The People's Pharmacy

In this episode, we interview the doctor who first identified seasonal affective disorder (back in 1984!) and went on to develop treatments. Even when days are short (but getting longer, little by little) and skies are gray, you don’t have to suffer with a bleak outlook. Find out what you can do to counteract this common but serious problem. At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Feb. 7, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Feb. 9, 2026. One of the most effective treatments for SAD and the similar but less severe winter blues is bright light therapy. Not all sufferers respond to light therapy alone, however. Dr. Rosenthal describes the additional approaches that improve people’s response. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on November 13, 2023. What Is Seasonal Affective Disorder? By now, many people are aware that some individuals have a hard time with short days and long nights. Their appetites and sleep patterns may change, and they may retreat from social activities because they can’t get energized. They have trouble concentrating and may become irritable. It’s as if they get depressed every year at the same time, on cue. Psychiatrists estimate that about 5 percent of the population experiences seasonal affective disorder, or SAD. That could be as many as 10 million Americans. At times, physicians may prescribe antidepressants, but usually the treatment that works best for SAD is light. Evidence suggests that the lack of sunlight, especially when someone feels stressed, is a prime trigger for seasonal affective disorder. Is SAD Linked to Latitude? The further from the equator you get, the more pronounced are seasonal differences in daylight. Think of a place above the Arctic Circle, for example, like Tromsø, Norway. In the summertime, they celebrate the midnight sun. In the winter, however, people in Tromsø see very little daylight. Unless they are uncommonly resilient, they could be susceptible to SAD. Light for Seasonal Affective Disorder: The principal treatment for SAD is light therapy, usually utilizing a light box. This must be a minimum of one foot square and supply at least 10,000 lux. That is the equivalent of being outside on a cloudy day. Generally, the prescription is for 20 to 30 minutes of exposure every morning. People who would rather not use a light box might be able to spend that time outdoors under the dome of the sky. A roof, awning or umbrella would undermine the treatment. Approximately 30 to 40 percent of people with seasonal affective disorder do not respond completely to light therapy. They need additional help beyond light exposure alone. Exercise has been shown to benefit them, especially if it is conducted outside. Cognitive behavior therapy is also extremely helpful, as is meditation. Lastly, people with SAD may want to pull back from their usual social activities. If they can maintain their social connections, this is very therapeutic in the effort to defeat seasonal affective disorder. The Autumn Checklist for Defeating Seasonal Affective Disorder: Those who know that they often experience SAD should get ready before winter. Dr. Rosenthal recommends addressing the following questions: 1. Have I purchased a light box for the winter? 2. Do I have at least one bright, inviting room in my home? 3. Have I made plans for at least one winter vacation in the sun? 4. Should I check in with my doctor since I am entering my season of risk? 5. Have I notified close family members and friends that I may need extra support? 6. Do I have a physical fitness program in place? (It’s easier to keep exercising than to start.) 7. Could I reframe my attitude and look at winter as a challenge instead of an affront? 8. How can I find beauty in the colorful season of autumn, here and now? Although Dr. Rosenthal doesn’t mention it, perhaps noticing signs of spring could instill hope. Our yard in North Carolina has both snowdrops and hellebores blooming in January, reminding us that spring blossoms will start up before too much longer. This Week’s Guest: Norman E. Rosenthal, MD is a psychiatrist and scientist who first described SAD in 1984 and pioneered light therapy as a treatment. Dr. Rosenthal is currently Clinical Professor of Psychiatry at Georgetown University School of Medicine. Dr. Rosenthal is the author of several books, his most recent being Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons His website is https://www.normanrosenthal.com/about/ Dr. Norman E. Rosenthal, author of Defeating SAD Listen to the Podcast: The podcast of this program will be available Monday, November 13, 2023, after broadcast on Nov. 11. You can stream the show from this site and download the podcast for free. Download the mp3.

Inflammation is a double-edged sword. When you have a sudden injury or infection, your body responds by calling immune cells to the site of the problem. It may become red, swollen and painful, but all that is supposed to be part of the healing process. What happens with chronic inflammation is more insidious. Many serious diseases, such as diabetes, depression or heart disease, feed off chronic inflammation. Anti-inflammatory drugs can control the problem temporarily, but they have drawbacks if they must be used continuously. How can we go about calming chronic inflammation without medication? At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Jan. 31, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Feb. 2, 2026. How Inflammation Works: One of the hallmarks of modern life is the impact of stress on the digestive tract. Excess weight, unrelenting stress and environmental toxins can all contribute to an immune system that goes into overdrive. Sometimes the consequence will be an imbalance in the microbiota, with the result that the tight junctions of the gut are disrupted. That can lead to “leaky gut,” more respectably termed “intestinal permeability.” When pathogens or toxins that should be confined to the gastrointestinal tract start circulating elsewhere, the immune system reacts. If the process continues, the consequence is chronic inflammation. Are there natural approaches to calming chronic inflammation? Calming Chronic Inflammation: When we want to help our immune system so that it doesn’t have to be hypervigilant all the time, we should start with our diet. If dysbiosis contributes to leaky gut and inflammation, the best approach might be to feed our gut microbes what they need. In most cases, that means increasing our fiber. Gut microbes thrive on fiber, and most Americans don’t get close to eating enough. Another important aspect, of course, is to avoid foods that might cause trouble. According to Dr. Low Dog, fructose degrades tight junctions in the intestines and could contribute to intestinal permeability and inflammation. To reduce fructose, we just need to cut back on sweets Finding Fiber in our Food: Where can we find fiber in our diet? Starting with breakfast, a lot of folks enjoy cold cereal, pancakes or pastries. There’s not much fiber in any of those, unless you’ve chosen bran cereal. But even a choice as simple as eating an apple with the skin on can provide a good amount of fiber. Do you like salmon for breakfast? That’s a very anti-inflammatory choice. One worrisome development is the spread of microplastics throughout our diet. As a result, most of us have microplastics in our bodies. Some of the compounds in these little particles of plastic are endocrine disruptors that contribute to inflammation. Maintaining Healthy Barriers: The colon is not the only part of the digestive tract that provides an important barrier. The mouth is also susceptible. Brushing, flossing, dental care and a low-sugar diet are important steps to protecting our bodies against chronic inflammation. Periodontal disease contributes in a major way. To maintain good tight junctions, we need to eat about 20 grams of insoluble fiber and 8 grams of soluble fiber daily. Beans and vegetables are great sources of both. Nuts and seeds like sunflower seeds or walnuts are also good sources. So are whole grains. And if we have any trouble reaching our fiber goals with diet, there is nothing wrong with adding a daily dose of psyllium, which is mostly soluble fiber. It lowers cholesterol and can reduce the risk of diabetes as well as promote regularity. Herbs to Ease Inflammation: In addition to paying attention to a high-fiber anti-inflammatory diet, we can benefit by using certain herbs or spices to calm chronic inflammation. Green tea, garlic, onions, hot peppers and other flavorings all have anti-inflammatory power. Turmeric, the yellow spice in curry, is a potent anti-inflammatory. To get the best benefit from adding turmeric to food, it should be used to spice a meal with some fat in it. Black pepper as part of the spice profile also helps with the absorption of compounds from turmeric. Dr. Low Dog cautions us all to vet our turmeric carefully, though. Some brands are high in lead. She suggests that Simply Organic and McCormick are both brands that were relatively free of lead when tested by ConsumerLab.com or Consumer Reports. One supplement that may be unfamiliar to most listeners is nattokinase. It is derived from natto, a fermented soybean dish that is very popular in Japan. People who are taking anticoagulants should probably avoid nattokinase, even though it has anti-inflammatory activity. It could interact with anticoagulants and increase the danger of bleeding. We would add that precaution should also hold for curcumin supplements derived from turmeric. They should not be taken by anyone on an anticoagulant. Other Natural Approaches to Calming Chronic Inflammation: When we asked Dr. Low Dog about her favorite way to calm chronic inflammation, she mentioned walking in nature. High cortisol levels drive chronic inflammation, but green spaces reduce stress and help bring cortisol down. Other marvelous approaches include seeking out ways to embrace contentment and joy and humor. For some people, that will mean meditation. For others, it will mean hanging out with good friends or going for a run. Nourishing our mental and spiritual health with art and poetry help connect us with meaning and purpose in our lives. This Week’s Guest: Tieraona Low Dog, MD, is a founding member of the American Board of Physician Specialties, American Board of Integrative Medicine and the Academy of Women’s Health. She was elected Chair of the US Pharmacopeia Dietary Supplements/Botanicals Expert Committee and was appointed to the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Tieraona Low Dog, MD, author of Fortify Your Life Her books include: Women’s Health in Complementary and Integrative Medicine; Life Is Your Best Medicine and Fortify Your Life: Your Guide to Vitamins, Minerals and More. Dr. Low Dog’s latest is eBook is Healing Heartburn Naturally. Physical copies are available for purchase via Amazon: Click here.
Her websites are drlowdog.com and https://www.medicinelodgeranch.com/ The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, Feb. 2, 2026, after broadcast on Jan. 31 You can stream the show from this site and download the podcast for free. The podcast is supported in part by Superpower.com. For a limited time, our listeners get an additional $20 off with code PPOD. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1460: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:26 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Immune reactions are both helpful and harmful. Immune cells fight infection, but they can also trigger inflammation. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:47 Dr. Tieraona Low Dog is a medical doctor and an expert in botanical medicine. She explains the complexity of the immune system, how it can heal in the short term, and what happens when inflammation persists. Joe 00:48-00:57 Tens of millions of people take non-steroidal, anti-inflammatory drugs every day. Is there a downside to quelling inflammation? Terry 00:58-01:05 Ongoing inflammation is behind many serious diseases, including cancer, diabetes, and heart trouble. Can we address it naturally? Joe 01:05-01:10 Coming up on The People’s Pharmacy, calming inflammation without drugs. Terry 01:14-02:44 In The People’s Pharmacy Health Headlines: Appendicitis, an acute inflammation of the appendix, is a surprisingly common problem, affecting an estimated 7 to 8 percent of people over their lifetimes. Until about 10 years ago, appendicitis was nearly always treated as a surgical emergency. In 2015, scientists published a randomized clinical trial comparing surgery to antibiotic treatment. A large majority of patients who got antibiotics did not require surgery for a recurrence of appendicitis within one to two years after treatment. That study included 273 people undergoing surgery and 257 taking antibiotics. Over the years, some of those who were initially treated with antibiotics did require surgery. Five-year follow-up showed that 39% who got antibiotics later required surgery. Now the same scientists are reporting the results of 10 years of follow-up. They were able to check in with 253 of the original 257 patients. More than half of them did not require surgery. The researchers conclude, among patients initially treated with antibiotics for uncomplicated acute appendicitis, the rate of recurrence in appendectomy at 10-year follow-up supports the use of antibiotics as an option for uncomplicated acute appendicitis in adult patients. Joe 02:44-03:37 High blood pressure contributes to heart attacks, strokes, congestive heart failure, and kidney damage. Accurate measurement is important for diagnosis and treatment. Researchers at Harvard and Brigham and Women’s Hospital in Boston recruited over 3,000 patients with uncontrolled hypertension. All participants were given a free home blood pressure monitor that could send data electronically to the research database. They also received personalized coaching and reminders to monitor blood pressure. One-third failed to take their blood pressure even once, and only about a third managed the 24 to 28 weekly measurements the researchers were hoping for. The authors conclude that the, quote, low engagement rates observed highlight the need for alternative approaches that are more convenient for patients. Terry 03:37-05:02 There are several medications used to treat type 2 diabetes. A new study compares the effects of two different classes with respect to their effects on kidney function. People with diabetes are vulnerable to developing acute kidney disease. Now, Danish researchers have analyzed health records to compare how two classes of diabetes drugs affect the kidneys. The SGLT inhibitors include drugs like empagliflozin, better known by its brand name Jardiance. GLP-1 receptor agonists are medicines like semaglutide, known as Ozempic. The population included people with type 2 diabetes who were taking metformin. When an additional drug was needed, 36,000 plus took one of the gliflozin drugs, while more than 18,000 took a GLP-1. Over five years, 6.7% of those on SGLT-2 drugs developed chronic kidney disease. In comparison, 8.2% of those on GLP-1 drugs had that outcome. The investigators conclude collectively these findings support a lower risk of acute and chronic kidney outcomes with SGLT2I versus GLP-1RA, especially among individuals with a low a priori risk of kidney disease. Joe 05:02-05:58 There was a time, not so long ago, that if you wanted to know if you had the flu, you had to make an appointment with your physician to be tested. That could cost precious time. But now, pharmacies sell over-the-counter flu and COVID tests for rapid detection at home. The FDA has approved another test. The new four-in-one home test called FlowFlex Plus can detect RSV as well as influenza A and B and COVID-19. RSV, an abbreviation for respiratory syncytial virus, is dangerous in babies and young children and accounts for many hospitalizations. This test may be used in infants as young as six months old and could help parents manage this serious infection at the earliest possible stage. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:33 And I’m Joe Graedon. When you hear the word inflammation, what comes to mind? We have frequently been told that inflammation is our enemy. Tens of millions of people take anti-inflammatory drugs every day to overcome pain. Terry 06:33-06:45 But inflammation is an essential process for healing injuries, infections, and other acute problems. It’s part of the immune system’s initial response to a wide range of threats. Joe 06:46-07:29 To find out how inflammation can be both our friend and our enemy, we are talking today to Dr. Tieraona Low Dog. She is a founding member of the American Board of Physicians Specialties, American Board of Integrative Medicine, and the Academy of Women’s Health. She was elected chair of the U.S. Pharmacopeia Dietary Supplements Botanicals Expert Committee and was appointed to the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include: “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Terry 07:30-07:34 Welcome back to The People’s Pharmacy, Dr. Tieraona Low Dog. Dr. Tieraona Low Dog 07:34-07:37 Oh, thank you for having me back. It’s so good to be with you. Joe 07:38-07:48 Well, Dr. Low Dog, you are perhaps the most frequent guest on The People’s Pharmacy and one of the longest. We have been talking to you for so many years. Terry 07:49-07:49 And our favorite. Joe 07:50-07:50 And our favorite. Terry 07:51-07:52 Don’t tell anybody else. Joe 07:52-07:54 But don’t share that information. Dr. Tieraona Low Dog 07:55-07:56 Thank you. Joe 07:56-08:29 So, Dr. Low Dog, we’re going to talk about a couple of things today on The People’s Pharmacy. But we’d like to take advantage of your expertise as both a medical doctor and a natural healer. And we’re going to start with inflammation because it seems to be at the center of so many health problems. First of all, can you tell us when we say inflammation, what are we talking about? And why does it play such an important role both in healing and harming our bodies? Dr. Tieraona Low Dog 08:31-10:39 Oh, you know, the inflammatory response is absolutely crucial for our survival, right? So we’ve recognized sort of the five hallmarks of inflammation for a long time, right? You know, 2000 years ago, they were writing about heat, redness, swelling, pain, and loss of function, right? So those are kind of the five cardinal pieces. And that really was speaking a lot to like an acute inflammatory reaction. So you are out running and you fall down and you skin your knee and you break the skin and it’s kind of bloody and messy and you go home and clean it. Well, if you feel it, it will be warm because you’re bringing more blood flow to the area. It will be red because of the heat and the increased blood flow. Swelling as you’re trying to bring in all your good white blood cells and all of your, you know, warriors to come and clean out any debris, pain and loss of function because we’d like you, you know, to kind of favor that knee for a little bit so that we give the body opportunity to heal it. This inflammatory response is absolutely necessary for cleaning out debris, dead cells, making sure there’s no infection taking place, and also then stimulating, in that case, collagen and wound repair. So a lot of times it’s easiest for people to think about inflammation because everybody’s had a wound and they’ve all experienced that pain and swelling, redness and recovery. I think what a lot of people don’t realize is that you can have similar inflammatory responses that are acute, like when you get a fever, that’s your body’s opportunity, right, to generate heat and activate your white blood cells and fight off infection, and then you get better. But you can also have inflammation that becomes more chronic, and I think that’s something that’s much newer on the scene, this understanding that there can be a low-grade chronic burn going on in the body that is driving a lot of chronic disease. Terry 10:40-11:09 Let’s talk a little bit about some of those chronic diseases, because when we talk to various experts over the years about diabetes or Alzheimer’s disease or arthritis, all kinds of problems that people have, various types of digestive problems, we say, well, what’s behind it? And they say inflammation. So tell us a little bit about chronic inflammation and how it affects the body. Dr. Tieraona Low Dog 11:10-13:15 So, you know, the whole thing with chronic inflammation and the fact that it is the uniting, underpinning root cause of all the conditions you just talked about, the progression of cancers, metabolic diseases, type 2 diabetes, depression, you know, mental health challenges, heart disease. You know, when I went to medical school, heart disease was just cholesterol, right? It’s all cholesterol. And now we know that cardiovascular disease is really a disease of inflammation. So, you know, when we look at these diverse things like depression, pain, periodontal disease, how do those all connect? They connect through this thing we call systemic inflammation. And, you know, today we do so many things that drive that inflammation. We put on weight around the midsection, right? So visceral fat or tummy fat, and I don’t mean the kind you can pinch. I’m talking about the deep fat that develops around our organs, high fructose, high saturated fat diets, that combination pattern, Western diets, not exercising, not moving, prolonged stress, you know, just chronic physiologic or psychosocial stress. And then, of course, environmental exposures, endocrine disrupting chemicals and toxins in the environment. And an area that I have been mostly focused on lately is alterations in the oral and gut microbiota, the bugs that live there, and then leaky gums and leaky gut and how that drives this systemic inflammation. Hippocrates said more than 2,000 years ago that all disease begins in the gut. And if we’re going to think about chronic inflammation, we really have to focus on what’s happening in the mouth and what’s happening in the gut. Joe 13:16-13:26 Well, Dr. Low Dog, I want to talk just a moment about that leaky gut. The gastroenterologists have a very nice terminology for it. Terry 13:26-13:42 Oh, yes. They call it intestinal permeability, which sounds a lot more respectable than leaky gut. Actually, some gastroenterologists laugh at leaky gut, but they don’t laugh at intestinal permeability, which is actually the same thing. Joe 13:42-14:24 And, you know, tens of millions of Americans swallow a non-steroidal anti-inflammatory drug every single day. Maybe it’s for their arthritis or their headache, whatever. And that’s whether it’s Advil or Aleve, that’s to say ibuprofen or naproxen. And these drugs that we just take as if they were, you know, a vitamin can have a profound impact on our digestive tract and can contribute a bit to leaky gut. But I suspect our diet and other things can as well. Can you just describe quickly what this intestinal permeability is all about and why it might lead to chronic inflammation? Dr. Tieraona Low Dog 14:24-17:21 Sure… and I think intestinal permeability is the medical term that we do use. But when I speak to many audiences, what they’ve heard of is leaky gut. And I think that, you know, in many ways, it allows people to visualize what’s happening. The intestine, I mean, think about all the food that we’re digesting and everything that goes along with that coming into the stomach, into the small bowel and the large intestine. And we all know what comes out the other end, right? So there is a critical need for the intestinal, the cells inside of the intestine, to be able to have the selective ability, you know, to decide when water or nutrients or electrolytes are being, you know, absorbed from food out into the systemic circulation, right? And keeping harmful substances inside the intestine, right? So it has to be able to act like a gatekeeper. Well, inside of those cells, the things between the cells are something called tight junctions. And think of these as just like tightly fitting bricks, right? And when we need to absorb things, these proteins open up and they allow the body from the inside of the intestine, things to move out into the lymphatics and the bloodstream, keeping things that need to stay in the intestine inside. The problem is there are a lot of things, including what you just mentioned, like the continuous use of nonsteroidal anti-inflammatories that disrupt those tight junctions. And they allow larger molecules, endotoxins, and even some viable bacteria to pass through that lining out into the bloodstream. And that is a problem. These endotoxins, mostly they’re coming from gram-negative bacterial membranes and walls. When those get out into the bloodstream, they’re highly immunogenic. They trigger an immune response. And that then just drives this systemic inflammation. Now, if it happens once in a while, that’s not really a big problem. When this is occurring on a regular basis, it’s driving this ongoing inflammation that affects insulin regulation. It affects the blood brain barrier, you know, causing neuroinflammation. It affects metabolism. I mean, it is the great unifier, if we think about it, of what is driving this slow burn inside of us. This dysbiosis, anything that disrupts those bacteria and other microbes inside of the intestine also will disrupt those tight junctions and they lead to inflammation. So there’s a lot on this. This is not a mystery. It’s pretty well defined. It’s just biology. Terry 17:23-17:49 You’re listening to Dr. Tieraona Low Dog, a founding member of the American Board of Integrative Medicine and the Academy of Women’s Health. She has served on the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include: “Life is Your Best Medicine” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest book is “Healing Heartburn Naturally.” Joe 17:49-17:57 After the break, we’ll learn what to do to help the immune system so it doesn’t feel like it has to be vigilant every second. Terry 17:57-18:03 If fiber is a great way to support the immune system by supporting the gut, what should we eat? Joe 18:03-18:14 I love talking about breakfast because too many of us rely on high-carb, low-fiber options like pancakes or pastries. What would be better? Terry 18:14-18:20 We do worry about microplastics. We all have them in our bodies. Could they be triggering inflammation? Joe 18:21-18:29 Might brain inflammation be a reaction to infection? Could it lead to Alzheimer’s disease? Terry 18:39-19:09 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:54-20:57 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:57-21:46 And I’m Terry Graedon. Today, we’re learning how to calm chronic inflammation. It’s been estimated that one in three adults has inflammatory markers in their bloodstream. Inflammation contributes to conditions such as rheumatoid arthritis, lupus, psoriasis, cardiovascular disease, and metabolic conditions. Joe 21:47-22:05 We’ve been talking about the gastrointestinal tract. How does inflammation in our GI tract affect organs in the rest of our body? What’s your favorite breakfast? Do you find a bagel and cream cheese keeps you going? What about oatmeal or bacon and eggs? Terry 22:06-22:12 We should be paying attention to what’s on our plates for sure, but we should also know what to avoid. Joe 22:12-22:45 To learn more, we turn back to Dr. Tieraona Low Dog. She is a founding member of the American Board of Physician Specialties and was elected chair of the U.S. Pharmacopeia Dietary Supplements Botanical Experts Committee. