our microbial balance and immune response. This Week’s Guest: Robynne Chutkan, MD, a board-certified gastroenterologist, is a faculty member at Georgetown University Hospital and is the founder of the Digestive Center for Wellness, an integrative gastroenterology practice located in Washington DC. Dr. Chutkan is the author of the digestive health books Gutbliss, The Microbiome Solution, The Bloat Cure and The Anti-Viral Gut: Tackling Pathogens from the Inside Out. Robynne Chutkan, MD, author of The Anti-Viral Gut: Tackling Pathogens from the Inside Out An avid squash player, runner and yogi, Dr. Chutkan is passionate about introducing more dirt, sweat and vegetables into people’s lives. She also hosts the marvelous Gutbliss Podcast: The Gutbliss Podcast https://robynnechutkan.com/about/robynne-chutkan-md/ Listen to the Podcast: Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1336: 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. Some people are resilient and resist infections. Others are especially vulnerable to colds, flu, and COVID. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:46 What accounts for the differences in our immune systems? Why are some people so prone to infection, while others have an overactive immune response that causes damage? Does our digestive tract play any role? Joe 00:47-00:56 Dr. Robynne Chutkan is a gastroenterologist who’s been asking these questions for years. Her book, “The Antiviral Gut,” offers advice. Terry 00:57-01:03 Why is gut health so important to immunity? How can we eat to enhance our digestive microbes? Joe 01:03-01:09 Coming up on The People’s Pharmacy, tackling pathogens from the inside out. Terry 01:14-02:28 In The People’s Pharmacy health headlines: Many women would appreciate a little help losing the baby weight after giving birth. A Danish study shows that they are increasingly turning to GLP-1 drugs like semaglutide during the postpartum period. The scientists analyzed records on almost 400,000 pregnancies in Denmark between 2018 and 2024. During that time, use of a GLP-1 medication within the first six months after giving birth increased quite markedly. By 2023 and later, about 90% of these prescriptions were for the weight loss formulation, Wegovy. Earlier in the study, women who had diabetes prior to pregnancy were most likely to have a prescription. In the later part of the study, the motivation for taking semaglutide appears to be weight loss. The researchers caution that this early postpartum period is one of physiological and hormonal transition for the mother. The safety of semaglutide for breastfeeding infants has not been well studied. They urge their colleagues to conduct targeted studies on the best use of these medications for postpartum weight loss. Joe 02:29-03:27 The makers of GLP-1 receptor agonists have been expanding their horizons. Research has suggested that drugs such as liraglutide, semaglutide, and tirzepatide may be helpful against a wide range of health conditions, including cardiovascular disease, chronic kidney disease, polycystic ovary syndrome, and non-alcoholic fatty liver disease. The maker of Ozempic and Wegovy was also hoping that its semaglutide medication might help ward off Alzheimer disease. That’s because animal studies and epidemiological data had suggested such a possibility. But two new studies failed to demonstrate benefit for people with dementia. Volunteers were given oral semaglutide or placebo and tracked for about three years. People taking semaglutide did not fare better than those on placebo. Terry 03:28-04:46 Cardiology experts have spent a great deal of time coming up with risk calculators. These are supposed to predict a patient’s likelihood of a heart attack. A new study of people who had heart attacks suggests, though, that atherosclerotic cardiovascular risk calculators are not as helpful as expected. The idea was that these tools would allow cardiologists to focus on people most likely to benefit from treatment such as statins. But analyzing medical records of 465 people, 65 years old or younger, who had experienced a heart attack showed that only 10% of them fit the high-risk category before the event. A newer, different risk calculator called PREVENT would have identified only 3% as high-risk, although 23% were at intermediate risk. Most patients experience symptoms such as chest pain or shortness of breath only shortly before the event. If they’d been evaluated more than two days before their heart attack, the doctor would not have predicted the pending event. According to the authors, these risk assessment tools are good at the population level, but they may not help doctors treat individual patients more effectively. Joe 04:47-05:55 Doctors often perform surgery or place stents in patients with blocked carotid arteries. The surgical procedure is called an endarterectomy. It’s frequently performed on patients who have not experienced symptoms even though the blockage is visible on scans. Two large studies published in the New England Journal of Medicine compared stenting and surgery to medical therapy. Both trials lasted four years, and each contained over 1,200 patients with asymptomatic but substantial blockage in their neck arteries. Patients who received stents had significantly fewer strokes than those who received medications, but there was no significant difference in stroke outcomes between surgery and medical therapy. An editorial that accompanied the research concluded that there is no longer a role for routine carotid endarterectomy in persons with asymptomatic stenosis. 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. Why did some people seem especially vulnerable to COVID-19 while others barely experienced any symptoms? What factors determine who’s susceptible to various infections and who is resistant? Terry 06:33-06:44 Our immune systems play a crucial role in establishing our vulnerability. But what influences our immunity? How do our diet and lifestyle impact our immune systems? Joe 06:45-07:20 To learn more about the immune system and how it’s affected by our GI tract, we are talking with Dr. Robynne Chutkan. She’s a gastroenterologist and a faculty member at Georgetown University Hospital. Dr. Chutkan is the founder of the Digestive Center for Wellness, an integrative gastroenterology practice located in Washington, D.C. Dr. Chutkan is the author of the digestive health books, “Gutbliss,” “The Microbiome Solution,” “The Bloat Cure,” and most recently, “The Antiviral Gut: Tackling Pathogens from the Inside Out.” Terry 07:22-07:25 Welcome back to the People’s Pharmacy, Dr. Robynne Chutkan. Dr. Robynne Chutkan 07:26-07:28 Thank you so much for having me. It’s great to be back. Joe 07:29-08:23 Dr. Chutkan, we just love your new book, The Antiviral Gut. And I have to say, when I was in graduate school, I remember one lecture in particular on immunology. And the professor said, well, if we were to infuse rhinoviruses into the heating and air conditioning system of this room so that those viruses were spread out across the entire room, everybody was breathing in rhinoviruses. Not everybody would catch a cold. Our immune systems are amazing, but some people are more vulnerable than others. Can you tell us about this idea of why some people rarely get sick or barely have symptoms and others seem to catch just about everything that comes down the pike? Dr. Robynne Chutkan 08:24-09:51 Well, you hit the nail on the head with the entire theme of the book. And if I could sum it up in one sentence, it would be that host health matters, that we as the hosts who are hosting these viruses, our health, the strength of our immune system and other things going on in our body, many of them located in our gut, actually determine who gets sick when exposed to a virus. And that’s true of rhinovirus, it’s true of SARS-CoV-2, it’s true of HIV, Ebola, our immune system and other host defenses determine whether we’ll even become infected when we get exposed. And if we do get infected, also determine whether we’ll be mildly [symptomatic], have no symptoms, have severe symptoms, or possibly even succumb, and who will end up with post-viral symptoms. So all of this isn’t random. And it’s not due to the virulence of the virus. In your professor’s case with that experiment, he’s talking about the same rhinovirus that everybody would be exposed to. And we see within populations, everybody exposed to the same SARS-CoV-2, the same variant with the same degree of virulence, but we see widely varying degrees of host resilience and host susceptibility. And so really the whole point of this book was to highlight for people that there are things that we can do to be healthier hosts and to be more resilient to viruses. Terry 09:53-10:04 Dr. Chutkan, I wonder if we have any idea what the most important factors are to determine who is resilient and who is really susceptible. Dr. Robynne Chutkan 10:06-15:04 Terry, it’s such a great question. And a lot of the answers lie within that gut immune connection. So when I was in medical school, I didn’t really have a very good sense of what the immune system was. It was a sort of ethereal concept of like immune factors and cells floating around somewhere in the body. But I don’t think any of us were really sure where that was. It turns out that the vast majority of the immune system, about 70 to 80% of it is located in the gut. It is literally along the gut lining. So you have the trillions of microbes on the inside of the gut, which of course is outside of the body. And then just across that razor thin lining, one cell thick, you have all these immune cells and processes. And it really is a hand and glove relationship. Those microbes are communicating with the immune cells across the gut lining. And they’re literally guiding and modulating the immune system. They’re telling them when to react, when to stand down, when to mount a big response versus a little response. And so you start to see that if you have a disruption in the microbiome or a disruption in the gut lining across which they’re communicating, you’re going to end up with a disrupted immune system. And so that gut-immune connection is really key. There are other important host defenses, stomach acid that doesn’t just help digest food. It also unravels viral protein that gets into the body. We often, we swallow these viruses as a very common, you know, we can breathe them in and they get into our lungs or we can swallow them. And in fact, we have about 100 times more of those ACE2 receptors that bind SARS-CoV-2 in our GI tract compared to in our lungs. So it’s a common, the GI tract is a common portal of entry, if you will. And it explains why so many people with COVID have GI symptoms. So if you have stomach acid, that affords you an additional layer of protection. There was a study that came out in 2020, a population-based study looking at 53,000 people. And that study asked a simple question. Does being on an acid-blocking drug like a proton pump inhibitor increase your risk of COVID? And the overwhelming answer was yes. And in fact, people taking a proton pump inhibitor once a day had double the risk. And people taking a proton pump inhibitor twice a day, as many people do, had three to four times the risk. And while that seems sort of like, you know, wow, hot off the press, we’ve known for decades that these drugs, these acid blocking drugs, and the three of us have had many conversations about acid blocking drugs. So we’ve known for decades that they increase the risk of certain infections, enteric infections, meaning infections that affect the gut. So not just SARS-CoV-2, but other viral infections, foodborne bacterial infections, because that stomach acid is really a critical host defense for unraveling viral protein, for killing unwanted bacteria that can get into our bodies through our GI tract. So there are other considerations like that. The gut lining, you know, it’s this one cell thick lining, but it’s really the only thing protecting us from the outside environment because our GI tracts, and you know, this is such an interesting concept. I didn’t think about this at all when I was in my GI training. I have to admit, it was only about a decade or so ago that I began to realize that when you eat food and it travels down through, you know, down that digestive superhighway, those products of digestion that are in our gut are not in our body. They’re in this hollow tunnel that runs from our mouth all the way down to our anus. And food has to get absorbed through the gut lining to get into our bodies, to get assimilated inside. And so the point of that gut lining is to act as a selective barrier to allow those important nutrients, once they’re properly broken down, to be assimilated into our body. Waste from cells gets excreted through the gut lining in the other direction. And of course, dead red blood cells, bacteria, et cetera, everything gets excreted out. And so toxins, viruses, pathogens from the environment that we swallow are in that gut lining. And a big role of the gut lining is to keep them out of the body, to keep them just there in the GI tract so they can be excreted. And we know that we excrete SARS-CoV-2. In fact, we see fecal shedding of the virus, meaning we’re excreting it in stool, much, much long after we are able to detect it from the nose. So it continues to be excreted in the stool in people who have COVID after a nasal swab, et cetera, would be negative. And so we want that intact gut lining to make sure that these pathogens that we swallow end up in the toilet bowl and not inside our bodies. Joe 15:05-15:48 You know what I found so interesting in reading your book, because you described the immune system so beautifully, the adaptive versus the innate immune system. But I begin to think about it a little as threading a needle or Goldilocks, not too hot, not too cold, because if your immune system isn’t up to snuff, you’re going to get sick. But if it’s too active, you’re going to also get sick, you may have immune reactions. It’s like, how does it know just the right amount of reaction and not too much or too little? Dr. Robynne Chutkan 15:49-17:48 Well, I’m so glad you mentioned that concept because I think that if you understand that concept, you probably understand 75% of immunology. And I think it’s so important that I just want to go over it a little bit more, and then we’ll talk about how to get the Goldilocks immune system. So I like to divide it up just as you did, Joe. So overactive immune system versus underactive immune system. But I like to divide it further. So think of that as there’s a line on a piece of paper and everything above that line is an overactive immune system and everything below that line is an underactive immune system. But I want you to draw another line in the paper, this one, a vertical line, not a horizontal line. And everything to the left of that line is internal threats in our body and everything to the right of the line is external threats. So now we have four quadrants. But let’s start with the internal-external discussion. Internal threats with an overactive immune system. So you’re in that top left-hand quadrant of your grid now of the four boxes we’ve drawn. So overactive immune system, internal threats. We’re our body responding inappropriately, overreacting to our body’s own normal tissue. In the case of rheumatoid arthritis, it’s the joints. In the case of psoriasis and eczema, it’s the skin. In the case of Crohn’s and ulcerative colitis, it’s our gut bacteria. So our body is mounting an abnormal high immune response to our own normal tissue. It’s treating our normal tissue as foreign, as a foreign invader and attacking it. And we have over 100 different autoimmune diseases now. One in four Americans, more than 50 million people. And many people have more than one because, of course, there’s sort of a common cause of these things. So autoimmune diseases are sort of modern day diseases, if you will, and they really are a sign of dysregulation of the immune system. It’s an overactive immune system responding to internal threats. Joe 17:48-17:58 Now, Dr. Chutkan, I’m going to ask you to hold that thought. We’re going to take a break, and when you come back, we’re going to talk about the under-reacting immune system. Terry 17:59-18:07 You’re listening to Dr. Robynne Chutkan. She’s the author of “The Antiviral Gut: Tackling Pathogens from the Inside Out.” Joe 18:08-18:14 After the break, we’ll find out more about what happens when the immune system is under- or over-active. Terry 18:14-18:21 Too much and too little are both problems. How can we help our bodies get this just right, like Goldilocks? Joe 18:21-18:27 We’ll also learn how a patient with Crohn’s disease tackled her condition with food. 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 18:54-19:50 And I’m Terry Graedon. How can you fine-tune your immune system so that it neither runs too hot nor too cold? In other words, is there something you can do to find the sweet spot where you’re protected from pathogens but not suffering from autoimmune attacks? Joe 19:50-20:22 We are talking with Dr. Robynne Chutkan. She’s a gastroenterologist and a faculty member at Georgetown University Hospital. Dr. Chutkan is the founder of the Digestive Center for Wellness, an integrative gastroenterology practice located in Washington, D.C. Dr. Chutkan is the author of the digestive health books: “Gutbliss,” “The Microbiome Solution,” “The Bloat Cure,” and most recently, “The Antiviral Gut: Tackling Pathogens from the Inside Out.” Terry 20:24-20:59 Dr. Chutkan, you’ve just described a graph in which we have a horizontal line and above the line, the immune system is overactive. Below the line, the immune system is underactive. And we have a vertical axis, which divides our immune system from internal threats to the left, external threats to the right. We’ve just talked about the upper left quadrant in which we get autoimmune diseases because the immune system is overreacting to what it perceives as internal threats. So tell us about the other three quadrants, please. Dr. Robynne Chutkan 21:00-29:17 What a beautiful summary. Thank you so much for that. So if we go to the other side of the overactive immune system, so now we’re talking about external threats. We’re talking about allergies, allergies to bees or wasps or seasonal allergies. And I think back to when I was in elementary school, there was one kid in my entire school who had a food allergy. Everybody knew him. He was kind of famous because he was allergic to peanuts and nobody else was allergic to anything. Now it’s rare to find a kid who isn’t allergic to something. So we’ve seen this explosion of allergies. And again, that is a sign of immune dysregulation, dysregulated immune system overreacting, but to external threats in the environment, whether it’s an insect to food, et cetera. So now let’s travel down to the underactive immune system. And on the left side, internal threats, we’re talking about cancer, because our immune system doesn’t just protect us from infection and pathogens. It’s also our cancer surveillance system. It goes about our body and it weeds out cells that are starting to divide a little precariously where the genetic material is not being reproduced properly. Maybe it’s starting to develop a malignant cell line. And a big job of our immune system, a big role is to weed out those cells and make sure they’re destroyed. So when you have an immune system that’s underactive, it means that that cancer surveillance isn’t happening and we’re at risk for cancer. On the other side of the vertical axis for external threats, this is where we’re talking about infection, an immune system that is not strong enough to clear infection. So the really interesting thing here is that if we look at deaths during the COVID pandemic, we see that a large percentage of them weren’t really due to the virus itself, They were due to the immune response. People suffering from what we call ARDS, acute respiratory distress syndrome, where they had an overblown response to the virus. The immune response was so active that it destroyed normal lung tissue in the process. And people ended up on ventilators. Tragically, people ended up dying. But again, as a result of the immune dysregulation, we saw other people who weren’t able to clear the virus. And we worried a lot about people on immune suppressive drugs like steroids and biologics because those drugs suppress the immune system. The interesting thing is those people didn’t seem to do as badly. People who were immune suppressed and, you know, all of us in the medical community typically have patients who are on immunosuppressive medication. We worried about those patients, but they seemed to do okay. It was really the patients who had the overblown immune response who seemed to do worse. So to get back to your really important question, how do we cultivate a Goldilocks immune system? It turns out, again, that these gut bacteria are essential. They’re a critical part of the response. So you want to maintain a healthy microbiome. How do you do that? Well, you make sure you’re not killing off your microbes with unnecessary antibiotics and other medications that are disruptive to the microbiome. You eat a high fiber diet because what are those healthy microbes like to eat? They like to eat plant fiber. And you know, you don’t have to be a vegan, but you got to get those fruits, vegetables, whole grains, nuts, seeds, you want to get all of that in. And we know from a very important study in 2018 by the American Gut Project, a nonprofit doing wonderful microbiome research, their study in 2018 was the largest microbiome study done globally. They looked at over 10,000 people in more than 40 different countries. And they found that the most reliable predictor of a healthy microbiome was the number of different plants people ate, with the magic number being more than 30 per week. And so when I say plants, not just vegetables or fruits, but also whole grains, legumes, beans, nuts, seeds, herbs, spices, you get credit for all of it. And so that really was one of the most potent indicators of a healthy microbiome. So that’s something that, you know, people listening can do right away. You can start thinking about those 30 different plants. And it might sound daunting, but I like to take a bowl of oatmeal as an example and say, okay, let’s say you use some almond milk to make your oatmeal. That’s one. The oats, two. Walnuts, three. Pumpkin seeds, four. Raisins, five. Blueberries, six. Little maple syrup, seven. You get credit for that, too. I love to add a little shaved coconut, eight. Cinnamon, nine. You can get nine different plant foods in a bowl of oatmeal. You can easily get another 10 in a salad. You can throw in your lettuce, tomato, cucumber, olives, cabbage, broccoli, chickpeas. Just start throwing it in. So if you try hard, you can get to 30 in a day, but 30 per week. And one of the really important things about that concept is I have patients who are vegans but they’re only eating four or five different plants a week. They’re stuck in that same peas, carrot, broccoli, and sweet potato rotation. So variety is very important. But when you increase your consumption of plant fiber, what happens is that you increase the amount of certain healthy bacteria in your gut. F. prausnitzii is one of those important species. It’s important because it is one of the main producers of short chain fatty acids, things like butyrate, sometimes called butyric acid, propionic acid, acetate, acetic acid. And what these short chain fatty acids do is they regulate the immune system. They help you get to that Goldilocks immune response. And they also keep the gut lining healthy. And they also feed the gut bacteria themselves that are producing them. So it’s this incredibly synergistic cycle of events. And so patients come to see me and they want to know, what can I do to improve my gut immune connection? Is there a supplement? What should I do? What complicated steps do I need to take? And I remind them, you just need to eat more plants as the number one step that you need to do. And then you need to have a careful look in your medicine cabinet and think about medications you might be taking that could be harmful to either the microbiome or the gut lining or stomach acid. So are you taking non-steroidal anti-inflammatory drugs that are making little holes in your gut lining? Are you taking not just antibiotics, but any of the list of more than 42 different classes of medications that have been shown to be disruptive to the microbiome? Antidepressants, artificial sweeteners, laxatives, there are many of them. So you’ve got to be judicious about what you’re taking from a medication point of view. And then the other thing I like to remind people is where do we get our microbes from? Well, after we’re born and we get them from our mothers, particularly those of us who are lucky enough to be born coming out through the birth canal rather than a C-section, after that, we get them from our environment. We get them from soil. So exposure to nature is a really, really important way for us to replenish our microbes and have a healthy microbiome. So that refers to us being out in nature as well as eating food that’s grown in nature, not food that’s grown in a warehouse somewhere, not the sort of industrial organic food. So the steps to have a Goldilocks immune system are fairly straightforward. And then there are some other add-ons that are important too, like sleep, because we know sleep reboots the immune system like a computer and that it’s really essential. We have a very important study from the British Medical Journal that showed that people who were chronically sleep deprived had an 88% increase in risk of COVID. So sleep is essential. We know that controlling stress is important. We see stress as a risk factor for morbidity and mortality with this pandemic. So there are other things too that are maybe not directly related to the gut, but that are really important for keeping it all humming along and functioning well. Terry 29:17-29:42 And of course, getting out in nature might help you control your stress. I do want to ask about medications. You said you need to pay attention to what’s in your medicine cabinet. And I want to ask you about a patient that you treated early in your career, a woman with severe Crohn’s disease. She came to you and you prescribed medications because that’s what you would learn to do. Can you tell us what happened? Dr. Robynne Chutkan 29:43-36:47 Yes, yes. I remember her so well. And gosh, it’s so great that you’re bringing up her story. So I was a young gastroenterologist just in my first or second year on faculty at Georgetown. And as you said, doing what I was trained to do, which is to prescribe medication. She was around my age, and she actually worked at the hospital in the radiology department. And she left, she moved to New Jersey for a couple years. And then she decided to come back. She came back to the Washington area. And she came to see me. And as you said, she’d had Crohn’s disease and quite severe Crohn’s disease. And I had been up close and personal with her Crohn’s disease doing her colonoscopy several times in the past. So she came to see me in the clinic. And I remember we caught up. And I asked her, okay, ‘So tell me, you know, what are you on?’ And I got out my pen, because at that time, we didn’t have an electronic medical record, got out my pen to write a note. And she said, ‘Nothing.’ And I remember I froze. I was like, ‘What do you mean, nothing?’ And she said, ‘I’m not taking anything.’ And I gave her my little spiel about, oh, that’s like driving a car with no insurance. You know, things could go terribly wrong. And I was literally frightened for her because the idea that you could treat or control a serious autoimmune disease like Crohn’s without medication was just, I mean, that was frightening. It was a frightening idea to me. And she told me what she was doing. And at the time, you know, the diet didn’t necessarily have a formal name, but it was a variation of a diet called the Specific Carbohydrate Diet, which is a low complex carb diet, but not a low carb diet specifically, but it takes out a lot of the processed carbohydrates, like, you know, the baked goods and so on. The dairy other than on that diet, people can make their own yogurt, but takes out the processed dairy and the refined sugars and a lot of the processed grains. And she was having great results with it clinically. So I said to myself, okay, well, she’s feeling good, but that’s probably placebo effect. Let’s see what’s really going on in her colon. And I did her colonoscopy a few weeks later, and it was normal. Her severe ulceration from her Crohn’s disease had healed completely, completely. I mean, I remember thinking, this is magic. Like, how can this be? And I think back now, you know, 25 years later, and I think, no, it’s magic the other way. It’s magic to not consider the role of what we eat and how we feel and specifically on what’s going on in our guts. But I had been so trained and indoctrinated, quite frankly, to think that medication was the only path. And to be clear, the medications are fabulous. I’m glad we have them. We’re in an era of really effective medications for these diseases, but here’s a problem: when you treat a disease that is an overactive immune system, like Crohn’s, it’s an autoimmune disease, you treat it by suppressing the immune system. So now you’re down in that, below that horizontal line. And now you’re at risk for cancer and infection. And that is indeed exactly the risk factors of these medications. They all carry the risk of serious infection, viral, bacterial, fungal, et cetera, as well as cancer. And autoimmune diseases affect a wide range of people, but the ones I treat primarily, Crohn’s and ulcerative colitis, affect young people. And so we’re talking about putting people in their teens and early 20s and 30s on medications for life that have these potentially very deleterious side effects. So this patient was the first person who really opened my eyes to what was possible and sort of, you know, began my journey to see how we could treat these diseases with a food as medicine approach. And I’ll tell you, I saw a young man yesterday in my office, a new patient with ulcerative colitis, really lovely young man. And his mother was with him. He’s in law school. And he had been on these drugs for a long time. And he said, ‘You know, the drugs really helped me, particularly in high school when I was diagnosed. I just wanted to be a kid and, you know, do what the other kids were doing. And I didn’t want to be having 20 bloody bowel movements a day and, you know, having accidents.’ So he said, ‘I was very grateful to the drugs.’ He was on Remicade initially, infliximab, one of the first monoclonal antibody biologic drugs that we had for inflammatory bowel disease. So he said he was very grateful. But what he has noticed over the last decade is that he’s just not well. He’s sick all the time. I mean, yes, his colitis has improved a lot, but he’s sickly. He has colds, his skin, he’s gotten really bad acne. He’s sick all the time. He had COVID twice, serious episodes both times. And so he can feel that his immune system is suppressed, where he’s sort of half-masked. And one of the things, it’s really important to make sure people are good candidates for a food as medicine approach. Some people, quite frankly, are just too sick. There are many patients who I say, you know, you actually would probably benefit from going on a bigger gun medication like a biologic to get your disease inactive enough to a point where we can treat it nutritionally. Or sometimes people have strictures. If you have Crohn’s, you can have narrowing in the intestine. And so it’s a mechanical narrowing. And I explain, you know, no amount of kale is going to open this back up. You probably need to have this addressed surgically. And then we can really think about nutritional therapy to prevent recurrence. So just as we need to be judicious with our pharmaceuticals, we need to be judicious and realistic about what food can do. Food can do a lot, but it is also not magic. And in this particular case with this young man, he was a great candidate. He was already a pretty good eater. He was very committed to making some changes to his diet. And his disease at this point was just at the bottom part of the colon and not in terrible shape. So he’s a really good candidate. And I’m so excited to be working with him to see if we can get him off the biologic. But I never want people to feel like there’s a wrong or right path. There’s a path that’s right for them. And if you’re at the point in your life where you sort of, you know, you just need the quick fix to get this taken care of, you can’t maybe make that commitment to diet and lifestyle, that’s not wrong. But it is also important for people to know that there are other paths out there for treating these diseases without the immunosuppression. We have other medications for autoimmune diseases that don’t suppress the immune system. They tend to be not as efficacious, but sometimes using one of those medications with the diet and lifestyle can really get people where they need to go. So I always want people to know there are lots of options out there. We have a lot of tools in our toolbox and trying to find the right tool for people and particularly the tools where the side effects aren’t worse than the actual disease. That’s important. Terry 36:47-37:01 You’re listening to Dr. Robynne Chutkan. She’s a gastroenterologist and a faculty member at Georgetown University Hospital. Her most recent book is “The Antiviral Gut: Tackling Pathogens from the Inside Out.” Joe 37:01-37:09 After the break, we’ll find out  why the mucin lining your digestive tract is critical in protecting you from viruses. Terry 37:09-37:16 How do microbes interact with mucus? And how do medications affect our digestive lining? Joe 37:16-37:30 When the gastrointestinal tract loses integrity, the leaky gut that results can have serious consequences. Dr. Chutkan shares her plan for supporting an antiviral gut. She also tells us about some of her favorite foods to help. Terry 37:39-37:55 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 37:55-38:17 And I’m Joe Graedon. Joe 38:31-38:46 Today, we are talking about supporting your digestive tract so that it can protect you from invading pathogens. The lining of your digestive tract is especially important, but we don’t often think about it. What should we be doing differently? Terry 38:46-39:16 For answers, we’re talking with Dr. Robynne Chutkan, a board-certified gastroenterologist. She’s a faculty member at Georgetown University Hospital and is the founder of the Digestive Center for Wellness, an integrative gastroenterology practice in Washington, D.C. Dr. Chutkan is the author of the digestive health books, “Gutbliss,” “The Microbiome Solution,” “The Bloat Cure,” and “The Antiviral Gut: Tackling Pathogens From the Inside Out.” Joe 39:18-40:48 Dr. Chutkan, you’ve just been explaining the benefits and risks of some of the most popular pharmaceuticals in the pharmacy. I mean, we’re talking about billion-dollar drugs, Enbrel, Humira, these biologics, and they do work very well, but they do have an impact on the immune system. And so we hear on those commercials things like lymphoma, and we hear about other infections, and watch out for tuberculosis. And so I guess they’re double-edged swords, as are so many of the medications that we rely on on a daily basis, like the NSAIDs, ibuprofen, naproxen that people take for their aches and pains. But I’ve got a different question for you. When I was in graduate school, the head of the physiology department at the University of Michigan was a famous researcher by the name of Davenport. And he was particularly interested in the gastrointestinal system. And I remember he was really focused on mucus. And he asked us, as pharmacology graduate students, well, why doesn’t the stomach digest itself? It’s like battery acid. It’s so powerful. And there it is just sitting in your stomach and it’s not doing any damage. It’s all about mucus and the mucin lining. It is all about mucus. Tell us about it. Dr. Robynne Chutkan 40:50-45:17 Mucus is like a cross between jello and glue. And it’s this sticky polymer. And people think of mucus, first of all, as coming from the lungs. But the reality is most of the mucus in our body is made in our GI tract, about one and a half liters a day. And mucus serves a couple functions. One of them is just as a lubricant. So it lines all those organs that are in contact with the environment, our mouth, our nose, our upper, our oropharynx, if you will, our mouth and airway, our reproductive organs like the vagina, even the inside the urethra, and of course, the GI tract. So it helps to lubricate things. And in the case of the GI tract, it helps to lubricate the gut so that the products of digestion can move smoothly from north to south. But it also has another purpose. One purpose is a barrier. So between the microbes that are floating around in the gut and the gut lining is a thick layer of mucus. And so that helps to protect the gut lining. And the other is that mucus has enzymes in it that can actually degrade viruses that get in. So mucus traps viruses like SARS-CoV-2 in its sticky matrix. And then it has enzymes that will degrade and sort of dissolve the virus. And then, of course, you have those cilia, those finger-like projections in the lungs that can move the virus up and out. And if you swallow it, ideally stomach acid works on it some more. So you see how this is all designed to work together. So it’s like your body’s internal flypaper that catches these viruses. And, you know, there’s this, when we think about this concept of super spreaders, we know that super spreader events aren’t explained by differences in the virus. They’re not based on viral behavior. You can have a large gathering where few people, if any, get a virus, or you can have a small event where everybody gets it. And of course, there are things like how close you’re in contact with people, whether you’re indoors or outdoors. But it turns out that when some people sneeze on you and transmit a virus versus somebody else who’s infected sneezes on you and doesn’t, it has to do with the mucus of the person who’s sneezing on you. Because if you have somebody whose mucus is very potent and it has trapped the virus and the mucins, the proteins in their mucus, have killed the virus, they’re going to sneeze on you and they’re going to transmit dead virus and you’re not going to get infected. But if somebody sneezes on you whose mucus is a little less potent and the mucins in their [mucus] may not have done as good a job as trapping and killing the virus, they are going to infect you. And what’s really interesting is that we, in addition, so the mucus can physically trap viral invaders. It has enzymes that degrade viral proteins and it has antibodies that can neutralize them. And mucins in saliva and breast milk also have antiviral activity that can inhibit even potent viruses like HIV. So again, you know, the quality of these host defenses is really important. And so when we think about something like mucus, we know that people who smoke, for example, have mucus that is much, much less potent in terms of its ability to protect us from pathogens. Being dehydrated would also affect your mucus. And so, again, there are, you know, there are some genetic factors with all of these things that many of these things are things that we can improve ourselves. We can drink more water. We can stop smoking. These are really important things. And along the line of mucus and pharmaceuticals, we know that cough syrups and these cough suppressants are really problematic because they prevent you from being able to expel these pathogens. We want to produce mucus and we want to cough it up so we can get rid of the pathogens. And so when you take these different cough syrups that suppress your cough reflex and or things like antihistamines that can dry you out and decrease your mucus production, you’re really sabotaging your host defenses. Terry 45:17-45:33 So Dr. Chutkan, if most of the mucus is actually in your digestive tract, it’s in there interacting with all the microbes in your digestive tract. What’s the impact of the microbes? Dr. Robynne Chutkan 45:33-47:23 Well, the microbes have to, you know, we don’t want those microbes to penetrate through the gut lining. They’re in the gut lumen for a reason. That’s where we want to keep them. And so it provides, you know, the intestinal epithelial barrier is only one cell thick. So the mucus really buffs up that barrier and provides an additional zone of protection. Because when we look at, for example, there was a study, a microbiome study done at University of Massachusetts in 2021. And that study found that the most important predictor of outcome from COVID was actually the composition of the microbiome. They found high levels of a bacteria called Enterococcus faecalis was associated with worse outcomes and death. And high levels, conversely, of the bacteria referred to earlier, Faecalibacterium prausnitzii was associated with good outcomes. Enterococcus faecalis is a bacteria that is also associated with post-op infections, and it can penetrate the gut lining and get into the body and get into the bloodstream and cause problems. So that protective barrier that mucus provides, I have an analogy in the book that I’ll share with you. It’s 5,000 times the diameter of a viral particle like SARS-CoV-2. So the analogy is a human wading through 150 gel-filled football fields to reach the end zone and score a touchdown. So it creates that buffer so that bacteria like Enterococcus faecalis have a difficult time penetrating that intestinal epithelial barrier, that gut lining. So it’s so beautifully and cleverly designed. And the main thing we have to do is not mess it up. Terry 47:24-47:38 And if we do mess it up somehow, then we run into problems with what the gastroenterologists like to call intestinal permeability and what the rest of us call leaky gut, right? Dr. Robynne Chutkan 47:39-48:36 That’s right. That’s right. And one of the most important points I want to make to people is that these are not things that you fix by taking a supplement. These are things that you primarily fix by not taking things. You know, people want a pharmaceutical fix, whether that’s a prescription, over-the-counter, or a supplement. But these are things that are mostly created as a result of too many of these pharmaceuticals, whether a prescription, over-the-counter, or supplement. So rather than, you know, telling people or people want advice about what probiotic, what supplement, I get them to bring all their pharmaceuticals and lay them out on my office table. And then I pull out my rubbish bin and one by one, I usually drop them in and explain, you know, why they shouldn’t be taking this. And of course, particularly for a prescription drug, this needs to be done in concert with your healthcare provider. Please don’t just start getting rid of, you know, putting medications in the rubbish bin without checking with your physician. Joe 48:37-49:15 Dr. Chutkan, and a lot of people like to, dare I say it, play doctor by going to the pharmacy and buying over-the-counter medications. And now, of course, NSAIDs, non-steroidal anti-inflammatory drugs, are incredibly popular because everybody seems to have an ache or a pain or a fever or a headache. And so they’re taking Aleve. They’re taking Advil. They’re taking ibuprofen over the counter generically or naproxen. And then their doctors are prescribing these. So tens of millions of people are taking these drugs on a daily basis. And they’re affecting intestinal permeability. Dr. Robynne Chutkan 49:16-50:57 Yeah, they are. It’s not just the NSAIDs. It’s also you think about the antipyretics. So the things we take for fever, which would be NSAIDs, but also Tylenol. It turns out fever is one of our body’s most important host defenses. So if we look at poliovirus, poliovirus replicates 250 times faster at normal body temperature compared to when we have a fever. So a fever is our body’s way of trying to slow down viral replication, trying to keep us safe. But what do we do? We suppress a fever. And so, you know, the pediatric guidelines for a while now have talked about, you know, not using cough suppressants, not using antipyretics, fever medication, but we still intrinsically reach for them. And we reach for them because we don’t understand the feedback our body’s giving us. So we confuse a physiological response like a fever. We think it’s an illness. We confuse a physiological response like a hangover, a physiological response like reflux. Reflux is our body’s way of telling us you have overfilled your stomach, you have eaten too late, you have eaten too much fatty food, whatever it is. And that’s why this stuff is coming up. And I’m giving you feedback. And so again, we’ve got to understand the feedback our body’s trying to give us and not just suppress all these symptoms with pharmaceuticals without understanding the messages, the important information that’s contained in them. I mean, I said to a friend the other day, imagine if people didn’t get a hangover, how many people would die from alcohol poisoning because they just keep drinking. Terry 50:57-50:58 Right. Dr. Robynne Chutkan 50:58-51:07 And they wouldn’t get that terrible, you know, headache and you feel horrible and you’re like, oh, oh, that’s what happens when I do that. Maybe I should do less of that. Terry 51:07-51:24 Not do that in the future. Dr. Chutkan, we have just a few minutes and I’m hoping that you’ll walk us through, briskly, your plan for an antiviral gut to protect us from infections. Dr. Robynne Chutkan 51:26-53:34 Absolutely. The difference with this book, and I’m proud of all of them, all four of them, but the difference with this book is that the plan is really a little over half the book because I wanted to be sure to give people the information, the practical steps, not just to say here’s what can go wrong, but to tell them here’s what you can do about it. So the plan is really divided into several chapters, the antiviral gut plan, and I consider sort of “strengthening-from-within” plan. So in the first chapter of the plan is called Securing Defenses. And it talks about how you can optimize your body’s innate capacity to neutralize viruses with stomach acid, to trap with mucus, to burn with fever, to wall off viruses with your gut lining, while simultaneously improving your reflux, your digestion, your overall gut health. The second chapter in the plan is called Mastering Your Mind. And that really focuses on stress and sleep and what you can do to improve those things, improve your sleep hygiene, improve your stress response so that you can be more resilient. The next chapter is Changing Your Environment. And I talk about the Japanese practice of shinrin yoku or forest bathing and how that can reduce stress hormone production, enhance your immune system, and what we touched on earlier, the importance of exposure to soil microbes. Chapter 12 in the plan is being Thoughtful About Therapeutics. So I go through each of the classes of medications that is sort of a threat to your gut health, I talk about potential alternatives, and I give people questions to ask their doctor. So I literally have the list of questions. You know, if you’re on this drug, here are the five questions you should ask your doctor, here are four or five alternatives. And then chapter 13 is a plan at a glance. It’s putting it all together with a kind of snapshot glance at what your daily antiviral gut routine would look like. And then the last section is recipes with some really simple, delicious food. Nothing in there is difficult to make and it’s all really quite delicious. So that’s a plan in a nutshell. Joe 53:35-53:49 In the minute we have left, Dr. Chutkan, some of your favorite foods. If we were to go out to lunch with you today, if we were to have dinner with you on Saturday night, what would be on the menu? Dr. Robynne Chutkan 53:50-54:14 I, you know, beans and greens are two of the things I really focus on. So, and I have to admit that my husband is a lentil maker in the house. So he makes delicious curry lentils and there’s lots of onion and garlic and different spices and curry and coconut milk would be lentils, curry lentils, some brown rice, and I would probably do some sauteed spinach with that. Terry 54:14-54:18 You’re already getting halfway to your 30 plants a week. Dr. Robynne Chutkan 54:18-54:31 Yeah, and exactly. So with the lentils, again, there’s ginger and onion and garlic and leeks and curry powder and bay leaves. So there’s probably six or seven different plants in there along with the lentils. Terry 54:31-54:39 It sounds nutritious as well as delicious. Dr. Robynne Chutkan, thank you so much for talking with us on The People’s Pharmacy today. Dr. Robynne Chutkan 54:40-54:46 Always such a pleasure to be with you on The People’s Pharmacy. I love the work you do. Wonderful to be a part of this. Terry 54:47-55:14 You’ve been listening to gastroenterologist Robynne Chutkan. She’s a faculty member at Georgetown University Hospital and is the founder of the Digestive Center for Wellness, an integrative gastroenterology practice in Washington, D.C. Dr. Chutkan is the author of the Digestive Health books, Gutbliss, The Microbiome Solution, The Bloat Cure, and “The Antiviral Gut: Tackling Pathogens from the Inside Out.” Joe 55:15-55:23 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 55:23-55:30 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 56:09-56:19 Today’s show is number 1,336. You can find it online at peoplespharmacy.com. That’s where you can share your comments. Terry 56:20-56:26 Our interviews are available through your favorite podcast provider. You’ll find the show on our website on Monday morning. Joe 56:27-56:48 At peoplespharmacy.com, you can sign up for our free online newsletter to get the latest news about important health stories. By subscribing to our newsletter, you will also have regular access to our weekly podcast and find out ahead of time which topics we’ll be covering. In Durham, North Carolina, I’m Joe Graedon. Terry 56:48-57:28 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 57:29-57:38 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 57:44-57:57 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.

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.

When the thyroid gland stops working efficiently, the effects resound throughout the entire body. That’s because this little gland controls metabolism in all our tissues. Before there was a treatment, thyroid disease was sometimes deadly. Doctors started prescribing natural desiccated thyroid derived from animals 130 years ago. This worked well. Synthetic levothyroxine (a thyroid hormone) was developed in 1970 and marketed aggressively. Now levothyroxine is one of the most commonly prescribed medications in the US. The FDA has announced that it plans to ban natural desiccated thyroid. What are the implications? We’ll check in with two experts to find out. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Nov. 15, 2025, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on November 17, 2025. What Should You Know about Natural Desiccated Thyroid? Thyroid extract from pigs contains two important thyroid hormones. Endocrinologists refer to them as T4, also called levothyroxine, and T3, known as liothyronine. The T4 molecule has 4 iodine atoms and is inactive. To activate it, the body uses an enzyme, deiodinase, that kicks off one iodine molecule resulting in activated T3 that does all the work in the tissue. When scientists discovered that T4 could be converted to T3, it opened the door to prescribing T4 alone, synthetic levothyroxine such as Levoxyl or Synthroid, to all hypothyroid patients. That became standard practice not long after Synthroid was introduced. There was a hitch, however. Some patients did not feel well even though they were taking levothyroxine. Until fairly recently, doctors downplayed these problems. Our guest, Dr. Antonio Bianco, helped conduct the research showing that some people have deiodinase enzymes that are less efficient at converting T4 to T3 (Current Opinion in Endocrinology, Diabetes, and Obesity, Oct. 2018). This enzyme activity seems to be under genetic control. As a result, endocrinologists may find it easier to understand why some patients don’t respond to prescribed levothyroxine as expected. They may need liothyronine in addition. This could be provided with a separate prescription. On the other hand, people get both T3 and T4 when they take natural desiccated thyroid. We think that Dr. Bianco is one of the leading thyroid researchers in the world. Here is a very short video clip from our interview with him: You will want to listen to the whole interview either live on Saturday morning or when it becomes available on this website Monday morning (11/17/2020). You can stream the audio by clicking on the white arrow inside the green circle under the photo of Armour Thyroid. You can also download the mp3 file by scrolling to the bottom of this article. Why not sign up for all our podcasts at this link so you will never miss another People’s Pharmacy episode again? What Symptoms Do People Suffer Without Natural Desiccated Thyroid? A majority of hypothyroid patients, perhaps 80 or 85 percent, are able to convert T4 to T3 well enough that they can use levothyroxine alone. The remainder, however, do not feel well on this regimen. They experience brain fog and low energy. They may also complain of other symptoms associated with undertreated hypothyroidism, such as difficulty with weight control, cold sensitivity and menstrual irregularities or fertility problems in women. An estimated 1.5 million Americans take natural desiccated thyroid. What will they do if the FDA bans this product? About half a million people take a combination of synthetic T4 and synthetic T3. That is one option, but some individuals prefer natural hormone. What Will Happen to Patients? We turn to patient advocate and activist Mary Shomon to learn about the patient perspective. She is concerned about the FDA’s announced plan to take natural desiccated thyroid (NDT) off the market in August 2026. (NDT is sometimes referred to as DTE, desiccated thyroid extract. They are the same thing.) It is not clear that the agency has considered what will happen to people forced to take a medicine that most of them have already tried without success, levothyroxine. Rethinking Levothyroxine Treatment: Mary Shomon points to recent research by Dr. Bianco and his colleagues suggesting that levothyroxine alone may not be quite as effective as most endocrinologists believe. In this analysis of medical records, hypothyroid people taking levothyroxine alone were twice as likely to die during the study period and had a 40% higher risk for developing dementia compared to people getting T3 along with T4 (Journal of Clinical Endocrinology, June 20, 2025). These new findings underscore the importance of information from the large number of patients in touch with Mary. As she says, there is enormous individual variation in which treatments help people thrive. She recommends that everyone who relies on natural desiccated thyroid should contact the FDA (as well as their Congresspeople) to let them know how banning these products would affect their lives. This Week’s Guests: Antonio Bianco, MD, PhD, is Senior Vice President of Health Affairs, Chief Research Officer and Dean of the John Sealy School of Medicine at the University of Texas Medical Branch at Galveston. Dr. Bianco is the author of Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do. Antonio Bianco, MD, PhDVP & Vice Provost Research & CRO, Research Services Mary Shomon is a patient advocate and author. Her books include the New York Times bestseller The Thyroid Diet and ten others. Her website is  https://www.mary-shomon.com She is also a Paloma Health Advisor & Patient Advocate. Find her online at https://www.palomahealth.com/authors/mary-shomon Her newsletter, Sticking Out Our Necks Hormonal Health News, is available on Substack. Here’s the link: https://hormones.substack.com/ Patient advocate Mary Shomon The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, Nov. 17, 2025, after broadcast on Nov. 8. You can stream the show from this site and download the podcast for free. This week’s episode contains additional discussion with Dr. Bianco of his research on the consequences of treating with levothyroxine alone. We also consider the FDA’s claim that natural desiccated thyroid suffers from inconsistent quality and dosing. Mary Shomon offers basic information on what the numbers from a thyroid test mean, especially the goals for T3 and T4. We also review the most common symptoms of hypothyroidism. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1452: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:26 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. The FDA has announced a ban on natural thyroid extracts like Armour that will impact over a million people. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:44 Most people with under-active thyroid glands take synthetic levothyroxine, but many patients feel much better if they take a natural desiccated thyroid instead. Joe 00:45-00:51 How will the FDA’s ban affect them? What could they do if their medicines were pulled off the market? Terry 00:51-00:57 We speak with an endocrinologist and a patient advocate about the possible ways people might deal with this situation. Joe 00:58-01:05 Coming up on The People’s Pharmacy, why is the FDA planning to ban natural desiccated thyroid? Terry 01:14-02:28 In The People’s Pharmacy health headlines: the FDA has just announced a change to prescribing information for hormone replacement therapy. For many years, this treatment for menopausal symptoms like hot flashes and night sweats has carried a black box warning. This warned women and their doctors that estrogen could increase the risk for endometrial cancer and could increase the risk for blood clots and cardiovascular problems. FDA Commissioner [Dr.] Marty Makary has expressed his belief that the boxed warning frightened women away from a treatment that could help them. He thinks that HRT might reduce the risk of bone fractures, dementia, and even heart disease in women who start taking it at menopause. According to Dr. Makary, with the exception of antibiotics and vaccines, there may be no medication in the modern world that can improve the health outcomes of older women on a population level more than hormone therapy. Some critics are concerned that this action, which was not vetted by an official FDA advisory panel, may undermine the agency’s credibility. Apparently, the warning about the risk for endometrial cancer will remain for products that contain estrogen alone. Joe 02:29-03:39 For years, cardiologists have warned patients with atrial fibrillation to avoid coffee. That’s because they worried that caffeine would aggravate heart arrhythmias. A new study titled DECAF, which stands for Does Eliminating Coffee Avoid Fibrillation, has produced surprising results. The study published in JAMA recruited 200 coffee drinkers with AFib. Half were assigned to drink at least one cup of caffeinated coffee daily. The other half were required to abstain from coffee or any other caffeinated beverages. The study lasted six months. The results were unexpected. Coffee drinkers had a significantly lower likelihood of recurrent atrial fibrillation. One possible explanation is that coffee has anti-inflammatory properties. Because some research suggests that chronic inflammation contributes to AFib, lowering inflammation might be beneficial. The authors conclude that one cup of coffee daily was associated with a lower risk of atrial fibrillation and atrial flutter recurrence. Terry 03:40-04:47 Cardiologists have long known that low levels of circulating vitamin D may increase the risk for a heart attack. A study presented at the American Heart Association’s scientific sessions showed that people taking vitamin D supplements to raise their blood levels to at least 40 nanograms per milliliter significantly reduced their chance of a second heart attack. The study included 630 people who had suffered a heart attack less than a month before entering the trial. Such individuals are at risk for a second heart attack. Investigators assigned them to a control group that received no vitamin D management or an intervention group that had regular measurement of vitamin D and adjustment of their supplements to reach the target blood level. When the study began, 85% of the volunteers were below target. Many required supplements of 5,000 international units of vitamin D3 daily to reach 40 nanograms per milliliter. Those taking supplements were half as likely to experience a second heart attack compared to those not receiving supplements. Joe 04:48-05:20 Metabolic syndrome is a cluster of three or more risk factors that increase the chance for cardiovascular complications such as heart attacks, strokes, peripheral artery disease, along with diabetes. Risk factors for metabolic syndrome include high blood pressure, abdominal adiposity, elevated blood sugar, and high triglycerides. A new study has found that six months of lifestyle interventions to encourage new habits of healthier eating and greater physical activity led to long-term benefits. Terry 05:21-05:53 Following a DASH diet rich in vegetables and fruits and low in processed foods can help lower blood pressure. But what about people who live in food deserts where fresh produce is not readily available? A study compared home-delivered DASH-type groceries and dietary advice to monetary stipends for groceries. Three months of DASH grocery delivery lowered blood pressure and LDL cholesterol levels more than the $500 monthly stipends. And that’s the health news from the People’s Pharmacy this week. Joe 06:14-06:17 Welcome to the People’s Pharmacy. I’m Joe Graedon. Terry 06:17-06:47 And I’m Terry Graedon. Hypothyroidism is surprisingly common, affecting over 20 million Americans. In this condition, the thyroid gland does not produce an appropriate amount of thyroid hormone. This leads to a wide range of uncomfortable symptoms and some serious health consequences. Treatment is thought to be simple, but not everyone responds to the standard therapy. What can people do if they still feel bad while taking their prescribed medication? Joe 06:48-07:21 To help us understand the complexity of treating hypothyroidism, we turn to one of the country’s leading experts. Dr. Antonio Bianco is professor of medicine and a member of the Committee on Molecular Metabolism and Nutrition at the University of Chicago, where he runs a laboratory funded by the National Institutes of Health to study thyroid hormones. Dr. Bianco is a former president of the American Thyroid Association and author of “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Terry 07:23-07:26 Welcome back to The People’s Pharmacy, Dr. Antonio Bianco. Dr. Antonio Bianco 07:27-07:29 Thank you. I’m glad to be here. Joe 07:29-07:45 Dr. Bianco, a lot of your colleagues, endocrinologists, family practice physicians, internists, they think that thyroid disorders are easy to treat. Why is that a mistake? Dr. Antonio Bianco 07:46-08:29 Well, the most common disease of the thyroid gland is hypothyroidism. And it is true that for the last 50 years, we have been treating patients with hypothyroidism with the daily tablet of what’s called levothyroxine. And the dose is easily adjusted. And usually we tell patients, come back in six months, come back in a year. And this is sort of very straightforward to the point that it doesn’t have to be even treated by an endocrinologist. They can be treated by a primary care physician, a gynecologist, a geriatrician. I mean, most internists can treat hypothyroidism. Joe 08:31-08:34 But you suggest it’s not as easy as that. Dr. Antonio Bianco 08:36-09:54 That’s right. And that has been a mistake that we did in the last 50 years, again. We assumed that once we achieved the dose of this magical drug called levothyroxine, patients will feel without symptoms, would be relieved of their symptoms. And in fact, it is true for most patients. We estimate that about 80%, maybe 85% of the patients are treated with this approach and they feel fine. However, we do have a substantial number of patients that it seemed small, 15%, but hypothyroidism is so prevalent. We have about 20 million people living in the U.S. with hypothyroidism. So if you estimate about 10%, 20%, we’re talking about 3 to 4 million people. And for those individuals, treatment is not as straightforward. Even though the doctor thinks that the treatment is okay, it’s as it should be, they remain symptomatic. They still have symptoms. Terry 09:55-10:48 Dr. Bianco, we have been hearing from people with hypothyroidism for decades ourselves. They write into The People’s Pharmacy or they call and they say, ‘I am taking Synthroid or Levoxyl, one of those T4 drugs, levothyroxine, and I still feel awful. I still feel tired, I still feel cold.’ Women still say, ‘I still am having problems with my menstrual cycles.’ Many people say, ‘I still can’t lose weight, in fact, I keep gaining weight even though I’m trying hard to lose it.’ They have many symptoms and they don’t feel good and they say, ‘My doctor doesn’t seem interested.’ Joe 10:49-11:03 Well, not only that, they say, ‘My doctor says I’m doing great. My TSH level, this monitor for my thyroid, is perfect. No problems, be happy, don’t worry.’ Dr. Antonio Bianco 11:04-11:40 In a nutshell, you capture exactly what the problem is. That’s exactly right. And so what we think is the problem is that these Synthroid or Levoxyl, they contain this molecule called levothyroxine, which is the thyroid hormone. And levothyroxine is not active, meaning when a patient takes a tablet of levothyroxine, levothyroxine by itself cannot relieve symptoms of hypothyroid. It just doesn’t do anything. Terry 11:41-11:46 I think that’s a really important point. That isn’t adequately appreciated. Say it again, please. Dr. Antonio Bianco 11:45-12:53 That’s correct. Yes. The substance contained in those tablets, either Levoxyl or Synthroid or any generic form of levothyroxine, it’s not active. It’s a dead molecule. And we rely on our body to take that molecule and activate, to process it, to transform it into a molecule that is biologically active, meaning can relieve symptoms of hypothyroidism. And some of us do their job very well. Unfortunately, some of us don’t do that. And those individuals that remain symptomatic. We believe they have a sort of a problem in activating the molecule, the T4, to this other molecule called T3. And so they live in a state of chronic T3 insufficiency. And it so happens T3 is the molecule that relieves symptoms of hypothyroidism. Joe 12:54-13:13 Perhaps we could take just a moment to review the physiology of the thyroid gland. Why is the thyroid, and in particular, that active form, T3, so crucial to every cell in our body? Dr. Antonio Bianco 13:14-15:17 The thyroid mostly makes T4, which again is this molecule that is not active. But T4 remains in the circulation, in the blood. A little bit of T4 goes into the cells. Most T4, it’s in the circulation. Now, once T4 gets into the cells and tissues and organs, T4 is rapidly activated in T3. So that inside that organ, T3 can act and relieve symptoms of hypothyroidism. Now, when doctors look at the TSH, and you mentioned TSH, TSH is this hormone that controls the thyroid gland. TSH likes to see T3 in the circulation within the normal range, so that if you have a healthy thyroid, the TSH controls the thyroid gland to the point that T3 in the circulation is normal. Now, when a patient has hypothyroidism and we give the patient T4, only T4, and rely on the TSH to estimate how much T4 we should give, then the system gets confused because TSH regulates the T3 levels in the circulation, and yet we’re giving a lot of T4 to the patient. Yes, we can regulate TSH with T4, but it’s not the same as having an intact thyroid. And that has been the mistake we’ve done over the last 50 years. We relied on TSH and treated patients with only one hormone. And all along, we needed two hormones to treat these patients. I mean, we believe that this T3 insufficiency should be fixed by adding a second hormone to the treatment. Terry 15:19-16:10 Now, Dr. Bianco, a little bit of personal information here: I am one of those people with hypothyroidism. I have had it since 1974. I am part of your 80% of people who actually feel pretty good on T4 alone. So I’ve been taking Synthroid all these years. When I go to my physician for a checkup and she orders a blood test to see how my thyroid is doing, the only thing she’s looking at is TSH. Is that a problem? When Joe gets his blood tested for his hyperthyroidism condition, his doctor is looking at T4, T3, all kinds of different thyroid hormone levels, not just TSH. Dr. Antonio Bianco 16:11-16:49 That is a problem. And that is part of that, I think that’s a big part of the problem. We got used to just looking at TSH to adjust the dose of levothyroxine. And we were missing the big picture, which is a relative T3 deficiency that these patients experience. And you’re right, some patients or most patients can cope with that. You know, they just don’t feel bothered by that. But there’s a small minority that those symptoms are really important. Joe 16:46-16:48 Whoa whoa, Dr. Bianco- Terry 16:49-16:51 15% is not a small minority. Dr. Antonio Bianco 16:49-16:52 Oh, yeah. No, that’s right. Joe 16:51-16:56 I mean, you’ve already, you’ve already said over a million, maybe as many as two or three million. Dr. Antonio Bianco 16:55-16:56 No, that’s correct. Joe 16:56-16:58 This is not a minority. Dr. Antonio Bianco 16:57-17:06 Oh yes, absolutely. Percentage-wise, yes. Percentage-wise, yes, but it is a vocal and it’s a very important minority. Joe 17:07-17:13 What else should doctors be testing for besides TSH? Dr. Antonio Bianco 17:15-17:39 Uh, T4 and T3. They have to control… the purpose of the treatment of hypothyroidism has been to normalize TSH. And I advocate that we have to look at T3 levels because T3 is the hormone that relieves symptoms. T3 is the hormone that actually [does] things. And we should be looking at normalizing those levels. Terry 17:41-18:07 You’re listening to Dr. Antonio Bianco, professor of medicine at the University of Chicago. He’s a member of the Committee on Molecular Metabolism and Nutrition there, and he runs a laboratory that studies thyroid hormones. Dr. Bianco is a former president of the American Thyroid Association and author of “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Joe 18:07-18:14 After the break, we’ll learn about the symptoms troubling some patients even though they’re being treated for hypothyroidism. Terry 18:14-18:21 Low energy and brain fog are not very specific. What should make us suspect they could be due to thyroid problems? Joe 18:21-18:28 Dr. Bianco is challenging the usual approach to hypothyroidism. How are his colleagues reacting? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:54-19:14 And I’m Terry Graedon. Today we’re analyzing the FDA’s plan to withdraw permission for natural thyroid extract, also referred to as desiccated thyroid. What will happen to patients who rely on products like Armour Thyroid if they can no longer access the medications their doctors have prescribed? Joe 19:15-19:36 We’re talking with Dr. Antonio Bianco. He is Senior Vice President of Health Affairs, Chief Research Officer, and Dean of the John Sealy School of Medicine at the University of Texas Medical Branch at Galveston. His book is “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Terry 19:38-20:38 Dr. Bianco, we really appreciate the overview and the history that we have gotten now. The reason we’re talking with you is that the FDA has announced that it is going to withdraw its permission from suppliers of desiccated thyroid extract. I’m not quite sure what the timeline is. I think they suggested perhaps about a year from last August. But thyroid patients who are relying on desiccated thyroid extract to treat their hypothyroid condition are worried that they are going to be left out in the cold. And because they are hypothyroid, they are really going to feel that cold. Can you fill us in on what the FDA has in mind, if you have any insight into that, and what people might be able to do? Dr. Antonio Bianco 20:39-22:19 Yeah, well, that is a problem. I agree with you. We have 1.5 million patients taking this drug. And the FDA just announced that in 12 months, starting in August, that drug is not going to be available. And what the FDA is asking physicians is to switch those patients that are taking desiccated thyroid extract to take levothyroxine, which is the recognized standard of care. But the problem is these patients are on desiccated thyroid extract most likely because they tried levothyroxine before and the levothyroxine was not sufficient to resolve all their symptoms. That’s why they were switched to desiccated thyroid extract. That’s the recommendation that the clinical professional societies are providing. You start treatment with levothyroxine, and if that doesn’t resolve all the symptoms, you can try combination therapy for these patients, either with desiccated thyroid extract or synthetic combination of levothyroxine and liothyronine. So these patients have tried levothyroxine, and levothyroxine failed them. And that’s why they’re happy on desiccated thyroid extract. So the idea that we should all move our patients to taking levothyroxine now, it’s a little bit concerning because it is my experience that these patients rely on that drug. Their lives are many times miserable without the desiccated thyroid extract or the synthetic combination. Joe 22:19-22:49 Let me interrupt you right there. Again, Dr. Bianco, what do you think will happen if a million to a million and a half people are switched from desiccated or natural thyroid to levothyroxine, people who have failed in the past on levothyroxine? What are some of the symptoms that they may encounter when they’re switched back to the pure synthetic levothyroxine? Dr. Antonio Bianco 22:50-23:40 Yeah, the main symptoms include brain fog, the inability to function normally. And I had many patients that complained of brain fog, patients that lost their jobs because they couldn’t focus. I have high school teachers that were functioning well. They were diagnosed with hypothyroidism, they were treated with levothyroxine, and by all accounts, they were okay, biochemically okay. The lab tests were okay, but they did not feel well. They had brain fog, they couldn’t focus, they lost their jobs. I have countless, countless stories, and my colleagues do too. So I think that if they are forced to go back to levothyroxine, it will be a problem for their lives. Joe 23:40-23:47 What are some of the other symptoms? Because we’ve heard of people who say, I just couldn’t lose weight on levothyroxine. Dr. Antonio Bianco 23:47-23:48 That’s right. Yes. Joe 23:48-23:49 And I feel cold. Dr. Antonio Bianco 23:50-23:50 Yes. Joe 23:50-23:52 And I’m constipated. Dr. Antonio Bianco 23:53-24:22 Yes. All the symptoms. The symptoms are very similar to the symptoms of hypothyroidism in lesser intensity. So the second most common is low energy: patients feel very tired, no motivation to do things. And that is very helpful. The third one is difficulty managing body weight, that’s also a major problem. So this is going to be very inconvenient for those patients. Terry 24:23-24:41 And that, I think, is why patients are really, I might say, alarmed at the prospect. Is there any possibility that a desiccated thyroid extract might actually be approved by the FDA? Dr. Antonio Bianco 24:41-25:29 Well, yes, that would be terrific. So we have, I’m aware of about two or three pharmaceutical companies that are currently running clinical trials in communication with the FDA. They are in constant communication with the FDA. The FDA knows about their results and they have these clinical trials that are ongoing and they are in the process of getting this drug approved. So it’s not that they’re doing it without the knowledge of the FDA. No, they know very well what they’re doing. But of course, it takes time because it involves hundreds, sometimes thousands of patients that have to be studied on trial. So it takes time. It’s a long process. Joe 25:30-26:41 Well, you know, I find it rather paradoxical that the overarching company that makes Synthroid, which is the best-selling brand name Levothyroxine, is AbbVie. And the same company, AbbVie, owns the company that creates the best-selling desiccated thyroid, Armour Thyroid. So you have AbbVie with its tentacles, so to speak, in both the brand name synthetic levothyroxine and the natural combination of desiccated thyroid. And so presumably they have enough money, resources, and expertise to be able to run the clinical trials that you’ve described. But the question is, will they be able to meet the timetable of the Food and Drug Administration? And what will patients do if for some reason, for example, they cannot access Armour or any other desiccated thyroid? Dr. Antonio Bianco 26:41-27:41 Right. No, that’s quite interesting. You pointed to a very interesting thing by, you know, it was fate that levothyroxine was going to be manufactured and sold by the same company that makes desiccated thyroid extract. That’s quite interesting. Now, they are running, they are one of the companies that are running clinical trials. They already have actually presented the results of their trial in the meeting of the American Thyroid Association two or three years ago in Montreal. And the results were quite satisfactory, meaning that following the guidance from the FDA, they were able to show scientifically that patients can effectively and safely be treated with desiccated thyroid extract. The results were presented in the American Thyroid Association meeting. Obviously, that’s the first step. Now they’re working with the FDA into the second step of the study, which involves a much larger number of patients. Joe 27:43-27:57 Dr. Bianco, perhaps you can give us an update on your latest research. We have been following you for a very long time, and we’d like to know what you have in the pipeline or what you have recently published. Dr. Antonio Bianco 27:58-28:36 Yes, thank you. So this is, we got very interesting results. So recently I moved to the University of Texas in Galveston. And here we have access to something unique, which is a computer network of electronic medical records. It’s called TriNetX. And once I moved here, I gained access to this network, which involves about 140 hospitals throughout the world, mostly in the United States. And we have access to more than 100 million patients’ electronic medical records. Joe 28:36-28:37 Wow. Dr. Antonio Bianco 28:37-31:02 So obviously, yeah, that’s amazing. My first question is that let’s look at patients with hypothyroidism. And so we were able to identify 1.2 million patients with hypothyroidism that were being treated. So we compared these patients with healthy patients that had a healthy thyroid. So we properly matched them for age, sex. We used about 20 variables to make sure we have two equivalent populations. And much to my surprise, we saw that patients, even though they are being properly treated, They have a higher incidence of dementia, and they have a higher mortality. Mortality is almost double in patients that have hypothyroidism, even though they are being appropriately treated. So that was very concerning to us. Now, the second question is, well, what if the patients were treated with combination therapy as opposed to levothyroxine? So out of these 1.2 million patients, we separated about 90,000 patients that were being treated with combination therapy. Half of them were taking desiccated thyroid extract, and the other half were taking synthetic combination, 90,000. And then we matched those 90,000 patients with 90,000 patients only taking levothyroxine. And we looked at [them] retrospectively for 20 years, how did these patients do? So first, we were expecting, with all honesty, that patients taking the combination therapy, the therapy that contains T3, were perhaps not doing so well as the ones taking levothyroxine. After all, there’s some concern that combination therapy could not be a safe route. Even in the letter of the FDA, they say that desiccated thyroid extract is not safe. So by looking at this population, seeing a very appropriate way of comparing combination therapy, desiccated thyroid extract or synthetic with levothyroxine. Much to our surprise, those individuals taking combination therapy, they had a reduction in mortality of about 30%. Joe 31:02-31:02 Wow! Dr. Antonio Bianco 31:02-31:48 They had a, yes, a reduction in the diagnosis of dementia over these 20 years. So not only the combination therapy were safe, but actually it showed to be slightly safer than levothyroxine alone. And again, this is not one site study. This is not a study that was done here in Texas. No, this was done in more than 100 hospitals across the country. So this is really a multi-center study. It’s a retrospective study. It’s not a prospective study. You can’t just follow 90,000 patients prospectively for 20 years. But even considering that is retrospective, the data is amazing. Terry 31:49-32:21 Dr. Bianco, this brings up a question to my mind, a very personal question. I have been taking levothyroxine in the form of Synthroid since about 1974 or 1975. I don’t remember if it was the end of 74 or the beginning of 75 when I started on it. But all this time, and I’ve counted myself as among that 80% of patients who do fine on synthetic levothyroxine. Dr. Antonio Bianco 32:22-32:22 Right. Terry 32:23-32:32 But what you’re suggesting is perhaps I could do even better if I also had a little bit of T3 in my treatment mix. Dr. Antonio Bianco 32:32-33:43 That’s correct, absolutely. And I think that my research in the laboratory now shows that there’s some clues to why this is. I think that when we treat patients with levothyroxine alone, we do not restore thyroid hormone action in all tissues. And it looks like the liver is one of the tissues that might remain slightly hypothyroid, even though the TSH levels are normal. Remember, the TSH is that hormone that doctors use to control the amount of the dose of levothyroxine that we give to patients. So the goal is to normalize TSH. So it turns out that even though TSH is normal, the liver may remain slightly hypothyroid. And why do I say this? Because patients with hypothyroidism that take levothyroxine, they have slightly elevated levels of cholesterol. Even though the TSH is normal, cholesterol remains slightly elevated. And you know what doctors do? They give statin. Terry 33:43-33:45 Yes, I do know that. Dr. Antonio Bianco 33:45-34:34 Exactly. So it turns out the number one co-prescription medication of levothyroxine is statin. Because, you know, you’re a doctor, you’re treating your patient, you’re giving levothyroxine, you normalize TSH, cholesterol remains elevated. Okay, I’m going to prescribe statin now. So it seems that we are creating patients that have a liver that’s slightly hypothyroid. Statin helps, but statin does not resolve all the problems. And therefore, that creates a risk factor for cardio-metabolic diseases. So these patients are dying of cardio-metabolic diseases. And I’m not surprised that when you use combination therapy, you actually improve a little bit. Joe 34:34-34:37 Dr. Bianco, have you published this new research? Dr. Antonio Bianco 34:38-34:44 Yes, it is published in the Journal of Clinical Endocrinology and Metabolism about two months ago. Joe 34:44-35:12 Well, it seems to me that if you were to present this data to the Food and Drug Administration, that is to say that people actually are doing better on desiccated thyroid, natural thyroid, in the long run with regard to key factors that people really care about. You know, they don’t care about lab values. What they care about is how they feel… Dr. Antonio Bianco 35:12-35:13 That’s exactly right. Joe 35:12-35:16 …and whether they’re living longer and healthier. Dr. Antonio Bianco 34:16-34:16 Yep. Joe 35:16-35:37 It seems like if you were to present this data to the Food and Drug Administration, they might say, ‘Oops, we just made a colossal mistake, we should be allowing natural desiccated thyroid on the market and maybe questioning the value of synthetic T4 levothyroxine.’ Dr. Antonio Bianco 35:38-36:29 Yeah, I agree 100% with you. Including in the letter, the FDA says, we are unaware of any studies demonstrating the safety and effectiveness of desiccated thyroid extract, which is, I mean, absolutely incorrect. There are several studies that have been published and are available on PubMed. There are two clinical trials that were done at the Walter Reed Medical Center, you know, in Washington. And, and uh, proving that this desiccated thyroid extract is effective and is safe. And you don’t even need to look at this study that we just published. The study that we published is powerful because it involves 90,000 patients for over 20 years. So that is very important, I think. Joe 36:29-37:00 I’m curious about your colleagues. I mean, you are one of the world’s foremost researchers in the field of thyroid physiology. Are other endocrinologists concerned about the FDA’s, shall we say, well, it’s just Joe speaking now, short-sighted decision to withdraw approval of desiccated thyroid? Are you hearing from any of your colleagues who are a little bit worried? Dr. Antonio Bianco 37:01-38:02 Yes. I think that I just recently went to the meeting of the American Thyroid Association in Arizona, and that was the conversation that we had with multiple individuals, colleagues of mine, very concerned. In fact, [AACE], the American [Association of] Clinical Endocrinology, put out a statement saying that they are supportive of the patients and they are stressing the FDA to reconsider and make sure that desiccated thyroid extract will remain available until the drugs are approved by the FDA. Because the companies are on track to get this drug approved by the FDA. Also, the American Thyroid Association put out a statement saying that they support the availability of desiccated thyroid extract at the same time that they support the companies going through the approval process. So I think that professional societies and my colleagues are very concerned with this move by the FDA. Joe 38:02-38:56 I do have one other question, and that has to do with quality. One of the concerns that the FDA has suggested is that, well, this natural thyroid stuff, this desiccated thyroid, it might be variable from one batch to another or from one company to another. And therefore, it might be unreliable. And what has me concerned about that perspective from the FDA is that we have received an awful lot of complaints from people who say, you know, generic levothyroxine that may be made in China or India or Thailand or Brazil. We have some problems with that generic thyroid. Terry 38:57-39:21 Well, the problem is that from one month to the next, when you get your prescription filled, you don’t know that the pharmacy is going to be using the same generic company to fill your prescription. And we have heard from people who said it was fine for, you know, three or four months, and then I got switched, and it really was not the same. Joe 39:22-39:42 So it seems a little, you know, I won’t say disingenuous of the FDA to be so worried about quality of the desiccated thyroid, but seemingly says, oh, all the generic levothyroxine is the same. Don’t worry. Everything’s fine and dandy when patients are saying it’s not. Dr. Antonio Bianco 39:44-43:27 Yeah. So you touched on two important problems. One is the variable potency of desiccated thyroid. The other one is the consistency of exchanging levothyroxine formulations. So the first one, it is true that desiccated thyroid extract was, there was this problem of inconsistency, but that was resolved in 1985. And if you look at the FDA letter, all the references that they quoted to support the idea that desiccated thyroid extract is inconsistent. They dated before 1985. I’m looking at the letter and it starts by 1978. So what happened in 1985? The United States pharmacopoeia changed the recommendation for how this desiccated thyroid extract is standardized. And they moved from measuring just iodine in those tablets by measuring T3 and T4 by HPLC. So now, since 1985, everyone, the pharmaceutical companies use HPLC to do this. And by doing that, the standardization became so much better, right? So the potency issue has basically been resolved. Of course, there are recalls. Yes, levothyroxine is also recalled all the time. If you go to the FDA website, drugs are recalled. Lots of drugs are recalled, you know, different lots. Because, and actually I’m happy when I see a recall, because it means someone is looking at it, someone is actually measuring it, and making sure that whatever remains available for the public is within the recommendations. So, recalls are normal. And I think that it means we are looking at, but if it’s not recalled, it’s consistent. It’s within the recommendations that we give by, that are given by the [USP], the United States Pharmacopeia. Now, generic versus brand and multiple generic formats for levothyroxine. Yes, this is an issue that has been in discussion for a number of years. And I have to tell you that most publications, or at least two major publications that I know that have been published in JAMA, show that it is totally possible for patients to switch from one brand to the other, from one generic to the other, because they are all equivalent. I know there are anecdotal reports by patients saying that they don’t feel well once they change, that might be because of the filler or the excipient that contain, [that] different formulations have. But as far as the hormones in the blood, the TSH, and as far, if you look at those, those drugs are interchangeable. So, and I, you know, this is, you cannot control that. That’s beyond our control. We did recently a study in which we saw that about 40% of the prescriptions are switched at the pharmacy level within the first year that patients started taking levothyroxine. If you go to the next second year, the number is even higher. So the exchange happens no matter what because pharmacists are allowed to do that. Joe 43:29-43:55 Now, for somebody who panics and they say, well, what will I do? They could ask their family physician or their endocrinologist to prescribe the synthetic versions. How different is it likely to be clinically if someone were to receive both levothyroxine and liothyronine? Dr. Antonio Bianco 43:56-43:56 Right. Joe 43:56-44:05 Two synthetic [hormones], the brand name, by the way, is Cytomel for that liothyronine T3. Just give us a clinical overview. Dr. Antonio Bianco 44:06-45:42 Yeah. I mean, I think that from a clinical point of view, that would essentially be the best alternative available. The physician will, obviously, it’s not going to be a primary care physician because they will have to refer these patients to the endocrinologist. I don’t think primary care physicians or family physicians will feel comfortable prescribing a combination of levothyroxine and liothyronine. So endocrinologists will be swamped with 1.5 million patients in this country that will be switching to synthetic combination of T4 and T3. Now, this is totally feasible, and I think it’s going to resolve most of the problems if that’s the route. However, two drugs requires two copayments in most cases, and it requires taking two tablets. And some patients, they say that they don’t do well with synthetic levothyroxine. So they just prefer the natural thing. They will tell you, my body does not accept the synthetic levothyroxine. Although I don’t see a scientific reason for that to be the case, the patients are adamant and they really feel the difference. So I’ve been wrong in the past, and I’d rather listen to what the patients are telling me and how they feel about it. And I would rather maintain them on the desiccated thyroid extract if that is the case. Terry 45:43-46:18 Well, we know that there are a lot of patients who would prefer that route as well. I don’t know if this has any relevance for how people might feel, but I know that some versions of levothyroxine– Synthroid, for example– does contain lactose as a filler. And if people were extremely lactose sensitive, it’s a small amount, so they’d have to be very extra lactose sensitive, that might be a problem for them. Dr. Antonio Bianco, thank you so much for talking with us on The People’s Pharmacy today. Dr. Antonio Bianco 46:18-46:21 That was my pleasure. Thank you very much for having me back. Terry 46:22-46:43 You’ve been listening to Dr. Antonio Bianco, Senior Vice President of Health Affairs, Chief Research Officer, and Dean of the John Sealy School of Medicine at the University of Texas Medical Branch at Galveston. His book is “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Joe 46:44-47:05 We turn now to patient advocate Mary Shoman to get some perspective from people who rely on natural desiccated thyroid for their treatment. She’s the author of The Thyroid Diet and 10 other books and a Paloma Health Advisor. You can find her newsletter Sticking Out Our Necks: Hormonal Health News, on Substack. Terry 47:06-47:09 Welcome back to the People’s Pharmacy, Mary Shoman. Mary Shomon 47:10-47:12 Thank you so much. I’m so excited to be here. Joe 47:13-48:02 Mary, we’ve just had an opportunity to talk with Dr. Antonio Bianco, and he shares with us that many of his colleagues who he has talked to, endocrinologists, are concerned about the Food and Drug Administration’s decision to, in a sense, eliminate the DTE, the desiccated thyroid extract, which is kind of shocking, I think, to a lot of us. So both the endocrinology community and, I suspect, patients are kind of worried. What are you hearing from your colleagues, your patients, the people who have been following you for many years? Mary Shomon 48:03-50:04 I am hearing a lot of confusion. As Dr. Bianco has said, there just is not enough information and that there is no real clarity coming out of the FDA and the Department of Health and Human Services. So it feels a little bit like a roller coaster for patients and for their providers, because we are in a situation where we have probably at least a million or more thyroid patients who rely on natural desiccated thyroid or DTE in order to treat their hypothyroidism. Yet the FDA, which we thought was giving us till the end of the decade to get this NDT, DTE situation sorted out, has now narrowed the timeframe, declared this drug to be a biologic after a hundred and some years on the market and has basically left us wondering, are they going to pull it off the market with no approved alternatives for us, which would force patients either to go without medication or to take medication that for many of us, we have taken in the past and it has failed us. It has not worked for us to serve as a thyroid hormone replacement. So it’s confusion on the part of the patients, the doctors and practitioners that prescribed for these patients are confused because they don’t know what to do to protect their patients’ continuity of treatment. And then we get mixed messages coming out of the FDA. You’ve got some of them saying, oh, we’re getting rid of it. We hate it. Dr. Tidwell apparently just can’t stand this, and he has made it very clear. Then we’ve got Dr. Makary, and we have Robert F. Kennedy, the secretary, saying, ‘Oh, no, we’re going to save it. We’re going to keep it. We’re going to make sure it’s available.’ What’s the actual plan? Right now, we think it’s going off the market in about a year, and that’s what we know. And that is a frightening concept for most thyroid patients who rely on it. Terry 50:05-50:21 Mary, I would like to just have you clarify for people who are listening and might not be aware of the abbreviations that we’ve been using, NDT and DTE, they’re really the same thing. Would you explain what those abbreviations mean? Mary Shomon 50:21-51:18 Sure. NDT is the abbreviation for natural desiccated thyroid, and DTE is desiccated thyroid extract. They’re basically synonymous or equivalent, and they are referring to a form of thyroid hormone replacement that comes currently from porcine or pig thyroid glands that have been prepared and dried and created into a thyroid hormone replacement that contains both T4 and T3, the two primary thyroid hormones that are needed to replace missing thyroid hormone in the body. They are different from the prevailing or most popular thyroid drug, which is levothyroxine, which is a synthetic form of only the T4 hormone, whereas the NDT or DTE contains both T4 and T3, but it’s coming from natural sources rather than synthesized. Joe 51:19-51:33 And it’s my understanding, Mary, that if the FDA follows through on its plan, the natural or desiccated thyroid extract will disappear from the market August of 2026. Is that right? Mary Shomon 51:34-52:38 Well, this is at least what the official statements have said. But we have posts on X, formerly Twitter, that suggest otherwise, that, oh, we’re going to ensure that patients still have access to their medication. But that has not been formalized with any releases or official guidance or official policy decisions that have come out from the FDA. So that’s all basically just a promise on social media, but nothing more. Currently, I’m operating as if the policies that are issued by the FDA are the ones that are going to be honored, in which case we’re looking at NDT going off the market sometime next year, probably late summer, as you said. Unless someone miraculously is able to get through the very onerous and expensive and time-consuming process of a biologic license approval to get the NDT approved as a biologic drug, which is what they are requiring for this drug to be able to be sold on the market and prescribed by doctors in the United States. Terry 52:40-52:47 You’re listening to Mary Shoman, patient advocate and author of numerous books about thyroid disease. You can find her newsletter on Substack. Joe 52:47-52:54 After the break, we’ll learn more about Mary Shoman’s 30 years as a patient advocate and her experience with Hashimoto’s disease. Terry 52:54-53:01 Dr. Bianco said that people on levothyroxine alone don’t do as well as those on DTE in controlling their cholesterol. Joe 53:02-53:07 Why hasn’t the endocrinology community taken that discrepancy more seriously? Terry 53:07-53:12 We’ll find out what steps Mary Shoman is taking to advocate for all thyroid patients. Joe 53:12-53:16 What about importing DTE from Canada? Is that feasible? Terry 53:26-53:29 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 53:38-53:41 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 53:41-53:58 And I’m Terry Graedon. Joe 53:59-54:13 Many people who have done well on natural desiccated thyroid extract are worried that the FDA is planning to eliminate these products. Most have already tried synthetic levothyroxine with limited success. Terry 54:14-54:17 What will they do if the FDA’s ban goes into effect? Joe 54:18-54:34 Our guest is Mary Shoman. She’s a patient advocate and the author of “The Thyroid Diet” and 10 other books. Mary is a Paloma Health Advisor. You can find her newsletter, Sticking Out Our Necks: Hormonal Health News, on Substack. Terry 54:35-55:08 Mary Shomon, you are widely recognized as an advocate for people with thyroid problems, especially hypothyroidism. Part of that is because you yourself have had a long-term personal experience with Hashimoto’s disease, which leads, can lead to hypothyroidism. Would you recap for us briefly, please, some of the milestones of your 30-year journey with Hashimoto’s? Mary Shomon 55:09-58:04 Absolutely. When I was first diagnosed with hypothyroidism and Hashimoto’s, it was really not very well known to me. I was in the process of getting married. I was engaged. I kept going for dress fittings. And every time I went for a fitting, instead of taking the dress in, as they often do, because brides are always eager to lose weight, they had to keep letting my dress out, which was unusual because I had always had a normal metabolism. I was fairly slender, I felt great, and all of a sudden, my dress is getting let out and I’m tired and I’m feeling kind of blue and depressed, which is not the norm for a bride to be. So I went to my doctor and I told her what was going on. And luckily, I had a very good integrative physician who immediately decided to go ahead and check my thyroid. And it came back that I was slightly hypothyroid and had slightly elevated thyroid antibodies. And so she said, we’ll put you on some medication. And I thought, OK, great. This is going to solve the problem because I really didn’t know anything about thyroid disease. She put me on the meds and things didn’t get better. I kept gaining weight, I was more depressed, my hair started falling out, I was tired and brain fogged and all of the symptoms that are characteristically associated with hypothyroidism. And I eventually went back to her. We worked on this multiple times and really got to a place where we were able to start changing around, switching over. I started out by taking a T4, T3 combination drug that is not on the market at present called Thyrolar. That was a synthetic combo of the two hormones. Then we switched over to natural thyroid. And at that time I was taking Armour Thyroid and I started to feel better. I also started to learn more, which back in those days, this is the very earliest days of the internet, was an adventure. There was not a lot of attention paid to thyroid. And doctors often said, oh, it’s easy to diagnose, easy to treat. Just take one pill every day. Don’t worry about it. Well, I discovered after talking with other thyroid patients and connecting and forming community with them. Not the case. A lot of people still were struggling. And that was really the beginning of my journey into patient advocacy and writing books and articles and providing information and creating support groups and other components to really help empower thyroid patients to develop their own information, empowerment, and to seek out and work with the physicians who really understood hypothyroidism. So it’s been a 30-year journey, and I’m still on it and still working to advocate for myself and helping others stay well because that’s really the goal is we want to feel well, we want to live well. Joe 58:04-59:56 And you have done an extraordinary job educating not just patients, but also I think a lot of healthcare professionals. One of the things that Dr. Bianco shared with us just blew my mind, just to be honest with you. I was like, oh my goodness, that’s extraordinary. He looked at this gigantic database that he has, and apparently he and his colleagues have just published this data a couple of months back. And it showed that people who are on standard levothyroxine, Synthroid and other products, they don’t do as well as the, I think, endocrinology community thought they were doing in terms of things like mortality, in things like dementia. I mean, so, you know, the stuff that people really care about, these patients weren’t doing as well, even though their thyroid levels seem to be, quote unquote, in the normal range. And Dr. Bianco then compared the outcome of these patients over a long period of time with people who were on desiccated thyroid extract, natural thyroid. And those people did better. They did better than the people on synthetic thyroid in terms of longevity, in terms of brain fog, in terms of just cholesterol levels in the liver. And when I got done listening to him, I thought, wow, why hasn’t the endocrinology community recognized that there are long-term consequences in terms of general mortality rates and how people are feeling? And why hasn’t the FDA recognized what Dr. Bianco has discovered? Mary Shomon 59:58-01:03:02 It’s a good question. And I have to say, I have the most incredible respect for Dr. Bianco because he has been out there for decades, really thinking outside the box from the endocrinologist standpoint, because endocrinologists tend to be fairly hidebound. They stick with what they know. They’re slow to change. They’re slow to move into new ways of thinking. I mean, think about how it’s taken decades for the medical establishment to accept that blood sugar levels over 100 are problematic and that we need to watch those because people are on the way to potential type 2 diabetes. It used to be unless your blood sugar was over a certain level, you were fine. Now we know there are gradations on the way to blood sugar problems. And I think it’s the same thing for thyroid. We are just now starting to see the endocrinology community accept that there is a subset of patients who absolutely need the two hormones rather than just the T4 hormone. The understanding was always, oh, patients get T4, their body converts it to T3. Everything’s great. We’re copacetic. Now we do know that there are problems with genetic changes. There are incapacity to convert T4 into T3 that’s built in genetically in some people. And they’re just now starting to say, okay, well, that makes sense. It’s not just a patient preference issue. Well, they’re going to be moving slowly in this direction towards understanding that the T4-T3 combination therapy may in fact be better for the majority of patients. But that said, my philosophy for 30 years has been the best thyroid medication or best thyroid hormone replacement for you is the one that works best and safely for you. And having been in touch with thousands and thousands of patients over the years, I can tell you that there is a patient for every possible permutation and combination where that has been the best choice for them. For some, synthetic is perfect. For others, they need a particular brand of whatever drug they’re taking. Others do better on combinations. Some people need compounded mixtures. Some people like the T4 and T3. Others do well with T4. And we have a small subset that do better with just T3. So safest and best relief of symptoms for you is ultimately the best option for patients. And the key for me is making sure that the medical world makes those options available to us and doesn’t take away options that we may need, at least a subset of us, me included, because I’m a desiccated thyroid patient. I use desiccated thyroid for my hormone replacement. Don’t take away options that work for me and for other thyroid patients. Make sure we have options and let us know what the different pros and cons are of the different options. Terry 01:03:04-01:03:18 Mary, I wonder if you can tell us what you are doing as an activist to see if this action of the FDA, this proposed action, it can be counteracted. Mary Shomon 01:03:19-01:05:17 Well, I have been talking with several of the drug manufacturers, number one, because they are all obviously quite interested in trying to, in some cases, they’re applying for their BLAs, but the biologic license applications for their formulations of natural desiccated thyroid. But that is going to be a lengthy process. Some of them are already in progress, but it’s probably not going to come early enough if the FDA does in fact pull the medication off the market in a few months into the summer of 2026. But what we’re doing is I’m talking with the manufacturers, we’re talking with the patient organizations, other patient advocates, and we’ve got patients reaching out to their representatives, to the FDA itself, writing in, making complaints, talking about and sharing their stories. Because there are patients who have done every possible trial in the world on all of the different options, and natural desiccated thyroid is the only thing that has worked for them. And I’m an advisor with Paloma Health, which is a large medical practice that focuses on hypothyroidism, and our team of doctors have also been reaching out to explain situations, obviously without violating patient confidentiality, but saying, look, I have patients that will not survive if you take natural desiccated thyroid off the market because we’ve tried them on synthetics. We’ve tried them on every option and it doesn’t work for them. So I need this as an available option for some of my patients that rely on it for their very survival. Because for those of us who are hypothyroid, thyroid medication is not an option. We have to have it in order to function for our body to function, all of our organs, tissues, glands, and cells. Terry 01:05:17-01:05:39 Mary, I wonder if you could tell us a story about one or two of those people who are going to be just completely in terrible trouble if the FDA completes its action as proposed and the companies don’t yet have their biologic license in place. Mary Shomon 01:05:40-01:07:32 Absolutely. I’m thinking of one patient that I know who’s also a friend of mine, and she’s in her early 70s. She’s a widow, and she has tried every possible thyroid medication. She got no response taking synthetics. The doctors haven’t really ever figured out why her body would not absorb them. We’re not sure if it was a malabsorption or ingredient allergy or sensitivity. But once she started taking natural thyroid, which was more than 10 years ago, she was able to get her thyroid levels under control. The blood tests showed that the thyroid hormone was getting into her system, which it had not been doing on the Synthroid. It helped relieve depression, fatigue, exhaustion, brain fog, muscle pain, and weakness. And she basically said to me, if they take my natural thyroid away, I think I’m just going to let myself die. She’s that depressed about the concept of having her medication taken away. And I don’t blame her because it took her a long time. She went probably a decade or more trying to find something that worked and was dragging herself along, trying to function on a daily basis, barely. Once she got the natural thyroid, it felt like her life had come back. And she’s like, don’t take my life away from me again. So she’s one of the people I know who has been most active. I think she has called every member of Congress, every one of her representatives multiple times. She’s talked with them multiple times. She has sent letters to everyone at the FDA. She is a one-woman advocacy campaign unto herself because it’s so important to her. It is her life. And so I think she’s a good example of how passionate patients can be when we know that this is something we rely on. We cannot function without it. Joe 01:07:33-01:08:09 Mary, I wonder if you would be kind enough to just run through some of the very confusing numbers that people need to know about when it comes to assessing their thyroid function, because a lot of times they get a lab report. It’s confusing to them. Their doctor may not explain it. So what would you consider, based on all of your research and experience, normal or achievable goals for people who are using a natural thyroid, desiccated thyroid extract so that they feel well? Mary Shomon 01:08:10-01:11:32 Well, typically, we want to look at, I think, four numbers. Most of the physicians that I have worked with over the last 35 years that are really knowledgeable about thyroid will focus in on four particular parameters. They’re going to look at the TSH, which is thyroid stimulating hormone. This is a brain hormone, not a thyroid hormone, but it is a messenger to the thyroid gland telling it to make more or less hormone. We’re going to look really carefully at the free T4 and the free T3. That’s free thyroxine and free triiodothyronine. And there we’re looking at the actual available circulating amounts of thyroid hormone going through the bloodstream. And in many cases, because Hashimoto’s autoimmune thyroiditis is the primary cause of hypothyroidism in the United States, we’re going to look at Hashimoto’s antibodies or thyroid peroxidase antibody levels. And so that set of four tests is really the basics. And for most people that are dealing with autoimmune Hashimoto’s or hypothyroidism, that’s going to cover most of the bases. We’re looking for a TSH that is going to be in the reference range. And the reference range, depending on the lab, typically runs from about 0.3 to 4 or 4.5, but with the understanding that the majority of the population is not walking around with a TSH at the high end of that range. Most people feel best when it’s under 2.5 or under 2. The free T4 and the free T3, those are usually, we want to see those levels in the middle point or maybe a little bit higher of the reference range. But the free T4 can sometimes be a little bit lower in some people, the free T3 a little bit higher when they’re taking a natural desiccated thyroid because it does contain some extra T3 in it. So that helps to bump those T3 levels up a little bit. And then the thyroid peroxidase antibodies or TPO antibodies, we typically are looking for those ideally to be in the reference range, which means there’s no active autoimmune disease, or if they’re elevated, we want to be watching them so that any dietary medication, thyroid treatment, lifestyle changes are bringing them down slowly and to a lower level. I think the cutoff, it depends on the lab, but cutoff is like 32, 35. Anything above that is considered active evidence of thyroid antibodies. But as they creep up towards that cutoff point, that can sometimes be the indications that autoimmune activity is already starting to take place. So there’s this concept of the reference range or the normal range, but what most of the really savvy practitioners are using is what they consider the optimal range. So that would be the lower end of the reference range for TSH and the midpoint to the upper end of the range for the free T4 and free T3. And again, with antibodies, getting them down as low as possible. Joe 01:11:32-01:11:41 And what would those free T3, free T4 levels be in general to be on the optimal side? Mary Shomon 01:11:42-01:13:03 Well, it depends on the lab that you go to, but let’s see. I believe that free T4, if I’m remembering correctly, runs about 0.8 to like 2.2 at many range. That’s many labs have a range of that. And we’d like to see that like at about the midpoint there. But typically with people taking natural desiccated thyroid, you would see levels maybe in the 1.2, 1.3 level. And with the free T3 levels, typically there we, I believe they run from like 2.2 to 4.3, give or take, depending on the lab. And there, a lot of people are walking around with 2.4, 2.5. They’re at the very low end of the range and they don’t feel well. The people that feel the best tend to be 3.2, 3.3, 3.4, up in the upper half of the reference range, up to maybe about the 75th percentile. Too high of free T3, and you can start to feel like you’ve had too many espressos, and you can get jittery, you can feel nervous, your heart rate can go up, which is a sign that maybe there’s too much T3 on board. So we want people to be at a place where their T3 is good, but not that they’re getting over-medicated to a point where they’re feeling overstimulated. Joe 01:13:04-01:13:14 And just to remind people, what are some of the most common symptoms of hypothyroidism, the people that you serve most frequently? Mary Shomon 01:13:15-01:15:28 The most common symptoms are fatigue. And when we say fatigue, we’re not talking about, oh, I’ve had a busy day. I’m a little bit tired. We’re talking about having to go sleep in your car for 30 minutes at lunchtime to get through the rest of the day or having to have a nap when you come home because you can’t get up to make dinner. Uh, we’re talking about people that sleep 15 hours on the Saturdays, uh, mornings in order to get back to some level of energy after a busy week. This is bone numbing fatigue for many people. Uh, we also see brain fog, cognitive changes, difficulty remembering things, wondering, oh my gosh, do I have Alzheimer? Why am I having so much trouble remembering a particular word or a particular thing? People often see some weight gain, especially if there’s no change to diet and exercise like I did when I was first diagnosed. Just no change, but all of a sudden gaining weight. People will also have dry skin. They can lose hair. They can often lose, one of the most characteristic signs is the outer edge of the