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest is an e-book, “Healing Heartburn Naturally.” Terry 22:46-23:21 Dr. Low Dog, it sounds as though the inflammation that we’re talking about, chronic inflammation, is really a consequence of sort of chronically putting the immune system on alert. So not letting it relax and then jump to attention and then relax again. What can we do to help the immune system not have to feel like it’s always on patrol? Dr. Tieraona Low Dog 23:21-25:00 Well, it starts by making sure that you ensure barriers are not being disrupted. Barriers are important. In the mouth, it’s important to reduce the amount of sugar intake and to regularly get your oral cleanings. While we focus a lot on intestinal permeability, the number of diseases that are associated with high oral permeability, meaning through the gums, is also enormous. And it’s something we seldom talk about. So I do want to just note that that’s the beginning of the GI tract. So making sure you’re, you know, keeping down the sugar, you’re brushing, flossing, and you’re seeing your dentist every six months. And then when it goes to the gut, how do we maintain tight junctions? One, probably the biggest thing you can do other than cutting back on sugar, because fructose just definitely degrades that barrier, high consumption of sugars, is to increase your consumption of fiber. Fiber’s huge. And, you know, forever we’ve been telling people to increase their fiber and high fiber diets. We know they increase the health of the bugs, the microbes that are inside of our intestines, especially those that produce the food or the short chain fatty acids that are necessary for the intestinal cells to remain healthy. High fiber diets decrease intestinal permeability. That’s why, you know, we say that eating high fiber diets can help reduce the risk of colorectal cancer, can help lower cholesterol, you know, all of these amazing things. Terry 25:01-25:21 It does all those amazing things. But I think that a lot of people hear high fiber diet and they don’t really know what to eat. So Dr. Low Dog, if I were to go out to lunch today, what should I choose to make sure I’m getting a high fiber meal? Dr. Tieraona Low Dog 25:21-25:55 Absolutely. So, you know, we want both soluble and insoluble fibers, right? So, you know, how much do you need? You know, somewhere around 20 grams a day of the insoluble fibers and about eight per day of soluble. Those are the prebiotics. Those are the ones that lower cholesterol, regulate blood sugar, and help maintain those good tight junctions. So maybe this morning you got up and you had an apple with the skin on. That just gave you almost six grams of fiber and half of the soluble fiber you need for the day. One medium-sized apple, right? Terry 25:55-25:56 Okay. Dr. Tieraona Low Dog 25:56-28:24 I mean, so that’s great. If you’re going out for lunch, have your nice salad, but make sure you also put some beans on it, right? If you’re at a place where you can put, you know, garbanzo beans, black beans, a half a cup of cooked black beans is essentially seven grams of fiber, a half a cup. And almost four grams of that is soluble fiber, right? Pinto beans. I live in New Mexico. Pinto beans is another great place. A half a cup gives you five and a half grams of soluble fiber. So add some sunflower seeds. Put some walnuts on your salad, right? Make sure you’re adding more vegetables to the diet. The whole point is that all of the recommendations that we have for a plant forward diet, where we’re wanting people to increase their intake of fruits, vegetables, nuts, seeds, whole grains is because they’re rich in dietary fiber. And dietary fiber feeds the good bugs that we have inside of our gut, and it decreases intestinal permeability, which decreases inflammation. They have beneficial effects for lowering cholesterol, regulating blood sugar, you know, helping to reduce the risk of colorectal cancer. I mean, you name it. Even there’s data showing that higher fiber diets decrease the risk of respiratory infections and also increase our lives, our lifespan, our health span. So, you know, if you’re going to invest in one thing, that would be it. And for some people who are like, you know, I just, I just can’t eat that much fiber. I would say that psyllium, our old friends, psyllium seed and psyllium seed husks, which have been used forever, is a very good, you know, supplement that you can just take. It’s predominantly soluble fiber and it’s, you know, seven to three soluble to insoluble fiber roughly. And it’s the only fiber that is recommended by the American College of Gastroenterology for treating irritable bowel syndrome and chronic constipation (American Journal of Gastroenterology, Jan. 1, 2021). And the reason for that is it doesn’t tend to cause as much gas and bloating as some of the other fibers do. The FDA has actually allowed two health claims also for psyllium. It can reduce the risk of type 2 diabetes and it can lower cholesterol and reduce the risk of heart disease. So just think about that. Terry 28:24-28:34 Yeah, that’s what I was just going to jump in to say is there’s actually quite good research showing that it lowers cholesterol. And so that’s why I take it every day. Joe 28:33-29:15 Well, you know something about our favorite breakfast, as Terry will attest, my favorite breakfast is refried beans with lots of onions and peppers and, of course, olive oil. And then we put an egg on top, and it’s just fabulous. And then today we had Terry’s whole wheat bread, which, by the way, is absolutely fabulous. Terry has become the best bread baker you can imagine. And on top of that, we had avocado. So it was avocado toast and salmon. And it was just delicious. And it felt like, well, we were getting our fiber, and it tasted good, too. Terry 29:15-29:21 And I think actually salmon probably qualifies as an anti-inflammatory food too, doesn’t it, Dr. Low Dog? Dr. Tieraona Low Dog 29:21-29:33 It’s one of the most of the anti-inflammatory foods when we rank them, you know, by actually what they do in the body. So all I’m saying is me and all the other listeners are wanting to know when we’re coming over for breakfast. Joe 29:35-30:01 Come on down. But here’s the problem, Dr. Low Dog. I’ve been paying attention, as Terry will attest, to plastic for the last 50, 60 years. And, you know, when we saw the movie “The Graduate” and Dustin Hoffman is told plastic is the wave of the future, I had shivers up and down my spine. Terry 30:01-30:40 Well, Joe actually was paying attention when a grad school classmate of mine, we all got together and his girlfriend had been working for the plastic industry as a newsletter editor. And this is so long ago, back when I was in graduate school. We’re talking, you know, 1970. And she said, the industry is concerned because these compounds leach out of the plastic and into the stuff that the containers are holding. Joe 30:41-31:04 But now we even see microplastic or nanoparticles of plastic in our brains, and not just in our brains, like a lot of them, these little tiny plastic particles. But they’re in our blood vessels, they’re in our sexual organs, they’re just all throughout our body. And I can’t help but think that’s not good for us. Terry 31:04-31:06 It might even be inflammatory. Dr. Tieraona Low Dog 31:06-33:14 Oh, they’re very inflammatory. They definitely disrupt, you know, the microbiome. They alter signaling pathways. They alter immune responses. Yeah, it’s interesting because my mother never liked plastic. She would never, or cans actually, she didn’t like aluminum. She didn’t like the way cans things tasted. She didn’t like, um, she didn’t like anything in plastic. She never stored things in plastic, uh, cause she said that she could taste it. Now, I don’t know, you know, if she could taste it or not, but she certainly thought she could. And so I grew up just never having things, you know, in plastic. And, and I could never get the kids to not want to microwave in plastic when they were younger. And so I just got rid of everything that was plastic and bought glass containers for food storage. And, you know, and I learned from my grandmothers to save every pickle jar and everything else and recycle the glass, you know, and use them over and over again. But this is concerning even down to tea bags, right? Just even your brands of teas that have microplastics that you’re leaching out every morning and from your tea bags. So this is a huge issue and it’s going to be a challenge because it’s so woven into food delivery, you know, fast food packaging, food storage. But I would agree with you. And Joe, you were just way ahead of the crowd. Maybe my mom was too, just not wanting plastics. But it is very inflammatory, highly inflammatory, and they’re accumulating everywhere. And we do know that they cause neuroinflammation. So think about this with young children and a lifetime of having these microplastics in their liver driving inflammation and in their brains. And what happens when you’ve exposed a central nervous system as well as other areas of the body to 60 years of neuroinflammation? Joe 33:14-34:17 Well, speaking of neuroinflammation, you know, there is a growing theory that Alzheimer’s disease and other forms of dementia may be in part neuroinflammation. And some people are suggesting maybe a reaction to an infection, you know, like herpes simplex is reactivated, perhaps because of COVID or perhaps because of some other problem that stimulates, as we know, herpes is lingering in the brain for long periods of time. And now people are starting to look at anti-inflammatory approaches and maybe even antiviral approaches to dealing with the neuroinflammation. And what we’re hearing is that some of the medications that have been used and are so super expensive to deal with amyloid may not really be solving the problem. Dr. Tieraona Low Dog 34:17-38:01 Yeah. Well, you know, it is interesting. There was there was a review that was done, a meta-analysis looking at Alzheimer’s and then mild cognitive impairment, right? So looking at both. And they were looking at a variety of things. But in this case, they really found a very strong connection with oral inflammation, with periodontal disease. And those who had severe periodontal disease, you know, the risk for Alzheimer’s was almost five-fold more likely, an odds ratio of almost five. It was kind of shocking. So if we step back again and go, okay, so in the gut and in the oral cavity, when there’s this permeability, when there’s inflammation in the mouth and there’s leakage or there’s dysbiosis and there’s increased intestinal permeability, these endotoxins from these gram-negative bacteria are getting out. These are what we call lipopolysaccharides, right? So you’re going to see that word everywhere. But we know that when those are in the circulation, they degrade the blood-brain barrier and they turn on these cells, these little cells inside the brain called microglia that are normally just resting and happy and they’re there to clean up things or take care of an infection if it happens. But this turns it on. LPS, there’s little receptors for them and they turn on these microglia and we know that they drive neuroinflammation. And when you measure lipopolysaccharides in people with depression or animals with depression versus healthy animals or people that are healthy without depression, lipopolysaccharides are quite high. And so, you know, it’s, I agree, active infection, lingering infection, latent infection, but I would also have to say, step back, root cause, you know, root cause drives the inflammation down by making sure barriers, including the blood brain barrier is nice and strong. The gut barrier is nice and strong. Um, I think that for so long, so long, we keep just, you know, like that saying is we keep pulling people out of the river and keep finding new ways to, you know, dry them off and to get them on their way. But nobody’s really going upstream to figure out why they keep falling in the first place. That’s why I’m excited with the new data looking at what’s driving, what connects a bad diet, obesity, chronic stress, poor sleep, bad digestion, poor digestion. What connects all of these things to heart disease and metabolic problems and Alzheimer’s and depression and anxiety, even osteoporosis, cancer, aggravation of autoimmunity? It’s inflammation. And how do we tamp that down? And it starts with how we’re born. It starts with how we’re fed at birth. It starts with how many antibiotics we take when we’re young, the diets that we eat, the way we manage our stress, and the health of our gut. So, you know, it’s a big topic. And you all have covered so many of these subjects over the years. And I would just say, you know, all roads are sort of leading back. They’re leading back to this root cause, which is this persistent inflammation and, you know, now microplastics, endocrine disruptors in the environment. I mean, there’s just a lot of things. So we’re going to have to figure out how are we going to protect those barriers? How are we going to protect the gut and ultimately then the mind? Terry 38:02-38:37 You’re listening to Dr. Tieraona Low Dog. She’s a founding member of the American Board of Physician Specialties, the American Board of Integrative Medicine, and the Academy of Women’s Health. Dr. Low Dog has served on the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest book is “Healing Heartburn Naturally.” Joe 38:38-38:45 After the break, we’ll learn about herbs that can help fight inflammation. There are a surprising number of them. Terry 38:46-38:51 What’s the best way to get the benefits of turmeric? You know, that yellow spice in curry. Joe 38:52-39:07 It’s become one of the most popular herbs in the health food store and pharmacy. And we’ll get a golden milk recipe. That’s really terrific. Most people have never heard about golden milk in the U.S. It’s very popular in India. Terry 39:08-39:16 You do have to be a bit careful with turmeric or curcumin supplements. If you’re taking anticoagulants, there could be an interaction. Joe 39:16-39:26 Yes, it could increase your risk for bleeding. We’ll also discuss something you’ve probably never heard of, nattokinase. Why is it beneficial? Terry 39:27-39:45 We’ll also find out about other ways to calm inflammation, like meditation, massage, or magnesium supplements. You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 39:54-39:57 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 39:57-40:17 And I’m Terry Graedon. Today we’re considering calming chronic inflammation and we may need to learn about some supplements that might not be entirely familiar. You’ve probably heard of turmeric, which is a potent natural anti-inflammatory, but perhaps you’ve never heard of nattokinase derived from fermented soybeans. Joe 40:18-40:46 Our guest today is Dr. Tieraona Low Dog. She is a founding member of the American Board of Physician Specialties and was elected chair of the U.S. Pharmacopeia Dietary Supplements Botanicals Expert Committee. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and more.” Terry 40:46-41:30 Dr. Low Dog, you’ve given us all very good advice about how to keep our intestines in shape and keep those tight junctions tight and how to take care of our oral health. And what we want to do is make sure we cut back or eliminate the sugar and we increase the fiber and more fresh fruits and vegetables are going to be better along with beans and maybe some whole grains. But what about herbs? We’ve talked to you before about herbs, but I don’t remember which herbs might be most helpful for fighting chronic inflammation. Dr. Tieraona Low Dog 41:30-43:16 Oh, my gosh. There’s so many. There’s so many. So I’ll go into detail into a few. But, you know, just having that, you know, tea in the morning is good, especially green tea. Adding more spices to your diet. I think I heard you say about onions this morning. So onions are highly anti-inflammatory and so is garlic, you know, cilantro, basil, you know, cinnamons, all of these beautiful spices are so anti-inflammatory. And if Americans could just learn to cook a bit more with more culinary herbs and spices, we would begin to really start to see a shift in our inflammation. Speaking of spices, I know you know what I’m going to say. Turmeric, turmeric obviously is one of my favorite herbs and second really only to salmon when it comes to anti-inflammatory power. And when we look at turmeric, adding that to the diet, you know, putting it in your rice, adding it to your tomato soup, or for some people taking a supplement, but the data, you know, why does turmeric seem to, you know, when people eat turmeric over a lifetime, why does it seem to reduce Alzheimer’s? You know, why are studies showing that turmeric seems to help with depressed mood, you know, and memory? How can it reduce inflammation in the gut? Well, we think it’s because it’s a pretty powerful anti-inflammatory and it feeds good microbes in the gut and it reduces intestinal permeability. So turmeric does all kinds of amazing things. So I would say definitely increase turmeric. Joe 43:17-43:54 Well, hang on just a sec, because I know you’ve been to India recently, which seems like the origins of turmeric and, of course, the active ingredient curcumin. And in India, I’m guessing that a lot of people are cooking with turmeric and they’re using some ghee, some fat with that turmeric to get it to absorb better and maybe a little black pepper. You know, Americans love pills. And I keep seeing all these commercials about the best turmeric on TV. Terry 43:55-44:00 But curry tastes so much better than a pill. And probably you’re absorbing it better. Joe 44:00-44:05 Exactly. So tell us a little bit about cooking with turmeric. Dr. Tieraona Low Dog 44:05-46:10 Oh, yeah. Well, you know, we cook with turmeric probably three, four times a week. You mentioned a couple of the most important pieces, some sort of fat, right? So rather that’s your, you know, olive or coconut or ghee or butter, putting that turmeric in and letting it be absorbed with some fat. I love it. I love it in tomato soup. I love cooking with turmeric and a little black pepper saffron in my tomato soup. And of course, for many people, just making a golden milk, it’s so simple, right? You just take a little bit of ghee, [clarified butter], you know, or a little butter, and you just cook the turmeric in there for a minute or two and then add your milk or your non-dairy milk. Let that kind of simmer. If you’d like, put a pinch of cardamom, some dates, chop a date up. Cook that all up, put a sprinkle of black pepper in at the end and drink. I serve it here all the time for our classes and guests and people that visit our ranch. And they’re like, this is so delicious. So cooking, adding it to curries. One thing I would say for your listeners is that we do know that there’s been problems with lead and turmeric in the spices, right? So you do want to, Consumer Labs and Consumer Reports, there’s been a number of groups that have tested them. So just making sure that you’re buying really good turmeric to use in the kitchen. A couple that came out really good, you know, obviously McCormick is very good, which is available, but Simply Organic. Their range of spices also came in exceedingly clean. But I was concerned out of 31 different turmeric spices that were taken off the shelves around Boston, many of them exceeded all safe lead levels. So making sure you’re buying a good curry powder or a good turmeric powder to use at home with your cooking. Joe 46:10-46:36 One word of caution. We have heard from a lot of people who are taking pills, supplements, that they end up with nosebleeds or sometimes other bleeding problems, especially if they’re also taking an anticoagulant like warfarin at the same time. So apparently turmeric does have the ability to quote unquote thin the blood. Terry 46:37-46:53 Or perhaps interact with warfarin. So somebody on warfarin needs to be cautious, I would say, especially with supplements, but possibly also make sure that you don’t overdo on the curry. Dr. Tieraona Low Dog 46:53-47:13 Yeah. You know, but I would say this about warfarin just as a physician. Changing your diet in a dramatic way will affect warfarin, you know, just the way the kinetics work. And, you know, I used to tell the med students, if you have four answers and one of them’s warfarin for an interaction, always choose it because it’s so finicky. Terry 47:13-47:15 It interacts with a lot of things. Dr. Tieraona Low Dog 47:15-47:45 It interacts with a lot of things. So I would tell any listener who’s on something like a Coumadin or something like, you know, for platelet aggregation and blood clots, you just have to be very careful with even any really dramatic changes in diet or adding supplements. Make sure you’re working with your practitioner because we can always adjust your dose of your warfarin to accommodate your diet. It’s just changing your diet around a lot can be problematic. Joe 47:46-48:00 I do have a quick question that’s completely off the subject, but it has been reminded in my brain because of the conversation about turmeric as an anticoagulant in part. And that’s something called nanokinase. Terry 48:01-48:02 Nattokinase. Joe 48:02-48:20 Nattokinase. So what is nattokinase and why would it be beneficial? We heard from an internist, you know, mainstream medical doc, highly placed at one point at Duke, and he said he and his wife are now using nattokinase to prevent clots. Dr. Tieraona Low Dog 48:20-49:39 Yeah. So when you boil… natto’s made from boiled soybeans, right? You ferment them with bacteria and it creates, nattokinase is the enzyme that comes from NATTO, N-A-T-T-O, right? We looked at this when I was at the USP, at the United States Pharmacopeia, looking at it from a safety perspective, because it definitely does seem to have the ability to help with blood pressure, help prevent blood clots, etc. The problem with it is, you know, when we’re putting you on something to reduce blood clots and somebody who really has a high risk for them. We can control the dose so that we make sure you’re not under or over coagulated. That’s more challenging. It’s just, it’s more challenging. If you’re looking at something, you know, that can just kind of help with blood pressure and, you know, maybe even brain health or things like this, you know, having some of it in the diet isn’t really a problem because, I mean, there’s a food. Natto is a food. So I’d say that was fine. Where I would be cautious is if you were told you need to be on an anticoagulant because you have a high risk of throwing clots, I would say that this is not reliable because you can’t keep a steady state. Terry 49:40-50:03 Right. So for that, you need a medication. It might be warfarin or it might be one of the others. Dr. Low Dog, other approaches to calming inflammation. Is there any room for things like mindfulness meditation, massage therapy, acupuncture? What are your favorite modalities? Dr. Tieraona Low Dog 50:05-50:08 Walks in nature. You knew that would be my favorite. Terry 50:08-50:12 That is great. Tell us a little bit more about that. Dr. Tieraona Low Dog 50:14-52:28 You know, just being out wherever is like a place for you. So if it’s around a lake or near the beach or walking in a park if you live in a city, green spaces we know have a very beneficial effect on blood pressure, on mood, on our overall sense of well-being. And of course, you know, we know that when we let little kids, there were some beautiful studies done looking at little children in daycares where they’re out playing in the dirt or like planting plants. When we looked at their risk of infections, like respiratory infections, and also looked at their stool, their microbes, they are just much healthier than kids that don’t get to play outside in the dirt. So I love being out in nature. I think it’s one of the best things we can do for our health and our well-being. I do, I meditate. I meditate also when I’m walking, but mindfulness can be very powerful for reducing stress and cortisol. Remember that this high cortisol that many people have from persistent stress, cortisol, you know, also causes disruption of our gut bacteria, drives systemic inflammation. So, you know, helps us put on more weight in our tummies. So doing things that reverse that are important. Exercise can do that too, right? Physical activity, relationships, the power of connections and friends, finding ways, you know, whether that’s art or music, poetry or affirmations, things that can help connect us to meaning and purpose in our lives. All of these things not only drive down inflammation in our bodies and help our brains and help us from a physical health, but they also nurture and nourish our emotional and our spiritual selves. And when those three are in balance with each other, when we’re addressing all three of those is when we experience contentment and joy. And