eyebrows will disappear, and they’ll have to be penciling it in. I always say to women, if you’re penciling in your eyebrows, I want you to get your thyroid checked. Dry skin, constipation, feeling depressed, sometimes anxiety. People can have a lot of, their nails can break. Their nails become brittle, dry. They don’t grow, they break. And this is just the tip of the iceberg. There are dozens and dozens of other signs and symptoms. For younger women, we can see fertility issues, menstrual changes. For women going into perimenopause, we can see issues with worsening perimenopausal symptoms. There’s a whole range of different types of symptoms. For men, we can see low libido and women too, but low libido is often a complaint in men along with hair loss. So there’s a whole range. It’s essentially anything that slows down your thinking, your processing, your organs, tissues, glands, and cells can be a symptom of hypothyroidism because [the thyroid hormone] is helping to provide energy to all of those components of your physiology. Joe 01:15:28-01:15:49 I’m wondering, Mary, if people will be able to access natural thyroid from Canada once the ban goes into effect. A lot of people do buy their medications from Canada online, and the FDA hasn’t prevented that. But in this case, what are you hearing? Mary Shomon 01:15:51-01:18:23 Well, what I’m hearing is that there is a lot of confusion about it, but that because in the past, it was that the Canadian drugs were allowed to come in, the Canadian natural thyroid was allowed to be imported for personal use. I believe that is the language that the cross-border medication issue was you can’t bring in giant volumes and truckloads of it, but you can bring in enough for your personal use and you can get it in Canada with a prescription. But now that it is going to be designated as a biologic, unapproved, non-approved natural desiccated thyroid will technically be illegal. And so I’ve heard that there may be a crackdown on trying to import Canadian or potentially natural thyroid from other countries that might potentially try to fill the gap. So it’s really up in the air. And that’s part of the big problem with this entire issue is what are they going to do? Are they going to enforce it in 2026? Are they going to let it slide? Are they going to keep us from importing meds from outside or from Canada? Or are they going to crack down and say, no, nope, or maybe say, yeah, we’ll let you do it until things change. It’s really a question mark. And the question mark also goes into the motivations of the government, because we know that we have a new HHS secretary that’s focused on more natural approaches to things, a little bit of a battle with the drug companies to some extent that we’re seeing between the FDA and the HHS and the pharma industry. And so I’ve heard some patients say, I don’t understand this. I thought they would like a natural, inexpensive drug that seems to work pretty well for us for over 100 years. Now they’re putting it in for this biologic status. And frankly, that’s one of the other concerns I have is how much is it going to cost? Because biologic drugs in general are extremely expensive. These are the ones we see advertised on TV all the time. The Humira and Stellara and all these drugs that sometimes can cost thousands of dollars a month. How much is natural desiccated thyroid, which most of us can get for $30, $40, $50 a month, how much is it going to cost once it’s gone through this big approval and becomes a biologic drug? Who knows? It could be many times the price that we’re paying now, or potentially it may be priced out to a point where it’s unaffordable for most people. Joe 1:18:23-1:18:23 Right. Terry 01:18:24-01:18:32 Mary Shoman, thank you so much for talking with us on The People’s Pharmacy today and for leading the charge. Mary Shomon 01:18:32-01:18:40 Thank you so much and appreciate getting the word out because patients need to be informed in order to feel well and live well. Terry 01:18:41-01:18:56 You’ve been listening to patient advocate Mary Shoman. She’s the author of “The Thyroid Diet” and 10 other books. She’s also a Paloma Health Advisor. You can find her newsletter: Sticking Out Our Necks: Hormonal Health News on Substack. Joe 01:18:56-01:19:16 We spoke earlier with Dr. Antonio Bianco, Senior Vice President of Health Affairs and Dean of the John Sealy School of Medicine at the University of Texas Medical Branch at Galveston. He’s the author of “Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do.” Terry 01:19:16-01:19:25 Lyn Siegel produced today’s show, Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 01:19:26-01:19:33 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Terry 01:19:33-01:19:51 Today’s show is number 1,452. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You could also reach us through email, radio at peoplespharmacy.com. Joe 01:19:52-01:20:09 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. The podcast this week has additional information we couldn’t squeeze into the broadcast with updates on Dr. Bianco’s latest research showing that people on natural thyroid live longer. Terry 01:20:10-01:20:33 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also get regular access to information about our weekly podcast. We’d be grateful if you would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you use. Joe 01:20:34-01:20:36 In Durham, North Carolina, I’m Joe Graedon. Terry 01:20:36-01:21:12 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:21:12-01:21:22 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:21:22-01:21:27 All you have to do is go to peoplespharmacy.com/donate. Joe 01:21:27-01:21:40 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

For decades, neurologists and pharmaceutical firms have been focused on amyloid plaque building up in the brains as the cause of Alzheimer disease. Drug companies have developed compounds to remove that plaque, and they have been successful. There are medicines, notably lecanemab and donanemab, that reduce the amount of amyloid plaque visible on a scan. They may also slow the rate of cognitive decline somewhat.  But they may not make a substantial difference in problems patients and their families care most about–confusion, memory loss, difficulty making decisions. Is it time for us to start rethinking dementia? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Nov. 8, 2025, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on November 10, 2025. How Should We Be Rethinking Dementia? America is aging. Baby boomers, who make up a disproportionately large segment of the population, will soon be turning 80. That could be bad news as we imagine an enormous number of people disabled by dementia. There is a silver lining to that cloud, though. Compared to individuals born in the 1920s and 1930s, those born in the 1940s and 1950s have a lower risk overall of Alzheimer disease and other types of dementia (JAMA, May 13, 2025). Are there steps we can all take to reduce our risk of dementia even further? The Disappointing Results of Plaque-Removing Drugs: As we mentioned above, the FDA approved lecanemab (Leqembi) and donanemab (Kisunla) to treat Alzheimer disease (AD) because they reduce plaque in the brain. Family members may have had high hopes, but the only impact these drugs have on cognition is a slight slowing of the inexorable decline. They are, moreover, quite pricey and the scans to monitor potentially serious side effects are also expensive. Some people on these meds experience brain swelling or hemorrhage. Over the long term, they may be associated with whole brain shrinkage, although they seem to spare the hippocampus, known as the memory center. None of those reactions is desirable What Else Can We Do to Reduce Our Risk of AD? One approach we might consider as we start rethinking dementia is low-dose lithium. Lithium has long been used to treat bipolar disorder, but the doses used are large and can trigger adverse consequences, especially for kidney function. New research has shown that people with mild cognitive impairment, a possible precursor to AD, have low levels of lithium in their brains (Nature, Sep. 2025).  Studies in mice show that low lithium levels seem to lead to amyloid plaque and tau accumulation. These are signatures of Alzheimer disease. Can we prevent or reverse this with low-dose lithium, using a nontoxic formulation? That remains to be tested in a randomized clinical trial. Dr. Doraiswamy emphasizes that no one should be taking lithium, even at low doses, outside the context of a controlled study. Don’t try this at home. Rethinking Dementia May Mean Vaccines: An impressive body of epidemiological evidence links vaccination against influenza or shingles to a reduced risk for dementia. A natural experiment in Wales (Nature, May 2025) and another in Australia (JAMA, June 17, 2025) have confirmed the causal connection. Vaccination against shingles significantly reduces the chance of developing AD later. However, results from a trial of an antiviral medication were presented at a recent conference. Unfortunately, the medicine was not effective in preventing AD. Consequently, this strategy may not be as promising as we would like. People who get multiple vaccinations against the flu get a measure of protection from dementia, however (Age and Ageing, July 1, 2025). Another natural experiment in East and West Germany demonstrated that the BCG vaccine against tuberculosis unexpectedly led to “lower incidence of lymphomas and acute lymphoblastic leukemia in cohorts immunized by BCG compared to those non-immunized by this vaccine” (Frontiers in Pediatrics, July 31, 2025). There is also tantalizing evidence that people treated with BCG for bladder cancer are less likely to develop AD (PLoS One, Nov. 7, 2019). What Is Amyloid Plaque Doing in the Brain? Right from the start in 1906, when Dr. Alois Alzheimer described the condition, he flagged amyloid plaque in the brain as a distinctive feature. No wonder people thought of it as the cause of the disease. More recently, though, scientists have been rethinking dementia. They have found that beta amyloid has antimicrobial activity. Might the buildup of plaque indicate an infectious process? We still don’t know for sure, but it seems possible. Rethinking Dementia and Diet: Until now, scientists studying AD have paid very little attention to specific components of diet. They did not have much evidence that what we eat affects our risk for cognitive decline. There have been only a few large randomized clinical trials of diet. A recent trial of the MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay [MIND] diet) was disappointing. So far, none has lasted long enough to tell whether dietary changes in midlife might help prevent dementia. That said, Dr. Doraiswamy suggests that the Mediterranean diet has some supporting evidence. After all, what is good for the heart is also good for the brain. Physical Activity and the Risk of Dementia: There is some evidence that aerobic exercise can help reduce your chance of an AD diagnosis. Recent research shows that people who consistently rack up 5,000 to 7,500 steps a day are much less likely to develop dementia than those who are sedentary (Nature Medicine, Nov. 3, 2025). Likewise, those who habitually walk at least 15 minutes at a time during the day appear to be somewhat protected from cognitive decline. These results are from observational studies, however. Randomized clinical trials of movement to reduce the chance of dementia have not found benefits for memory. Executive function may improve, though. Dr. Doraiswamy cautions, in addition, that we should avoid sports that increase the risk for concussion or head trauma such as boxing, mixed martial arts, football or even soccer. He generally recommends walking for seniors because it offers aerobic physical activity with minimal risk of head injury. In fact, he suggests a walking book club would be ideal. Not only do you get the body in motion, you engage the brain and practice social connection. All of these can be helpful in keeping our brains in shape. Dr. Doraiswamy’s research shows solving crossword puzzles can improve their cognitive function over the course of more than a year (International Journal of Clinical Trials, April-June 2025). This could be an enjoyable approach to rethinking dementia and its prevention. Are There Drugs We Should Avoid? Certain medications work by interfering with acetylcholine, a crucial neurochemical. Such anticholinergic drugs, such as many urologists prescribe to treat overactive bladder, can impair cognition. One extremely common and potent anticholinergic is readily available without a prescription. Millions of seniors take it every night in the form of Tylenol PM, Advil PM or some other PM pain reliever. Diphenhydramine (Benadryl) makes people feel sleepy, so people often swallow it thinking that getting a good night’s sleep will help them stay sharp. Everyone concerned about preventing dementia should check with prescribers and pharmacists about all the drugs they take, including OTC pills. Reducing the anticholinergic burden is an important step toward protecting the brain. This Week’s Guest: Murali Doraiswamy, MBBS, FRCP, is Professor of Psychiatry and Behavioral Sciences. He is Director of the Neurocognitive Disorders Program in the Department of Psychiatry  and a Professor in Medicine at Duke University Medical School. He is a faculty network member of the Duke Institute for Brain Sciences. P. Murali Doraiswamy, MBBS, FRCP, Duke University Listen to the Podcast: The podcast of this program will be available Monday, Nov. 10, 2025, after broadcast on Nov. 8. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1451: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. The CDC says nearly 7 million people in the U.S. currently have Alzheimer’s disease. How can we prevent it? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:44 Medications the FDA approved in the last few years have been disappointing. They are pricey, risky, and not very effective against Alzheimer’s disease. Joe 00:45-00:52 What else can we do to lower our chances of developing dementia? How could low-dose lithium be helpful? Terry 00:53-01:02 Could a vaccine against shingles help delay cognitive decline? What about diet and exercise? How many steps do we need every day to keep our brains healthy? Joe 01:03-01:10 Coming up on The People’s Pharmacy, Rethinking dementia: Is what we believe all wrong? Terry 01:14-02:42 In The People’s Pharmacy health headlines, scientists have long suspected that physical activity might help reduce the risk for dementia. Now they have proof, and it doesn’t take that much effort. A study published in Nature Medicine followed nearly 300 older Americans for almost 14 years. None of them had measurable cognitive problems at the start of the study. They wore pedometers to measure the number of steps they took. All the participants took tests to assess their problem-solving skills and memory at several points during the study. The researchers also scanned their brains to evaluate their levels of amyloid and tau. Over the course of the study, people who took at least 5,000 steps a day were significantly less likely than sedentary seniors to develop Alzheimer’s disease. People with relatively high levels of amyloid at the outset benefited most, but not because amyloid levels changed. Instead, more active people had significantly less tau accumulation, accounting for the benefits seen. Aiming for 5,000 to 7,500 steps daily is something most older people can manage to reduce their chance of cognitive and functional decline. According to the researchers, that level of activity slowed cognitive decline by the equivalent of seven years. Joe 02:43-03:33 Exercise may also be beneficial for people with knee osteoarthritis. According to the CDC, over 30 million Americans have some degree of pain, stiffness, and swelling in their joints. Nearly half have some discomfort in their knees. A systematic review in the BMJ analyzed over 200 studies and concluded that in patients with knee osteoarthritis, aerobic exercise is likely the most beneficial exercise modality for improving pain, function, gait performance, and quality of life with moderate certainty. The authors go on to specify that patients should engage regularly in structured aerobic activities such as walking, cycling, or swimming to optimize symptom management. Terry 03:34-04:23 Many people take melatonin as a supplement to help them sleep. This hormone, which is available without a prescription, has been widely seen as innocuous, even if it doesn’t ward off insomnia. Now researchers are taking a new look at the supplement. An analysis of health records from several different countries identified some 65,000 people taking melatonin for at least a year. In a span of five years, 3,000 melatonin users were diagnosed with heart failure. That comes to about 4.6%, compared to 2.7% of non-users. The findings have been presented at the American Heart Association scientific sessions and have not been published in a peer-reviewed journal. Joe 04:24-05:09 Treating diabetes with a GLP-1 agonist seems to protect the heart. Previous research has found benefit with the use of injectable semaglutide sold under the brand names Ozempic and Wegovy. A new study demonstrates that the same semaglutide in pill form sold under the brand name Rybelsus also prevents cardiovascular complications. A sub-analysis of the SELECT trial found that the benefits of semaglutide do not depend upon weight loss. Even people who did not lose significant weight had lower risks of heart attacks and strokes. A decrease in weight size, however, was associated with the protective cardiovascular effect. Terry 05:10-06:17 Researchers have been considering how to keep people with prediabetes from developing the full-blown metabolic disorder. In a new study published in JAMA, investigators assigned over 300 participants to either an artificial intelligence-powered diabetes prevention program or a human-coach-led similar prevention program. The AI-powered invention involved a mobile app and a Bluetooth-powered digital scale. The goal was to get the volunteers to HbA1c below 6.5%. Roughly 32% of the participants in each group achieved the goal. The researchers concluded no significant difference between the two programs. And that’s the health news from the People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:31 And I’m Joe Graedon. As America ages, people worry about their health. Of course, they think of heart disease and cancer, the two biggest killers, but many people are even more afraid of dementia. Terry 06:31-06:54 Today, we’re discussing how we can treat or possibly even prevent memory loss. What should we know about the drugs that FDA has recently approved to clear amyloid plaque out of our brains? Are there non-drug approaches that might reduce our risk for dementia in the first place? Is what we believed about Alzheimer’s wrong? Joe 06:54-07:23 Our guest today is an outstanding researcher in the field of cognitive decline. Dr. Murali Doraiswamy is professor of psychiatry and behavioral sciences. He’s the director of the Neurocognitive Disorders Program and a professor in medicine at Duke University Medical School. He’s a member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is a senior fellow of the Center for the Study of Aging and Human Development. Terry 07:24-07:28 Welcome back to The People’s Pharmacy, Dr. Murali Doraiswamy. Dr. Murali Doraiswamy 07:29-07:30 Thank you. Pleasure to be here always. Joe 07:31-08:01 Dr. Doraiswamy, I have to tell you, you are a specialist in the brain, especially neurocognitive disorders, whatever that means. But basically, you’re trying to figure out, A, what causes dementia and then what to do about it. But before we get into that really important subject, I would love to get your sense of how serious is this problem? It seems like America is getting older fast. Dr. Murali Doraiswamy 08:01-08:02 Absolutely. Joe 08:02-08:04 What does that mean for society? Dr. Murali Doraiswamy 08:05-08:57 Well, it’s not good news. As we get older, the risk for dementia disproportionately increases, so there’s fears of what we call a silver tsunami. So the original projections were that the number of cases of dementia, which is somewhere around 6 to 7 million today, might triple over the next 20, 25 years. But there’s a sliver of good news. We recently pointed out that there was an error in the projections. With consecutive birth cohorts, we’re getting healthier. Our cardiovascular risks are declining. Some of our risks for Alzheimer’s are also declining, but new risks may be emerging, such as obesity, diabetes, etc. But we believe the rate of increase over the next 20, 25 years is not going to be as high as feared, but it’s still going to go up. So we have to be very, very vigilant and invest in research. Terry 08:57-09:05 So it goes up in part just because there are so many more older people as the baby boomer moves into its 80s. Dr. Murali Doraiswamy 09:05-09:06 Correct. Terry 09:05-09:08 And later, even more. Dr. Murali Doraiswamy 09:08-09:09 Correct. Terry 09:09-09:16 But we baby boomers are not quite as likely as our parents or our grandparents were to develop dementia. Dr. Murali Doraiswamy 09:17-09:28 Absolutely. I think the risk for those born, like, say, in the 1920s or 30s was far higher than the risk for those born, say, 10, 20 years later for a variety of reasons. Joe 09:29-09:47 Now, Dr. Doraiswamy, the drug companies have seen a pot of gold. I mean, when you talk about 7, 10, 15 million Americans with this devastating condition called dementia, they go, well, let’s get some new drugs out there. Terry 09:48-09:49 We’re all for that, right? Joe 09:50-09:51 Absolutely. Dr. Murali Doraiswamy 09:51-09:52 100% We need it. Joe 09:51-10:09 We’re desperate, desperate for something that really, really works. They’ve been all in on amyloid: amyloid being the cause, and if we could just get amyloid out of the brain, problem solved. It hasn’t worked that way, has