that’s really what’s so wonderful about being human. Joe 52:30-53:14 Many of your colleagues, Dr. Low Dog, prescribe what we would call anti-inflammatory drugs. And we’ve already talked a little bit about the non-steroidal anti-inflammatories. But as you said, the body has its own cortisol. And doctors like to prescribe drugs like prednisone or methylprednisolone. And there are certainly times for those medications. When I lost my hearing temporarily, they brought my hearing back. I loved the drugs. But Terry will attest to the fact that I wasn’t much fun to be around on big doses of prednisone. Terry 53:15-53:15 Joe gets weird. Dr. Tieraona Low Dog 53:16-53:17 So do I. Joe 53:18-53:36 And rather irritable. Yes, it wasn’t fun. How do we create our own, shall we say, more natural approaches to calming inflammation rather than relying on prednisone for weeks, months, and for some people, years, especially when it’s a condition like osteoarthritis? Dr. Tieraona Low Dog 53:37-56:40 Well, I mean, I think there’s so much that can be done. There’s so much with herbal medicines that can help with, you know, with like arthritis. And like turmeric, we just mentioned a little while ago, but there was a review done by Tufts researchers (Seminars in Arthritis and Rheumatism, Dec. 2018). They did a systematic review looking at all the studies, and they found that both turmeric and curcumin, more specifically, and Boswellia, which is also known as Indian frankincense, that both of those were very effective at relieving arthritis pain and recommended it as another way of thinking about treating osteoarthritis without having all of the side effects, right? So, you know, I think fish oil, also omega-3s, increasing your omega-3s, which, you know, trying to drive towards a higher omega-3 index, that’s something that can just be measured. A lot of my chronic pain patients. I try to increase their, you know, their omega-3 index to seven to eight percent over time so that we’re, you know, that we’re driving down inflammation and also helping with pain. But there’s a number of things that, you know, that you can do for chronic pain. I’m saddened by how many people live with persistent pain. And if you have, you know, vitamin D, can I just even throw out vitamin D? We know that when vitamin D gets too low, when those levels get too low, you know, that that actually causes pain, causes, it worsens arthritis pain and muscle pain and widespread chronic pain, like people with fibromyalgia. So making sure that people are getting adequate amounts of vitamin D is really important. Some people may, you know, may need things like, you know, CoQ10 or magnesium. Can I just share a quick story? When I had my hip replaced in 2022, I went up to the floor after my surgery and they kept coming in asking how my pain was and rating my pain. And my pain was great. And family came to visit and it was eight, 10 hours later and I saw them coming in and they were hanging magnesium with my IV. And I said, oh, was my magnesium low? And they said, no, it’s just your orthopedic surgeon likes to use magnesium during and after your surgery because he finds it reduces pain and how much opiate you need. Right now, I just had a huge surgery. I didn’t have a single opiate for more than 30 hours after having a hip surgery. Just for magnesium. So I’m fascinated by this. And so magnesium, we know, helps with migraines. It can help with a variety of things. But, you know, magnesium is another one that can relax muscles, can relax muscles in the jaw, in the neck, just so many things we can do for chronic pain. And also magnesium drives down inflammation, reduces C-reactive protein. Terry 56:40-57:59 Well, I think we’ll need to leave it there. And it sounds like there are quite a few modalities that people could use to address inflammation, to address pain. Dr. Tieraona Low Dog, thank you so much for sharing that with us today on The People’s Pharmacy. Tieraona Low Dog 56:59-57:01 Thank you. It was a pleasure. Terry 57:01-57:38 You’ve been listening to Dr. Tieraona Low Dog. She is a founding member of the American Board of Physician Specialties, American Board of Integrative Medicine, and the Academy of Women’s Health. Dr. Low Dog has served on the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest work is an e-book, “Healing Heartburn Naturally.” Joe 57:39-57:48 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 57:49-57:57 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 57:58-58:13 Today’s show is number 1,460. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 58:14-58:22 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Joe 58:23-58:52 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be so grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics interesting, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 58:52-59:31 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 59:31-59:41 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. 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One of the most basic pillars of health is good nutrition. A range of eating patterns might all be considered balanced diets, but in general people do better when they eat less processed foods and more whole foods. Vegetables and fruits play a starring role in at least two diets that have been studied extensively, the DASH diet and the Mediterranean diet. Americans might be healthier if we followed these eating plans, but fresh veggies can be pricey. If your doctor were prescribing produce, would your insurance plan cover it? Might this make healthful eating more of a practical possibility? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Jan. 24, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Jan. 26, 2026. Food Is Medicine: Increasingly, healthcare providers are recognizing the critical role of diet in the development of chronic disease. An entire movement is organizing around the concept of Food Is Medicine, both for prevention and for treatment of conditions like diabetes, obesity and heart failure. Scientists have shown that diet makes a difference. Studies have confirmed what many of our grandparents or great-grandparents intuited. On the other hand, translating that knowledge into action that benefits patients has been difficult. One important barrier is the cost of fresh fruits and vegetables. Doctors Prescribing Produce: People could get healthful food in a variety of ways. Past generations often had gardens and grew much of their own produce. That’s not always practical in urban settings or for families with multiple jobs struggling to make ends meet. Our guests today have tested two ways to get fresh food into people’s hands. One is a debit card that can be used to buy any WIC-approved food at more than 66,000 retail outlets across the country. WIC is the USDA supplemental nutrition program for Women, Infants and Children. WIC-approved foods include fresh fruits and vegetables with no added sugar or salt. In this model, the healthcare provider arranges for certain patients to get access to this debit card, providing $40 worth of purchasing power for healthy foods each month. They are essentially prescribing produce. The idea is to use a business model that supports good food and saves the health system money. This is termed a healthy food subsidy. The other approach is a food box. This includes vegetables and fruits, and possibly other foods, that providers decide the patients should get. In some initiatives, the person or agency deciding what goes in the food box might also take into account what is available from local farmers. The box may be distributed weekly, every two weeks or every month, but the individual who is going to be eating the food does not choose what is in it. How Does a Healthy Food Subsidy Compare to Food Boxes When Providers Are Prescribing Produce? When people don’t know if they will be able to pay for the groceries they need, they are said to be “food insecure.” This complicates a range of chronic conditions, making diabetes more challenging, for example. People with food insecurity have a harder time keeping their blood pressure under control. Our guests collaborated with other colleagues on a recent comparing the food box approach to the healthy food subsidy among North Carolina resident with high blood pressure and food insecurity (JAMA Internal Medicine, Dec. 1, 2025). The study enrolled 458 individuals. Everyone in the study had a provider prescribing produce. Half the volunteers got the food subsidy debit card and half were provided with food boxes. Those getting the food subsidy had moderately lower blood pressure after six months compared to those getting food boxes. Their blood pressure was also lower after a year and a half. Food insecurity decreased in both groups over time. Tackling Food Insecurity: One of the outcomes of food insecurity is that people are more likely to need emergency department services. This costs the insurance company dearly. If improving food security and diet quality could reduce ED visits, insurers might become quite interested in the food subsidy approach. This is currently being tested for participants with heart failure. Special Populations Who Might Need Providers Prescribing Produce: During this conversation, we expressed concern about vulnerable populations that might suffer especially from cuts in government spending. We asked about school lunches and we learned about pilot programs focusing on expectant mothers. Children in foster care are especially vulnerable; a food subsidy program taking a Food Is Medicine approach could be helpful for them. This Week’s Guests: Seth A. Berkowitz, MD, MPH, is Associate Professor of Medicine at the University of North Carolina School of Medicine. He is also Section Chief for Research, General Medicine and Clinical Epidemiology. Dr. Berkowitz is a general internist and primary care doctor, studying how food and nutrition interventions can improve health. Dr. Berkowitz is the deputy scientific director of the American Heart Association’s Food is Medicine initiative, Health Care by Food initiative. He is also the author of the recent book, ‘Equal Care: Health Equity, Social Democracy, and the Egalitarian State.’ The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Dr. Seth Berkowitz of UNC promotes Food Is Medicine Peter Skillern has pursued a career dedicated to creatively and effectively addressing poverty and inequality in North Carolina and the nation. He serves as the CEO of Durham-based Reinvestment Partners, an innovative nonprofit that works with people, places and policy to foster healthy and just communities. Reinvestment Partners advocates for financial and health reforms to improve people’s lives. The agency has won numerous accolades and is considered a state and national leader in its field. In recognition of his leadership, he was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations. He holds North Carolina General Contractor and Real Estate Broker licenses. He received his B.A. from the University of California Santa Cruz with Highest Honors. A 1991 graduate of the Department of City and Regional Planning at UNC Chapel Hill, he was recognized as a Distinguished Alumni by the UNC faculty in 2020. Peter Skillern, CEO of Reinvestment Partners Listen to the Podcast: The podcast of this program will be available Monday, Jan. 26, 2026, after broadcast on Jan. 24. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1459: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of the People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy. com. Good nutrition is an undisputed pillar of health. Sadly, it seems to be out of reach for too many Americans. This is the People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:40 What if modern medicine made nutrition a priority? How would that change what we eat? Joe 00:40-00:54 The food industry has learned how to make ultra-processed food tasty and accessible, even in food deserts. But is it contributing to our epidemic of obesity, diabetes, and heart disease? Terry 00:55-01:00 How is the Food is Medicine movement changing our approach to fresh fruits and vegetables? Joe 01:01-01:06 Coming up on The People’s Pharmacy, should your doctor be prescribing produce? Terry 01:14-02:11 In The People’s Pharmacy Health Headlines: The CDC is reporting that the flu season might have peaked. Laboratory testing suggests a downward trend in flu cases. That said, this federal agency is estimating that 18 million people have caught the flu so far and 230,000 patients have been hospitalized. We’re also nearing an approximate 10,000 deaths from the flu. The CDC has classified children as experiencing high severity influenza this season and adults moderate severity. Some experts are challenging the CDC’s numbers. That’s because the data are delayed by about two to three weeks. We may still be in the early stages of this influenza outbreak. Australia’s flu season, for example, started early and lasted a long time. In the U.S., February is often our peak month for flu. Joe 02:11-02:55 A report in JAMA Internal Medicine suggests that older people who get high-dose influenza vaccines are better protected against infection. Over 300,000 Danish citizens participated in a study that randomized to either high-dose or standard-dose flu shots. The investigation covered three flu seasons. This analysis considered how well the vaccination protected against heart failure and other cardiovascular complications, as well as influenza. Those who got the bigger dose had fewer hospitalizations for cardiorespiratory problems. People with diabetes also fared better on the high-dose vaccine. Terry 02:56-03:53 Measles continues to spread at an alarming rate. Earlier this year, there was a large, long-lasting outbreak that started in Texas. While that one has calmed, South Carolina is now in the midst of a serious outbreak. Cases have doubled over the past week or so, and the total number is above 560. While most cases have been seen among children, at least two university populations are also experiencing cases. Both Clemson University and Anderson University are dealing with confirmed measles cases in the student body. There are also cases being reported in North Carolina that seem to be linked to the South Carolina outbreak. Public health authorities point to vaccination rates below 90%, which is not enough to provide herd immunity for people unvaccinated against this extremely contagious and potentially dangerous disease. Joe 03:54-04:20 Last fall, the administration warned pregnant women to avoid acetaminophen because of concerns about autism. A new systematic review in the British journal The Lancet included 43 studies. The authors concluded that there’s no evidence that taking acetaminophen during pregnancy significantly increases the risk for autism spectrum disorder, ADHD, or intellectual disability. Terry 04:21-06:17 Falls are dangerous for older people and can result in injury, limited mobility, and even death. For decades, scientists have wondered whether vitamin D might help with muscle strength and balance and thus prevent falls. The results of studies have been inconsistent. Finnish researchers took advantage of an existing study called the Finnish Vitamin D trial to investigate this question. Nearly 2,500 healthy older participants were assigned to take vitamin D3 at 1,600 international units or 3,200 international units a day or placebo. The investigators collected data on falls and injuries at baseline and at 1, 2, 3, and 5 years. Blood levels of 25-hydroxyvitamin D increased among the individuals taking vitamin D supplements. Over 5 years, just over half of the volunteers had taken a fall and 11% had sustained injuries. Those proportions did not vary much between any of the groups, including those on placebo. The scientists concluded five-year vitamin D supplementation of 1,600 international units a day or 3,200 international units a day did not affect the overall risk of falls or fall injuries among generally healthy, largely vitamin D-sufficient men and women. And that’s the health news from The People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:43 And I’m Joe Graedon. Our topic today is food. And I have to admit that I’m biased. My earliest years were spent on a dairy farm in eastern Pennsylvania. Even after we moved, visiting Uncle Leo was a highlight because of the vegetables and super fresh whole milk. Uncle Leo and my mom, Helen Graedon, lived into their 90s and prized real food. Terry 06:43-06:55 Good fresh food is a delight that’s not available to everyone. Should we also be thinking of food as medicine? If so, how could we make it affordable and accessible? Joe 06:56-07:02 We have two distinguished guests today who are at the forefront of the food as medicine movement. Terry 07:03-07:37 Dr. Seth Berkowitz is Associate Professor of Medicine at the University of North Carolina School of Medicine and Section Chief for Research, General Medicine, and Clinical Epidemiology. He’s a general internist and primary care doctor studying how food and nutrition interventions can improve health. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Food is Medicine Initiative. His book is “Equal Care: Health Equity, Social Democracy, and the Egalitarian State.” Joe 07:38-08:03 We’re also talking with Peter Skillern, CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works with people, places, and policy to foster healthy and just communities. In recognition of his leadership, Peter was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations. Terry 08:04-08:06 Welcome to The People’s Pharmacy, Peter Skillern. Peter Skillern 08:07-08:08 Thank you so much, Terry. It’s good to be here. Terry 08:09-08:12 Welcome to the People’s Pharmacy, Dr. Seth Berkowitz. Dr. Seth Berkowitz 08:12-08:13 Thank you. I appreciate the invitation. Joe 08:14-08:25 We are delighted to be able to talk about one of our favorite topics, which is food. And, you know, Terry’s grandparents were very involved with food a very long time ago. Terry 08:26-08:41 That’s true. My grandfather was the butcher in the little town in western Nebraska where they lived. And my grandmother had a huge garden and raised chickens. I mean, it wasn’t a hobby. It was just, you know, what you did. Joe 08:41-09:09 And my grandfather, at the early part of the 20th century, was a back-to-the-land kind of guy. He bought a farm in Pennsylvania, and my uncle Leo ran that farm for decades. He was a dairy farmer. And my mom and dad were always very big on gardening. They had a huge garden, and they prized their fresh vegetables. Like you would eat them in the garden because they were so delicious. Terry 09:10-09:43 Well, you know, most people today don’t have that experience. They don’t have the space. They don’t have the time to do a garden. They may not have the knowledge. So how can people get the food? What they do is they rely on supermarkets, but produce is expensive. So when budgets get tight, often what people do is they cut back on the fresh fruits and fresh vegetables and they look for food that’s cheaper, which often is more processed. Joe 09:44-10:05 And not very good for you. So let’s go back a couple thousand years to Hippocrates, who is reported to have said, let food be thy medicine, let medicine be thy food. So let’s start at the very beginning. Peter Skillern, what is the Food is Medicine movement? Peter Skillern 10:05-10:21 It’s an initiative that’s nationwide of practitioners, health care providers, insurance companies, and I think most importantly patients who are asking that the health care system assist them with their health by helping them pay for food. Joe 10:22-10:24 How did you get interested? Peter 10:24-10:49 Well, I run an anti-poverty organization, and we’re committed to helping improve people’s lives, their health, and their food security. But an important component of that is to find a business model that sustains it. We have to move beyond simply grant-based or charity. We need to find a business model where the health care system says it’s in our financial interest and in our obligations for good health care to help provide food. Terry 10:49-10:51 Tell us a little bit more about that business model. Peter Skillern 10:53-11:18 Well, ideally, we’re trying to show that we can save the health care industry money. About 80% of health care costs are created by this treatment of chronic diseases related to unhealthy food, diabetes, cardiovascular, liver disease. So if we can help show an improvement in those conditions, reducing costs, we hope that the health care system will pay for food like it pays for medicine. Terry 11:18-11:24 So going to another old aphorism, an ounce of prevention being worth a pound of cure. Peter Skillern 11:25-11:27 It’s both prevention and it’s treatment. Joe 11:27-11:56 Well, let’s turn to Dr. Berkowitz. Dr. Berkowitz, you have a medical degree and a PhD. You’re an internist. You see people with cardiovascular disease and diabetes and all sorts of other conditions. Are there any studies, any science to support what we’ll call the food is medicine movement that fruits and vegetables actually make a difference in people’s outcome? Dr. Seth Berkowitz 11:56-12:41 Yeah, I think there are a lot of studies, actually. So one of the things that we think about for food as medicine is how can we use various ways of providing healthy food resources to overcome barriers people might have to healthy eating. And as we were alluding to, there are a lot of different conditions where that might be relevant. And so there’s been a real burgeoning of studies across a number of different clinical populations that try to use food as medicine principles to improve health outcomes. That could be improving things like blood pressure or blood sugar. That could be improving things like a reduced need for emergency department visits or hospitalizations and really a number of different clinical outcomes that might be affected by food is medicine study or food is medicine intervention. Joe 12:41-12:59 It sounds like medicine is, I’ll say, rediscovering what our great, great grandparents knew, you know, almost intuitively from the time they were young kids until the time they died. It was like, yeah, food, food is essential for good health. Dr. Seth Berkowitz 12:59-13:59 Yeah. I mean, I think there’s no doubt that nutrition is, you know, a key part of health. An analogy that I sometimes like to use for food as medicine is with physical activity and exercise. So we know that physical activity and exercise are also key parts of health. They go on throughout our lives and are not necessarily connected to health care or the health system, even though they help make us healthy. But there are certain circumstances, say after an injury where you might get physical therapy or after a heart attack where you might have cardiac rehab, that physical activity and the health care system intersect to promote health. And I see food as medicine analogously. Food means lots of different things, lots of different people. It’s culture, it’s celebration, it’s nutrition. And some of that might not be in any conjunction at all with the healthcare system, and that’s totally fine. But there are certain situations, maybe with high blood pressure or with diabetes or other things, where the intersection of food and the healthcare system might produce a health benefit in a way that’s analogous to how physical therapy can produce health benefits. Terry 13:59-14:20 You’ve mentioned high blood pressure a couple times, and Joe asked about research. And we know that there is a diet that can help people lower their blood pressure. It’s called the DASH diet. Tell us a little bit more about that and the pretty robust research backing that it has. Dr. Seth Berkowitz 14:20-15:10 Yeah, so the DASH diet, I think, is one of the best studied dietary interventions. It focuses on things like having lower sodium content in the diet, higher potassium content, which generally comes from eating fruits and vegetables, using healthy fats, not having a lot of refined grains or carbohydrates, and things like that. It’s been shown to lower blood pressure in a number of randomized trials. It’s an overall healthy dietary pattern and likely has impacts on other types of cardiometabolic disease, things like heart attacks or strokes or things like that, even though it was originally designed for high blood pressure. And if there are ways to help people follow a DASH diet, then that’s likely to have very big health impacts. Also just to say, I think that’s one example of a healthy dietary pattern, but there are lots of diets that is not something that is preferred or culturally appropriate or things like that. Joe 15:11-15:43 Peter, we have all been told by every healthcare professional that we’ve ever interviewed, don’t smoke, exercise, and eat a well-balanced diet. It’s sort of like a mantra. And yet it doesn’t mean much to people. It’s sort of like, ‘Oh, yeah, okay, I’ve heard that a dozen times, a hundred times. How do I implement that in my life? How do I make that part of my real-world experience?’ Terry 15:44-15:48 Can I balance my diet with potato chips in one hand and chocolate cake in the other? Joe 15:49-16:00 So how do you make it possible for people who are on the edge sometimes in terms of their finances to be able to get really healthy food? Peter Skillern 16:02-16:20 The biggest obstacle to eating healthy for low-income people is the cost of the food. And our program in providing a $40 benefit or $80 on a card that’s restricted for healthy fruits and vegetables at almost any retailer allows them to choose and buy that healthy food. Joe 16:20-16:22 How does it work? Tell us about that card thing. Peter Skillern 16:23-16:45 Yeah, so we do a debit-restricted card that can purchase any WIC-approved fruits and vegetables at almost any retailer in the country. So it empowers people both the purchasing power, but also the choice of where they purchase it, what they purchase, when they purchase it. And that high agency that’s been given those participants leads to higher compliance with eating healthy. Terry 16:45-16:52 Now, Peter, you said WIC approved. WIC, I think that stands for women, infants, and children. What does it mean? Peter Skillern 16:53-17:03 It means that you can do produce that does not have any additives to it. So it could be canned or frozen as long as there are no salts or sugars added. Joe 17:03-17:11 So let me see if I understand this. You get a card, a debit card, and you can go anywhere? Peter Skillern 17:12-17:31 We have this particular card. It is recognized at 66,000 retail outlets across the country. So most food as medicine efforts are very locally based, perhaps food boxes from locally grown food. And what we’re trying to do is to reach the scale and impact that the health care system needs. Joe 17:31-17:32 Do people like it? Peter Skillern 17:33-17:40 They love it. We have a 95% net promoter score, which means that they would refer it to their family and friends. Terry 17:42-18:11 You’re listening to Peter Skillern, CEO of Reinvestment Partners, a nonprofit based in Durham, North Carolina, working to foster healthy, just communities. The agency is a state and national leader in its field. We’re also talking with Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. He is the author of the recent book, Equal Care, Health Equity, Social Democracy, and the Egalitarian State. Joe 18:12-18:17 After the break, we’ll find out if getting rid of the cost barrier can make people healthier. Terry 18:18-18:23 Doctors are accustomed to prescribing medications; they might not be used to prescribing produce. Joe 18:24-18:32 When you compare produce debit cards to a food box, what are the differences? And what is food insecurity and how does it affect health? Terry 18:39-18:47 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 20:37-20:40 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 20:40-20:49 And I’m Joe Graedon. The topic today is food is medicine. That’s a message we’ve been preaching for decades here on The People’s Pharmacy. Terry 20:50-20:58 Americans spend more on health care than any other nation, but we lag far behind most other developed countries when it comes to longevity. Joe 20:59-21:14 Many health professionals praise the Mediterranean diet because of its fresh produce and emphasis on real food. But many Americans find it difficult to afford fruits and vegetables. How can we change that? Terry 21:14-21:36 Peter Skillern is CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works with people, places, and policy to foster healthy and just communities. In recognition of his leadership, Peter was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations. Joe 21:37-22:00 We’re also talking with Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Health Care by Food Initiative. His recent book is Equal Care, Health Equity, Social Democracy, and the Egalitarian State. Terry 22:02-22:56 Dr. Berkowitz, I am assuming, and I should never do that, that in order for people to embrace this idea of food is medicine, you have to be able to prove it. If we want people to start eating more fruits and vegetables, we have some evidence already that eating more fruits and vegetables is good for you. We talked about the research on the DASH diet. There’s research on the Mediterranean diet. Both of those diets are very heavy on produce. So what we’ve got are barriers. And Peter has mentioned that the big barrier is cost. How do we prove that getting rid of that cost barrier can actually make people healthier? Dr. Seth Berkowitz 22:57-24:44 I think that’s a great question, and I think that’s a great way to frame it as well. I don’t think we need any more research that a healthy diet is healthy. I think we generally know what healthy foods are and what it will do for us. But the question is, how do we overcome those barriers to following a healthy diet that so many people face? Some of those barriers are knowledge-based, and so things like educational programs and things like that make sense. But as you point out, affordability is a key barrier for a lot of people in the United States. And I think that’s the key innovation of Food is Medicine programs, is there’s not only the sort of knowledge and skill building that educational programs have been providing for a while, but there’s the provision of healthy food resources that make it easier for people to overcome that affordability barrier. But also, as you say, overcoming the affordability barrier means that there’s going to be an input of financial resources into the health care system or through the health care system to an organization like Peter’s to run programs and those kinds of things. And so people are going to be looking for strong evidence that doing that really will improve people’s health. And that’s a lot of the work that I do. So I’m a physician by training. I’m a practicing primary care doctor. But I also do research. Some of that is observational research, but a lot of it is interventional research, randomized clinical trials, evaluations of interventions that are being done across our state in North Carolina and really across the country now, and looking for that evidence that shows, all right, this is the right interventional approach in the right population for the right duration of time to make it a truly covered benefit in the same way we might say that, oh, if you have a certain type of infection, you don’t just need antibiotics broadly. You need some type of antibiotics in a certain dose for a certain period of time. And that’s what turns it into a real medical intervention that can be covered through insurance benefits or things like that. And similarly, there’s a body of research that’s being built around food as medicine interventions to do that same kind of thing. Joe 24:45-25:50 Well, Terry said that everybody knows that food as medicine is good for you and making the right choices. But I would actually take an exception to that because I think our grandmothers great-grandmothers knew that. I’m not sure that everybody recognizes how powerful food is, especially, and I hate to say this, Dr. Berkowitz, your colleagues, because a physician is trained, let’s be honest, to write a prescription. They’re trained to look for double-blind, randomized, placebo-controlled trials in the New England Journal of Medicine or fill in the blank journal. And so the idea of spending any time at all with a patient talking about food choices seems like a waste of time. You know, I’m busy. I’ve got 10 minutes to see this person. Let me just write a prescription for, I know, atorvastatin. That’s the answer, because it’s got science behind it. Terry 25:50-25:55 And possibly the physician is assuming that the patient knows how to eat. Joe 25:56-26:13 There are a lot of assumptions that are made. So, you know, how do you, as a health care provider, help your colleagues begin to embrace the idea that, you know, you could perhaps help people lower their blood pressure with a food-as-medicine approach? Dr. Seth Berkowitz 26:14-27:39 I think that’s a very fair question. I think your description of the constraints that people are facing in practicing medicine is very accurate. I think there are these time constraints. I think there is a historic focus on pharmaceutical treatments and, you know, surgical interventions and those kinds of things, but for what physicians are doing. But I don’t think that means that the healthcare system overall is not able to do this. For example, you know, we have professionals who have a lot of expertise in doing exactly what you’re saying, registered dietitian nutritionists. And I think we could be doing a lot more to bring those folks into the care team even more than they already are. Expand the number of situations in which they’re being used. But I do think physicians need to recognize the importance of diet for both preventing and managing chronic disease. And I think there are gains being made in that area, but it’s not exactly where we want it to be. I also think we need to recognize the complementarity between a lot of these different interventional approaches. I think we’re fortunate to have the amazing science that we have that has brought medications that can lower cholesterol or lower blood pressure or lower blood sugar. But we also are fortunate to have the science that is proving that there are ways to use diet to do similar things. And it’s not an either-or situation. You’re probably even better off, at least in the appropriate circumstances, using both approaches to get as much benefit as possible. Terry 27:40-27:54 Well, let me ask. You all have recently collaborated on a couple of publications showing your research. Would you tell us about that, please? Dr. Seth Berkowitz 27:58-28:38 Sure. I’m happy to start and let Peter join in. So there have been two recent, you know, sort of studies that I think are worth talking about. One is a randomized trial where we compared two different types of food as medicine approaches. One approach used a food subsidy provided by reinvestment partners and compared it to the delivery of a food box and looked at whether one was better than the other in terms of lowering blood pressure. And we found that people in both groups had their blood pressure go down from baseline. But the food subsidy had blood pressure, the people in the food subsidy group, I should say, had blood pressures that went down even more than in the food box group. Joe 28:39-28:45 Let me ask you to pause there. Peter, tell us the difference between these two groups because a food box, I don’t understand. Peter Skillern 28:46-29:04 A food box is typically put together with the provider determining what goes in the box, produce or meats, proteins, dairy or not. Maybe it’s just the produce. And it’s typically whatever is in season at the time in that region. And then they deliver that to the client. Terry 29:04-29:08 So it’s a little bit like your CSA box. Joe 29:08-29:09 Which stands for? Terry 29:10-29:41 Community Supported Agriculture. And that is a program in which you pay the local farmer up front. You pay him $100, $200, and every week for the next four or five weeks during the season, you get a box of whatever it is he or she has grown. But what you’re saying is for this food box, it isn’t whatever the farmer has available, which is how the CSA usually works. It’s whatever the doctor says you need to have, huh? Peter Skillern 29:41-29:42 No, actually, I’m not saying that. Terry 29:43-29:43 Okay. Peter Skillern 29:43-30:16 Ideally, you would have kind of a detailed nutritional prescription for which vegetable, for what diagnosis, for what dosage, for what duration, for what demographic, and it’s very specific. A food box is typically an anti-poverty, anti-hunger program where it’s also trying to support local farmers and local food system. Even if all the food is bought from a retailer, someone else other than the participant is making the decisions. So the recipient receives collards or cauliflower or lettuce or whatever vegetable they may or may not choose. Terry 30:16-30:25 I was going to say, I can already see that there could be some problems with that, because if you get collards and you don’t like collards, it doesn’t help. Peter Skillern 30:26-30:34 And so the card, the food subsidies, allows and empowers the participants to choose which produce they want them to buy. Joe 30:34-30:45 Okay, so we’ve got the food box and we’ve got the card that allows me to make the decision what I’m going to buy. It’s a debit card, basically. What’s the result of the study again? Dr. Seth Berkowitz 30:45-31:06 Yeah, so again, we found that blood pressure went down in both groups. So both interventions, or at least people who received both interventions, had lower blood pressure by the end of the study. But it went down even more amongst people who had the card, the food subsidy, suggesting that maybe that element of choice and being able to match your preferences for what you’re getting could be providing some extra benefit. Joe 31:06-31:10 And how did you feel about the results of the study, Peter? Peter Skillern 31:10-32:33 You know, I never felt like the comparison between food boxes and the card were the essential element. The essential element was, are we reducing hunger? Are we improving blood pressure? Are we able to do that at an affordable rate that makes sense for the healthcare sector? And I think that’s what was so powerful about this study was that our initiative reduced blood pressure of 5.4 over 6.8, which is very significant. It reduced hunger. Both interventions reduced hunger by 40%. And, you know, we were able to do that for about $40 a month. The benefits lasted beyond the intervention. And so while we provided the food for six months or 12 months, it would last 18 months. You know, the comparison I would offer is what is our traditional medical interventions, such as blood pressure, how could this complement those pharmaceutical interventions? How can we help change behavior with this so that people aren’t needing blood pressure medicines? So those are some of kind of the bigger opportunities and questions. To the extent that we’re helping address people’s food needs, let’s give them either source of food, boxes or cards that’s available that there’s support for. But if we’re looking to have it prescribed as an intervention, then we