it? Dr. Murali Doraiswamy 10:09-10:31 It hasn’t, unfortunately. Probably about 30 to 40 failed trials. And for the first time, we have two drugs that were efficacious in clinical trials, but the degree of benefit is extremely small, and they come with a lot of risks. So we still haven’t achieved drugs that are highly efficacious and safe. Terry 10:31-10:38 So let’s talk a little bit more about these medications. They are effective at removing amyloid plaque from the brain, correct? Dr. Murali Doraiswamy 10:38-10:55 Correct. Very effective. Almost 70, 80, 90% clearance to the point where some people’s brains are free of amyloid. Technically, if you base it on the definition that you have to have amyloid to have Alzheimer’s, they would have essentially have been cured of Alzheimer’s pathologically, but nothing has improved in their cognition. Terry 10:56-11:00 So their brains are beautiful, but they’re still demented. Dr. Murali Doraiswamy 11:00-11:00 Correct. Terry 11:01-11:08 They still can’t do the things that ordinary people can and want to do. Dr. Murali Doraiswamy 11:08-11:35 Absolutely. So there are two ways of interpreting this. The skeptic would say this flatly disproves the amyloid hypothesis because if you cannot show that removing amyloid produces an improvement in cognition or slows the degeneration of the brain or slows the deterioration of cognition, then the hypothesis is wrong. But those who support the hypothesis say, oh, we’re giving these drugs too late. Had we given the drugs a lot earlier before the brain had been damaged, we might have seen a greater benefit. Terry 11:37-11:43 Now, there was a trial, wasn’t there, in which they gave, which one? Donanemab? Lecanemab? Joe 11:44-11:55 Well, it was one of the MABs, and they said, even before people really have symptoms, they’re just at potential risk, we’re going to start giving the drug early, early. Terry 11:56-11:57 And it was a big disappointment. Dr. Murali Doraiswamy 11:58-11:59 Yes, it was. Joe 12:00-12:14 So at the moment, let’s just say that the amyloid hypothesis hasn’t panned out the way we would have hoped if these drugs worked. What about side effects? Because the FDA has now issued some new cautions. Dr. Murali Doraiswamy 12:16-13:25 So the amyloid drugs have some very serious side effects. For the vast majority of people, fortunately, our tolerance levels are high. So they may just have infusion reactions. These drugs are given by infusion. We just reported a case that’s coming out this week on somebody who had severe urinary incontinence, almost permanent urinary incontinence as a result of one of these infusions. The most serious side effects are fortunately somewhat rare, even though we don’t know the exact rate at which they occur. The two most serious side effects are bleeding in the brain. They either take the form of what we call macrohemorrhages, means overt strokes, leading to serious clinical symptoms, or microhemorrhages, meaning small ditzels in the brain, which are areas of like ruptured blood vessels. We don’t exactly know what the consequences are. They may have cognitive symptoms, but in many of these people, they’re silent because we’re not testing them serially. And then the second type of side effect is called edema or swelling of the brain. And there have been several deaths. The FDA recently tightened the warnings because of six deaths. Terry 13:25-13:27 How did they tighten the warnings? Dr. Murali Doraiswamy 13:27-14:07 They require more frequent MRI scans to monitor the brain and at earlier time points to see if someone’s having these areas of small bleeding or edema. And if you spot those, then you’re supposed to either lower the dose, stop the dose temporarily till the person gets better. But the reality is we don’t know what to do. We don’t know when a bleed has totally gone away because the MRI only picks up like really, it’s a very crude indicator of if the brain has fully recovered from a bleed. And in many of these cases, probably the prudent thing to do is to stop their infusions and not treat them. We don’t have a good way of also predicting who is going to get it. That’s the other thing we’re shooting in the dark. Joe 14:07-14:27 These are pricey drugs. They cost twenty-some-thousand dollars, but the scans are also expensive. So these PET scans, which have to be done before you start treatment, and now the FDA is saying during treatment just to make sure something bad isn’t happening, the costs start to really add up. Dr. Murali Doraiswamy 14:27-14:44 Well, the costs definitely add up. Just to clarify, yes, the PET scans only need to be done before treatment to ensure that they have plaque buildup in the brain. The monitoring for bleeding is done using regular MRI scans. They’re not done using PET scans. Joe 14:44-14:45 But MRIs are not cheap. Dr. Murali Doraiswamy 14:45-14:51 They’re not cheap, and the average person has to have four, five, six MRI scans. That adds up quite dramatically. Joe 14:52-15:17 So let’s switch gears for a moment because clearly the anti-amyloid drugs have not been a revolution, and they do have side effects. There have been some new studies that are quite fascinating. And I know that you have been looking at lithium, not just for a few weeks or months or years, but going way back. Tell us what is lithium and why are you paying attention to this mineral? Dr. Murali Doraiswamy 15:18-16:40 Yeah. So, you know, lithium is absolutely fascinating. And, you know, America’s fascination with lithium goes back almost 80, 90 years, I think. So lithium, you know, for people who don’t know, is a metal, and it’s a very soft metal, like cheese that can be cut. It’s found in almost every body tissue. It’s found in rocks. It’s found in lots of water sources. Many of us are consuming large amounts of lithium without even knowing it. In fact, I just read an article that in Chile, South America, which is a very rich source of lithium batteries, everyone’s fighting for lithium batteries from there. The average person gets almost five or six times more lithium than, say, the average American. Almost at sub-therapeutic medical doses, that’s what that person in Chile is getting. So fascination with lithium started around 1940s when it was discovered that lithium can calm the brain and can be a useful treatment for people with manic depression, especially people who are very euphoric, very agitated, are hallucinating. It can calm them down. It was completely accidental discovery. And then America went crazy for lithium, and they started putting it in every soft drink imaginable. That’s how 7-Up came about, because one of the isotopes of lithium exists. 7-Lithium is the molecular isotope, and so 7-Up is lithiated lime soda. Joe 16:40-16:41 But no more. Dr. Murali Doraiswamy 16:42-16:57 No more. Well, yes, more, because every water contains lithium. So, yes, it just has very small amounts, but not the slightly bigger amounts that it used to contain. Coca-Cola used to have, there was a version of Coke that had lithium, and doctors used to prescribe it for all kinds of conditions. Joe 16:57-17:01 So, Coca-Cola had cocaine and lithium? Dr. Murali Doraiswamy 17:01-17:13 Well, okay, I don’t know about the, let’s skip the cocaine part. There was a version of cola with lithium marketed by that company. It was not called Coca-Cola, but it was a lithiated cola. Joe 17:15-17:32 So we’ve had a lot of experience. We just have about 30 seconds before we go to the break. There certainly is a lot of data to suggest that very high doses can be extremely helpful for people with manic depression, or what we now call bipolar disorder. Terry 17:32-17:33 But also toxic. Joe 17:34-17:55 Lots of side effects. And you can tell us more about those in a moment. Kidneys can be affected, a number of other organs. But low-dose lithium, that’s where all the excitement is right now. And when we come back from the break, let’s talk about the newest research. I think it was published in Nature, is that right? Dr. Murali Doraiswamy 17:55-17:56 Correct. Joe 17:56-18:00 Looking very promising, at least in an animal model. Terry 18:01-18:11 You’re listening to Dr. Murali Doraiswamy, Professor of Psychiatry and Director of the Neurocognitive Disorders Program at Duke University School of Medicine. Joe 18:11-18:19 After the break, we’ll learn more about lithium and its application against dementia. What are low doses of lithium compared to standard doses? Terry 18:20-18:24 We’ve just alluded to a study published in Nature. Why are people so excited about it? Joe 18:25-18:33 Is it a good idea for people to start taking low-dose lithium as a supplement, or do we need to wait for more definitive studies? Terry 18:39-18:55 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 18:55-19:12 And I’m Joe Graedon. Terry 19:12-19:27 Today, our topic is dementia. How can you reduce your risk of losing your memory? What can we do to keep our brains as healthy as possible as we age? Are there supplements that could be helpful or perhaps dietary choices? Joe 19:28-20:00 To learn more about preventing and treating Alzheimer’s disease and other dementias, we’re talking with Dr. Murali Doraiswamy. He’s professor of psychiatry and behavioral sciences. He’s director of the Neurocognitive Disorders Program and is a professor in medicine at Duke University School of Medicine. He’s a member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is a senior fellow of the Center for the Study of Aging and Human Development. Terry 20:01-20:13 Dr. Doraiswamy, we were just discussing lithium, and I’m hoping that you’ll be able to tell us about low-dose lithium and why it might be of interest against dementia. Dr. Murali Doraiswamy 20:14-20:44 Low-dose lithium has been of great interest to researchers because observational studies, what we call as epidemiological studies, have shown that people who live around certain water sources that contain naturally high levels of lithium have reduced rates of suicide, reduced rates of drug abuse, and even potentially reduced rates of dementia. So these suggest that it might have therapeutic effects at sub-threshold doses, not the high doses we use to treat bipolar depression. Joe 20:44-20:55 And let’s get some sense because as a psychiatrist, you are prescribing big doses. What do we mean when we say big for people who have bipolar disorder? Dr. Murali Doraiswamy 20:56-21:29 So, lihtium as lithium carbonate is usually given two or three times a day. So, we might give somebody 900 milligrams, 1,200 milligrams a day. So, a lower dose may be something a fifth of that or even lower. One of the problems has been that these forms of lithium that we use to treat psychiatric illness don’t get into the body and the brain. They’re not as bioabsorbable. So we needed different formulations of lithium that are more easily absorbed at lower doses so that they also don’t produce the same side effects. Joe 21:29-21:36 So tell us about this study in Nature and why people have gotten very excited. Dr. Murali Doraiswamy 21:36-22:43 So we’ve known about the links between metals in the brain and dementia for a long time, right? We originally thought it came from pots and pans. And then in the 90s, there were links between iron, copper, zinc, and Alzheimer’s disease. But more recently, there’s been a lot of excitement about lithium being an essential nutrient in the brain. And these researchers, it was a tour de force, their paper in Nature. They first showed that deficiency of lithium resulted in buildup of Alzheimer type pathology. The second thing they showed was that replacing or correcting that deficiency with a special form of lithium that is available over the counter that can be given in low doses that is easily bio-absorbable reversed some of those deficits. And which form is that? It’s called lithium orotate. And this is available over the counter. It’s, you know, you can give it at maybe like a fifth or a fifth of the dose that you would give and it’s, anyone can buy it, but it’s not recommended, of course, for manic depression. Joe 22:43-22:56 Right. But the side effects presumably would be much lower if you’re only taking, you know, two or three milligrams or five or 10 milligrams compared to 800 milligrams or in some cases even 1800 milligrams. Dr. Murali Doraiswamy 22:56-23:31 Correct. Now, of course, where you’re talking about the dose of elemental lithium, which has to be, which is what you’re talking about, when you eventually combine it as a salt, the dose becomes much higher, even for lithium orotated can be 100 milligrams, for example. So yes, the presumption and the hope is that the side effects are much lower and the tolerability is much greater because you want to treat someone with, say, at risk for dementia, you could be treating them for 10 years, 15 years. So you want a drug that’s really safe for an older person to take. Joe 23:31-23:33 Now, we need clinical trials. Dr. Murali Doraiswamy 23:33-23:33 Correct. Joe 23:34-23:39 Nobody can patent lithium. It’s out there. Who’s going to do the study? Dr. Murali Doraiswamy 23:39-24:10 There are actually companies that have come up with proprietary formulations of synthetic lithium that’s combined with other ingredients. So you can patent those versions. And, of course, if they do the study and the study is successful, somebody may say, well, why not just take the cheap version that’s available for pennies? But so the short answer is, yes, there are studies being done. There’s at least one company I know that has a proprietary formulation. And then government agencies can always fund studies of the generic version of lithium, which I hope that they do. Joe 24:10-24:11 That would be wonderful. Terry 24:11-24:20 It seems that it might be very tempting for people to start taking low-dose lithium on their own, but it sounds as though that might be premature. Dr. Murali Doraiswamy 24:21-24:33 I think it’s completely premature because we have more than 200 drugs to cure Alzheimer’s in mice, but none of them have worked so far, including the amyloid antibodies that are currently on the market. Joe 24:33-24:37 Let’s talk about another area that’s fascinating: vaccines. Terry 24:38-25:03 Well, we have seen a couple of studies now that demonstrate that specifically the shingles vaccine, and it wasn’t the newest shingles vaccine, the Shingrix, but rather the previous iteration, Zostavax, that quite significantly lowered the risk of people coming down with dementia. Can you tell us about that, please? Dr. Murali Doraiswamy 25:03-26:41 Yeah, it’s a very plausible study, and I’m very excited about it. I truly believe that there is an infectious particle that probably underlies dementia, especially Alzheimer’s disease. We know, for example, syphilis can cause a type of dementia. We know HIV, the AIDS virus, can cause a type of dementia. We know herpes encephalitis, which is a type of herpes virus that goes and attacks the memory centers in the brain. So it’s completely plausible that herpes zoster virus may be involved in Alzheimer’s. So this study that was done in the United Kingdom and one in Taiwan, both of which are quite convincing, again, amazing studies. They looked at a whole bunch of different explanations as to why someone getting the Shingrix vaccine had a lower risk for dementia. And they ruled out many of the spurious epiphenomenon type of causes. They were able to show that these people had a lower risk than those who had gotten a previous version of the vaccine, which was not the same, and also people who were unvaccinated. And they showed that they were not due to other explanations, such as simply getting better health care or leading healthier lives. So, I think it’s plausible. It still has to be demonstrated in a randomized controlled trial, but that’s going to prove very difficult because how do you stop someone in a placebo arm for three or four years from not getting a zoster vaccine? It’s possible, but I’m hoping that someone will do such a trial. Joe 26:41-27:20 Now, it’s not just Zoster, as you refer to it. We’re talking here about the virus that causes chicken pox and shingles. But there are some studies that suggest that BCG, which is a really old vaccine, probably one of the very first vaccines ever developed, might be beneficial as well. And there’s just something new that’s come out with RSV vaccine. So give us this sense of infections and dementia and vaccines. It seems like a whole new way of thinking about Alzheimer’s disease and dementia. Dr. Murali Doraiswamy 27:20-29:01 It is. If you look at the pathology in the Alzheimer’s brain, there are two types of pathology, the plaques and tangles. And both seem to propagate in the brain as though they were like infectious particles. The only thing different about Alzheimer’s, unlike, say, tuberculosis, You don’t catch it by standing next to someone and breathing the air that they are breathing or, you know, by having sex with that individual. You don’t catch it. It’s transmitted and propagates internally. We know that brain-specific viruses can hide in nerve cell ganglions for long periods of time and then suddenly get reactivated. We’ve known that about mad cow disease, for example. So could Alzheimer’s be caused by a slow-growing virus like that? It’s entirely possible. Last month at a conference, they just presented the results of a drug against herpes simplex virus, valacyclovir, and that study was negative. It was a randomized trial. There was similar evidence suggesting that people who took valacyclovir may have a lower risk, but in the randomized trial, it did not prove effective. Now, the BCG for bladder cancer, now BCG is used against tuberculosis traditionally, but in this case, it’s infused locally into the bladder to stimulate the immune system to attack cancer cells. And they found that people with bladder cancer who had received BCG had a much lower risk of developing dementia. So again, this is all very promising approaches. I’m hopeful that we can develop a vaccine to stimulate innate immunity to fight a viral etiology. We’re not there yet, but I think that’s where the cure is going to come from. Joe 29:02-29:03 Terry, let’s talk about diet. Terry 29:04-29:05 Well, let’s do it. Dr. Murali Doraiswamy 29:04-29:26 By the way, there is also a rich body of work suggesting that amyloid builds up in the brain and it’s antiviral and antibacterial, that it’s there not so much as the cause of the disease, but as a defense mechanism in the brain. That somehow this defense mechanism goes awry and overreacts and causes a friendly fire. Joe 29:26-29:30 So trying to get rid of amyloid in the long run. Dr. Murali Doraiswamy 29:30-29:31 Might be friendly fire. Joe 29:32-29:37 Right. It might be a mistake. So we’ve been hearing about the Mediterranean diet. Terry 29:38-30:38 Yes. There was a recent study showing that the closer people come to following, these are American people. This is the Health Professionals Follow-Up Study and the Nurses Health Study. So many, many people followed for three decades. And the researchers at Harvard who run this study check in with these people every couple years to say, how’s your health? And by the way, what are you eating? Fill out this very detailed dietary questionnaire for us. So what they have just recently published shows that people who come closest to following a Mediterranean diet, even though they’re living in Boston or Cincinnati or wherever they might happen to be, they’re not in the Mediterranean, they’re here in the U.S., those folks are less likely to be diagnosed with dementia. What can you tell us about diet and dementia? Dr. Murali Doraiswamy 30:38-32:00 Yeah, I’m not surprised by that finding. You know, the old adage, what’s good for the heart is good for the brain is true here for dementia as well. I believe Alzheimer’s and all types of dementias have a very strong vascular contribution. If you have blockages in your blood vessels, you’re much more likely to be diagnosed with dementia and cognitive impairment. So anything you can do to clear atherosclerotic plaques from building up in your blood vessels helps. And the Mediterranean diet has been shown to help in that regard, both in terms of body weight in terms of your risk for diabetes, in terms of your risk for hypertension, in terms of your risk for high cholesterol levels. Now, there is a slight twist there. There are two newer trials. There’s a large randomized trial of something called the MIND diet. The MIND diet is a version of the Mediterranean diet, but also includes components of the DASH diet, which is used to treat hypertension. So it’s kind of a hybrid. That large randomized trial did not find a protective benefit, even though a number of epidemiological studies had shown that. And more recently, an even larger trial called the POINTER study was just published in JAMA last year, and they found that combining the MIND diet with an active social lifestyle and aerobic exercise three or four times a week does help. It adds an extra one to two years of your cognitive longevity. Terry 32:00-32:03 So it can delay the onset of dementia. Joe 32:04-32:14 So let’s talk about exercise because people always ask us, well, what should I do for good health? And the one thing that always seems to stand out is exercise. Dr. Murali Doraiswamy 32:16-33:00 Yes. A little bit of exercise is great, [a] moderate amount. Too much is probably not good. And let me tell you, so the best exercise I recommend for people is a walking book club because you want to exercise your body and your brain. And you want to exercise at a level that, you know, is not stressful for your body. So, you know, the average 75-year-old, I’m not going to encourage them to run on a treadmill and then they slip one day and fall and break their hip or something. And there goes exercise for the next two years. So, yes, aerobic, moderate aerobic activity three to four times a week is very important. But also exercising your brain is equally important through cognitive training. Joe 32:58-33:03 Well, let’s talk about your research and crossword puzzles. Dr. Murali Doraiswamy 33:03-33:04 Yes. Joe 33:04-33:06 Exercising your brain. Dr. Murali Doraiswamy 33:06-34:23 Thank you. So, you know, the old thinking was that the brain in older ages cannot be changed. It doesn’t have neuroplasticity is the term we use to see if the brain can change and grow. And studies have shown that the older brain, the aging brain, retains its capacity to change. So then the question is, what is the best kind of exercise? Should we do these computerized video games where you’re, you know, like paying a monthly subscription and doing, you know, sitting in front of the computer? Or do you do more natural things that you, you know, been doing for a long time, like a hundred-year-old pastime, like crossword puzzles or bridge or, you know, Sudoku or whatever. So we did this randomized trial, and we found that if you already had memory impairment, we’re not talking about normal older people with healthy cognitive abilities. If you already had mild cognitive impairment, then doing something like bridge or crossword puzzles is better than playing video games because a lot of people struggle with the computer. They struggle with learning how these games play, and they’re not technologically savvy. And we found crossword puzzles actually beat those computerized video games. Now we’re doing a second study to see what is the ideal dose of crossword puzzles. Terry 34:23-34:24 Oh, I like it. Dr. Murali Doraiswamy 34:24-34:40 Do we do it four times a week? Do we do it just once a week? Do we do the Monday New York Times, which is easy, or the Thursday New York Times puzzle, which is challenging? So we’re trying to understand, you know, how do we actually scale it so that people don’t quit? Terry 34:40-35:10 Well, I think that’s a very interesting concept because we know that if you want to build muscle. In physical exercise, you need to take it right up to the limit and then keep expanding your limit a little bit. So if you could walk 15 minutes the first day, you might then the next week want to be walking 20 or 25 minutes. Is the same thing hold for cognitive exercise? Dr. Murali Doraiswamy 35:11-35:39 Yes, beautifully put, because you have to personalize it also for each individual, right? Because some people come with an eighth grade education and some people come with a PhD degree. So the crossword puzzle is not the same. How do you design the right words for that individual so that it challenges them and they continue to learn and grow? So that’s why we’re doing it through the computer, where the computer has an algorithm that automatically selects the right words and phrases based on their previous crossword puzzle completion and makes it challenging the next time around. Terry 35:40-35:51 Well, I know my mother loved doing the crossword puzzle, and she hoped that it would keep her from getting dementia. Sadly, she did develop dementia at the end of her life, but she was also quite old. Joe 35:52-36:05 Well, she was in her mid-90s, and she did very well in her early 90s. So maybe it was the crossword puzzles, maybe it was her excellent diet, maybe it was her exercise. It’s a package, isn’t it? Dr. Murali Doraiswamy 36:05-36:05 100%. Joe 36:05-36:09 It’s all these things together not just one single thing. Dr. Murali Doraiswamy 36:05-36:15 Correct, we call it multi-domain intervention. So yes, it’s the package. Terry 36:15-36:40 You’re listening to Dr. Murali Doraiswamy, professor of psychiatry and director of the Neurocognitive Disorders Program at Duke University School of Medicine. He’s a professor in medicine and a faculty network member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is also an affiliate in the Duke Center for Applied Genomics and Precision Medicine. Joe 36:41-36:52 You know, Terry, it’s not just the package. It’s also the genes. And, you know, your dad was not a big crossword puzzle guy, but he lived into his late 90s as well. Terry 36:52-36:55 He did. And for much of that time, his brain was good. Joe 36:56-37:04 We’ve just discussed how exercise benefits the brain. After the break, we’ll find out about exercise that might be bad for our brains. Terry 37:04-37:15 We always think about traumatic brain injury from football or boxing or soccer. But what about less obvious pursuits like tennis or pickleball? Joe 37:15-37:21 There are medications that can be harmful as well. Anticholinergics have been linked with cognitive difficulties. Terry 37:22-37:31 I think that’s why we discourage people from long-term use of PM pain medicines or the antihistamine diphenhydramine, aka Benadryl Joe 37:32-37:34 Do sleeping pills increase the risk of dementia? Terry 37:39-37:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:52-37:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:55-38:14 And I’m Terry Graedon. Joe 38:15-38:47 Recently, a study published in Nature Medicine showed that older people who are more physically active have less cognitive and physical decline. That held even for those who already had amyloid buildup in their brains, apparent on scans. The amount of physical activity wasn’t extreme. People took at least 5,000 steps a day to 7,500 steps. The amyloid in their brains didn’t change, but with that activity, they had less tau accumulation. Terry 38:49-39:05 Walking seems like a pretty safe activity, as long as we can manage it without risking a fall. Some other physical activities may be riskier for the brain. We’ll find out about the dangers of football or soccer, in which there are repeated blows to the head. Joe 39:06-39:23 In addition to non-drug approaches to reducing the likelihood of dementia, we should also look at drugs. In particular, which drugs should we avoid? You might be surprised how many common medications may impact the brain. Terry 39:23-39:49 Our guest is Dr. Murali Doraiswamy, Professor of Psychiatry and Behavioral Sciences. He is Director of the Neurocognitive Disorders Program and a Professor in Medicine at Duke University Medical School. He’s a member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is a Senior Fellow of the Center for the Study of Aging and Human Development. Joe 39:51-40:25 Dr. Doraiswamy, we’ve been talking about the benefits of exercise, among other things, for the brain. But there are some things that might be bad for the brain when it comes to exercise. And I’m thinking about football for younger kids, even with a helmet on. I’m thinking about soccer and heading the ball. I’m thinking about boxing, especially, or any place where you might injure your brain. It just doesn’t seem like such a great idea. What does the science say? Dr. Murali Doraiswamy 40:26-41:40 I think you’re absolutely right, because we don’t have any way to grow new brain cells once the brain’s been damaged, and we don’t convey that information with enough urgency to our children and athletes, frankly. So I would say boxing and mixed martial arts are obviously the most dangerous. It’s a well-known phenomenon called dementia pugilistica, where virtually a very high proportion of boxers end up with either Parkinson’s or some form of dementia later in life. The same, I think, the frequency is not as high with soccer and with American football. But still, people who have had multiple concussions definitely have a higher risk for a type of dementia that’s caused by a traumatic brain injury. And we don’t have a cure or a treatment for it. So 100%, I would recommend wear a helmet. Protect your head. You know, try to avoid high-risk sports. Even bicycling without a helmet, if you press the brake in the wrong place, you can do a cartwheel and fall over and hit your head. So you have to be really careful. And that’s another reason why I recommend walking for seniors. Joe 41:41-41:42 I’m thinking tennis. Dr. Murali Doraiswamy 41:43-42:17 Tennis is fabulous sport. You know, of course, tennis, you can have other kinds of injuries and, you know, but tennis is perfect. I think for a senior pickleball to me, especially if you can move from start with doubles playing, you know, gently and then move to singles and then, you know, maybe move from there to paddle or something like that. Because they’re more likely to engage and persist with it rather than tennis. If you’re starting late in life, it’s really hard. Now, ultramarathons is another. There’s some new findings suggesting that if you do ultramarathons, the shrinkage of the brain. Terry 42:18-42:22 So you’d say don’t do an ultramarathon. Dr. Murali Doraiswamy 42:23-42:39 Well, I mean, do it once in a while. It’s okay. Like it would be like going on a binge drinking episode once. You’ve got to do it in college as a rite of passage maybe to run the New York Marathon. So I’m not telling anyone don’t do it, but don’t do it super regularly because it’s a stressful experience for your body. Joe 42:40-43:13 I’d like to ask you about medications because we’ve talked about some of the medications that have been developed for dealing with Alzheimer’s. They haven’t been very effective, but we have a whole slew of drugs, some of which are available over the counter, that might not be good for the brain. So perhaps you could start with what we call anticholinergics. What are they and why might they be deleterious? Dr. Murali Doraiswamy 43:14-44:29 Sure. You know, anticholinergics are called that because they block the actions of a system in the brain called the cholinergic system. The cholinergic system is highly prevalent throughout the body. In fact, the vagus nerve is called the vagus because it’s a vagabond. It runs throughout the entire body. It controls your memory in your brain. It controls your breathing. It controls your heart. It controls the movement of your intestinal tract. It controls how often you’re constipated or how often you move bowels. It controls the contractions of your muscle, everything, right? So, acetylcholine, the chemical that’s used by this system, is crucial for memory in the brain. And anticholinergic drugs, if they block this chemical, they impact your memory. Many of the older medicines, especially older antidepressants, some of the older, sleeping aids, medicines that are used by a urologist to control frequent urination. All of these can have friendly fire on the brain. And so those are some examples of drugs that we, you know, it’s very hard because as a urologist, you want to give them to help a person with an enlarged prostate. But then as a brain doctor, you want to take people off these drugs to improve their memory. So there’s a constant tug of war. Let’s talk about antihistamines. Joe 44:29-45:28 There is what we call the first generation antihistamines. One of them is chlorpheniramine, but the one that is so popular these days is diphenhydramine. It’s the ingredient in Benadryl. And it has become so popular in all of the over-the-counter PM pain medicines because it makes people drowsy. Anybody who’s taken Benadryl during the day will often complain, yeah, it makes me sluggish. I can’t think as clearly. But now millions of people are taking Advil and Aleve and you name it with diphenhydramine. It’s a low dose, but it’s day in and day out. Because once you get into a sleeping pill cycle, you just take it in case I might not fall asleep tonight. So your thoughts about diphenhydramine? Well, I think you stated it pretty well. Dr. Murali Doraiswamy 45:28-46:23 I think if you use it persistently for long periods of time, it’s going to have deleterious [inaudible]. And whether or not the effects are reversible still are not fully proven. But generally, we believe that with anticholinergic drugs, if you can stop using it, you can reverse the drugs for the most part. You may not get back to where you were. But while you’re taking them, you know, you’re probably performing at 15, 20% lower than what you ought to be. So it could impact your driving, it could impact operating heavy machinery. If you’re taking an exam or a test or mission critical like a pilot, you know, you need to be extremely careful with these drugs. The same may also be true for some over-the-counter, you know, what shall I call it, herbal products that claim to mimic some of these antihistamines. Terry 46:24-46:28 So perhaps you don’t want to be taking an herb that is supposed to put you to sleep. Dr. Murali Doraiswamy 46:29-46:36 Yeah. We don’t know. I mean, it depends on the herb, but yes, some of them, yes. Like Valerian, for example, could potentially do the same thing. Terry 46:38-46:52 And my question is about prescription sleeping pills. I know it’s been controversial. Do they or do they not increase a person’s risk for developing dementia? And perhaps you have some insight on that. Dr. Murali Doraiswamy 46:53-47:55 I don’t have any additional insight. It still remains somewhat controversial and unproven. There’s a big range of sleeping pills, the newer sleeping pills versus the older ones. And of course, some of the antihistamines are used as sleeping pills as well. And some of the antidepressants are used as sleeping pills as well. So I would say, you know, the evidence is mixed. We continue to have to use them because on the one hand, sleep we know is crucial for memory archival. Sleep we know is crucial for immunity. There’s even new evidence suggesting that if you don’t sleep well, then the clearance of some of the toxic products in the brain is impaired through the glymphatic channel. So you want people to sleep well. And we don’t have a great choice. Some of the newer sleeping pills that are more expensive, so people who can’t afford them need to take the older version. So it’s a constant battle. Joe 47:56-48:21 There is a lot of controversy around the benzodiazepines, the benzos, anti-anxiety agents. Also, the proton pump inhibitors, the PPIs that you can now buy over-the-counter, omeprazole, esomeprazole, lansoprazole. And doctors are now prescribing the gabapentinoids, the gabapentin and the pregabalin for pain. Dr. Murali Doraiswamy 48:21-48:22 Correct. Joe 48:23-48:37 We want to caution people, never stop any of these drugs suddenly because it can precipitate something called discontinuation syndrome. That’s the sanitized version. It’s otherwise known as withdrawal. Dr. Murali Doraiswamy 48:38-48:39 Sure. Joe 48:39-48:51 So give us a quick understanding that even though there is a bit of a cloud on some of these drugs when it comes to cognitive function, no one should undertake stopping these drugs because they’re a little concerned. Dr. Murali Doraiswamy 48:51-49:23 Yes, absolutely. Drugs like this should be tapered off. You should talk to your clinician, physician, and gradually taper them off. It’s a little bit like if someone’s been drinking for a long period of time, the chronic alcoholic, we never advise them to go cold turkey. I know we usually have them come in, put them on a regimen of a taper before they go cold turkey. So I think it’s somewhat similar to this because you don’t want your brain to go from one state to another state when it’s dependent on a medicine like abruptly. Joe 49:23-49:26 Now, I will challenge you on that taper problem. Dr. Murali Doraiswamy 49:26-49:26 Yeah. Joe 49:27-49:43 We have been complaining for years that the drug companies haven’t come up with guidance. The FDA hasn’t come up with guidance. And many of the professional organizations haven’t come up with guidance. As everybody says, yes, slow taper. Terry 49:43-49:59 Well, the drug companies have no incentive to help people get off their drugs. FDA, on the other hand, you know, you could argue that it is a public health question, that perhaps they should have done it, but they have not. Joe 49:59-50:27 And the FDA would say, well, it’s not our job. So how does a psychiatrist such as yourself, who is treating a patient with an SSRI-type antidepressant or perhaps a gabapentinoid for some nerve pain or fill in the blank drug, and somebody says, well, yeah, I really would like to stop taking my sertraline. There’s no cookbook. How do you advise them? Dr. Murali Doraiswamy 50:27-51:09 Yeah, it’s a huge gap. Even more fundamental is that physicians need to know what is the half-life of a particular drug before they counsel people on how to taper. And most doctors, because there’s so many drugs now, nobody even remembers. So you almost have to ask AI for how do I taper off this person. That’s the only solution. Somebody has to build an AI chatbot into your electronic health record. So just how I do it, for a drug with a very long half-life, it’ll taper itself out of your body. Because if it has a 30, 40-day half-life, you don’t need to worry as much about a drug as with a short half-life causing abrupt withdrawal symptoms. Terry 51:09-51:19 So that would be, for example, the antidepressant fluoxetine, which is not nearly as difficult to discontinue as a short-acting drug like venlafaxine. Dr. Murali Doraiswamy 51:20-51:30 That’s right. Beautifully put it. I love the way you give these concrete examples. Yes. I think AI is going to take over all of these solutions that the drug companies and FDA don’t want to tackle. Terry 51:32-51:48 Well, what about the potential for AI to help people in your situation who are trying to help people with psychiatric problems or with dementia? What do you see as the role for AI? Dr. Murali Doraiswamy 51:48-52:36 I think it’s going to transform the field. Just in mental health, for example, children. I have seen surveys would say 80-90% of kids would rather talk to a bot rather than a human who is judging them, especially an older human that’s judging them. That’s one. A lot of crises that kids have happen late at night or teens and college students. There’s nobody for them to talk to. And in terms of dementia, you know, I mean, look, people want cognitive testing in the comfort of their home. It’s too intrusive to go to a clinic and have someone poke and prod you and ask questions like this. If you can get tested in the comfort of your home with a reliable evidence-based test, and then it tells you, you know, here’s what you need to do, then people can decide with their family. I think that’s where we’re headed. Joe 52:37-53:01 Dr. Doraiswamy, we are almost out of time. As you look into your crystal ball, what do you see for the future, especially when it comes to Alzheimer’s disease or dementia? What would your hopes be over the next decade or two for better treatments, new ways of thinking, perhaps some kind of a breakthrough? Dr. Murali Doraiswamy 53:03-54:10 Well, I think the first thing I would hope for is there are five or six million people in the U.S. and maybe 30 million people around the world already living with dementia. We shouldn’t ignore these people. Even some of the people who are advanced stages, there’s a human still in there. We need to make sure that we have adequate resources to provide for them, to support their caregiver, to make sure that their lives have high quality. We should not neglect them because a lot of the drug discovery is moving to earlier and earlier and earlier stages, neglecting the later stages. So that’s one. So the human element needs to be brought back in. Second is we need to really set the bar for drug development so that it’s unambiguous. A very high bar for efficacy and a bar for safety so that we don’t have to be doing regular PET scans and MRI scans to monitor people. Ultimately, I think we need more investment from society because it’s a huge problem. I think we’re going to have a combination of drugs, much like cancer and other specialties. I’m not optimistic we’ll find a cure, but I’m hopeful that we’ll have a lot of very, very highly efficacious drugs in the next five to 10 years. Joe 54:10-54:17 And in the one minute we have left, your recommendations for people who want to try and prevent the development of dementia? Dr. Murali Doraiswamy 54:19-54:30 What’s good for the heart is good for the brain. Heart healthy diet, exercise regularly, get seven, eight hours of sleep, be socially and cognitively very active. Terry 54:31-54:38 Dr. Murali Doraiswamy, thank you so much for coming to talk with us today on The People’s Pharmacy. Dr. Murali Doraiswamy 54:38-54:39 You’re welcome. Always a pleasure. Terry 54:40-55:05 You’ve been listening to Dr. Murali Doraiswamy, Professor of Psychiatry and Director of the Neurocognitive Disorders Program at Duke University School of Medicine. He’s a professor in medicine and a faculty network member of the Duke Institute for Brain Sciences. Dr. Doraiswamy is also an affiliate of the Duke Initiative for Science and Society. Joe 55:05-55:14 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 55:15-55:23 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 55:23-55:42 Today’s show is number 1,451. You can find it online at peoplespharmacy.com. At peoplespharmacy.com, you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 55:42-56:16 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. There, you can also find our posts on the week’s health news. We’ve included links to articles that we’ve written about the possible association between some infections and the risk of dementia. Could vaccines against shingles, influenza, or tuberculosis help slow cognitive decline? Might amyloid plaque be part of the brain’s immune defense against infection? Joe 56:17-56:37 You know, Terry, I have been so fascinated with BCG. This is a vaccine that’s over 100 years old, but there was a recent study, sort of an analysis overview from Frontiers in Pediatrics last summer. And it really suggested that BCG might have an important role against some dementias. Terry 56:38-56:40 We’ll put a link to that on the website as well. Joe 56:40-56:55 At peoplespharmacy.com, you can sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. In Durham, North Carolina, I’m Joe Graedon. Terry 56:55-57:28 And I’m Terry Graedon. Thanks for listening. Please join us next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 57:29-57:38 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 57:39-57:43 All you have to do is go to peoplespharmacy.com/donate. Joe 57:43-57:57 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

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

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