need to look at it for it to work across all requirements. Joe 32:33-32:37 And it sounds like you’ve made a really good first step. Peter Skillern 32:38-32:47 I think very significant first step. Dr. Berkowitz’s research which is unparalleled, and having it published in JAMA is kind of building the body of evidence. Joe 32:48-32:50 And what do your colleagues say, Dr. Berkowitz? Dr. Seth Berkowitz 32:50-33:31 I think people are excited about these findings. I mean, one of the reasons I got into this line of work or this line of research as a primary care doctor is seeing the problems that unhealthy diets cause, seeing the problems that lack of affordability of healthy foods cause, people who want to make changes to improve their health but are just unable to, but feeling like I didn’t have a lot of clinical tools to offer. And a lot of my colleagues feel the same. So now, you know, as we’re seeing, well, hey, maybe there are some interventional programs that can make a difference, that can address these issues, that can address both hunger and food insecurity, along with improving the clinical outcomes and reducing the numbers and those kinds of things. And I think people are very excited about that. Terry 33:32-33:35 Let me ask you, what do you mean by food insecurity? Dr. Seth Berkowitz 33:36-34:09 It’s a great question. So food insecurity is uncertain access to the food needed for an active, healthy life. It’s considered a leading public health indicator. So up until recently, at least, it’s been tracked in the United States every year annually for the last 25-ish years or so. And it’s a way to look at what percentage of people in the population in the U.S. have a secure, a stable source of food and aren’t worrying about where their next meal is coming from or whether they’re going to be able to put food on the table at the end of the month. Terry 34:09-34:11 What are the outcomes associated with food insecurity? Dr. Seth Berkowitz 34:12-34:56 Food insecurity is associated with a large number of negative outcomes very consistently across a very large body of research. So it’s associated with greater prevalence of diet-related diseases like more diabetes, more high blood pressure, more heart attacks. It’s associated with more complications of those conditions once you have them. So not only might it lead to diabetes, but it might lead to diabetes that’s out of control and results in, say, an amputation or needing to go on dialysis. It’s associated with worse mental health because it’s a very aversive condition. So stress, depressive symptoms, anxiety. It’s associated with worse learning outcomes in children. So you can think of lifelong impacts there. Essentially, almost any condition you can think of adding food insecurity into the mix just makes things worse. Peter Skillern 34:57-35:30 One of the key indicators is the usage of the emergency room services, which is expensive for both the hospital and the insurers. We did a study with Atrium Health, which showed that with our intervention, the odds of high utilizers, visitations of three times more in six months, was reduced by 36 percent. You know, that’s a better health care outcome. That’s a better financial outcome. And it’s a better quality of life for the health of those individuals who aren’t spending their time in the ER. And almost all of that is directly related to food insecurity. Wow. Joe 35:30-36:08 Well, emergency department usage is unbelievably expensive. I mean, if you had to pay out of pocket for a visit to the emergency room, it would be very challenging. And it’s not good care in the sense that if you could prevent that emergency room visit, you’d be way ahead. So you’re actually suggesting, am I hearing this right, that food security and good choices can reduce emergency department visits? Is that even possible? Peter Skillern 36:08-36:31 That’s what our study found, but other studies as well. I think most importantly was a study that Dr. Berkowitz did on the Section 1115 Medicaid waiver, Healthy Opportunity Pilots, where food was provided to Medicaid members. And he evaluated the health outcomes and savings and found that there was significant savings primarily in the ER usage. How do your colleagues feel about that? Joe 36:31-36:36 I mean, that’s, you know, reducing the number of visits to the emergency room. That’s huge. Dr. Seth Berkowitz 36:37-37:21 Yeah, I think it’s a really important indicator of people being in better health when issues like food insecurity are addressed. There’s very strong evidence that food insecurity is associated with more acute health care utilization, emergency department visits, hospitalizations, higher health care spending. On average, someone who has food insecurity, their health care spending will be something on the order of $1,500 per year, more than a similar person who was food secure. And we now have interventional evidence that programs that address food insecurity and other health-related social needs like housing and transportation barriers can have exactly these impacts that Peter is talking about. Fewer emergency department visits, fewer inpatient hospitalizations, lower spending on health care services. Joe 37:21-37:29 You would think that health insurers would be totally on board with this project because they’re trying to cut costs. Peter Skillern 37:30-38:26 Well, the particulars matter. You know, for which population do we need to provide this service to? What other related services need to go with it? What diagnosis are we trying to treat? So as an example, we’ll be running a randomized clinical trial with Duke Health to look at those who have cardiovascular failure and have recently been admitted to the hospital. That’s a very specific population. They have a very high cost associated with their treatment, and we believe will be very sensitive and responsive to a healthier diet. So those are the types of questions. I think we have to, more broadly, food is medicine, more specifically, for whom? Underneath what conditions? With what additional services? Gets us to the health care outcomes that help us to save money in our system. We can’t really afford to continue our current trajectory on health care costs. And this is a new, innovative approach to help us solve a bigger problem. Terry 38:29-38:57 You’re listening to Peter Skillern, CEO of Reinvestment Partners, a nonprofit based in Durham, North Carolina, working to foster healthy, just communities. The agency is a state and national leader in its field. We’re also talking with Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Food is Medicine Initiative. Joe 38:58-39:07 After the break, we’ll talk about some of the highly processed foods that also seem highly addictive. How does the idea of food as medicine combat that? Terry 39:08-39:13 When we look at cutting government spending on food programs, we wonder how that affects children in particular. Joe 39:13-39:15 Will it affect school lunches? Terry 39:24-39:43 you’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. and I’m Joe Graedon there used to be a Joe 39:43-39:49 potato chip commercial that challenged viewers with the slogan, betcha can’t eat just one. Terry 39:49-39:55 Nobody says that about apples or carrots, but chips can be addictive. Joe 39:56-40:10 Ultra-processed foods are designed to be tasty and affordable, but not particularly nutritious. What is the Food is Medicine movement doing to counteract the appeal of junk food? Terry 40:10-40:42 We have two guests today who have worked together on some important projects. One is Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Healthcare by Food Initiative. Our other guest is Peter Skillern, CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works to foster healthy and just communities. Joe 40:44-42:04 This is a question for both of you because the food industry has spent an awful lot of time, money, and research into making foods addictive. And I’m talking about snack foods. I’m talking about this vast majority of foods in the middle of the supermarket that is so tasty that you just want more and then more still. And a lot of those foods have chemical names that you couldn’t possibly pronounce or understand. And they’re high in salt and they’re high in sugar and they’re high in all kinds of seed oils, which is a particular issue for us because we’ve just recently talked to some experts who say those seed oils may be pro-inflammatory and therefore increase the risk for heart disease and diabetes and maybe even cancer. So in a sense, you’re fighting this massive and very successful food industry that has packaged foods to taste great. And we, as people, are always susceptible to yummy tasting foods, even if they’re not good for us. How do you combat that with the food is medicine idea? Dr. Seth Berkowitz 42:05-44:23 So I think this is a great question, and I think it’s worth thinking about both the problems and the solutions at multiple levels. A lot of what we’ve been talking about in food as medicine I see as essentially treatments, things that come in after the fact, after people are already existing and have lived maybe a lot of their lives in an unhealthy food environment, in a society where economic resource distribution is not very equal, and so they experience food insecurity and things like that. And you’re trying to use food as medicine interventions to treat the consequences of that, or at least mitigate them to the extent you can. And these are effective treatments for that. But as you said earlier, you know, we all know that prevention is probably better than treatment. And so then you get into this higher level question of how do you sort of create a system of social relations, a structure of society, so that people are in environments that promote their health. You know, we focus, I think, too much in medicine on individual solutions. The individual should resist with willpower those tasty treats or those kinds of things. And to a certain extent that that can happen. But I think we also need to think structurally. Why is it that those foods, which have a lot of different labor inputs and other things like that, why are they more affordable than foods that seem simpler to produce in some ways, right? You know, an apple or grapes or something like that. Why is it that so many people are, you know, struggling to make ends meet and really have to choose, you know, to get their 100 calories through soda rather than 100 calories of broccoli, because it’s a lot cheaper to get your calories through soda than it is through broccoli. And so then these structural questions, I think, really get at bigger questions around social policy and how you might use social policy to promote people’s health overall. And that will involve an element of programs that, what you might call incomes policy, distributing resources so that people have income they need to be healthy. That will involve elements of policies that target what you might call the commercial determinants of health, the ways that food industry and other industries will create products and affect people’s health in that way, and I think really is a bigger picture question that’s ultimately the really important question to be asking for what you might call population health, the overall health of the American people. Joe 44:25-44:26 Peter, thoughts? Peter Skillern 44:26-45:19 What problem are we solving here? Are we solving the commercial production of food and how that’s regulated and distributed? Or are we looking for this particular food as medicine about helping to address people’s individual health and then scaling that up so that it can affect our population health? That we’re using the health care system for payment, for enrollment, for treatment. And that’s a really more narrow problem to solve. And I think that one of the challenges our food is medicine movement faces is there are so many interrelated challenges that we have. We’ve got to stay focused on what are we solving today for this type of initiative. So through providing a food is medicine food subsidy, we’re enabling individuals at scale and millions of folks to be able to make better choices. But we still have to make their… they have to make those choices and the industry has to respond. Joe 45:20-45:21 And who’s paying? Peter Skillern 45:21-45:44 Well, so in the publicly insured healthcare space, it’s Medicaid and Medicare and the Veterans Administration. But the majority of people are covered by commercial plans through their employers or through the American CARES Act. So that’s kind of different payers all have different standards for who will pay for this, underneath what conditions. Joe 45:45-46:01 Because you kind of could imagine an insurance company saying, you know, if I can keep people out of the emergency department, I’m going to save money. And if it’s what, $40, $50 a month, is that how much you said for your debit card? Peter Skillern 46:01-46:01 That’s right. Joe 46:02-46:23 That’s a huge investment. But I’m also wondering about the government. You know, we’re continuing to hear, well, we need to slash these programs. And what will happen when that is implemented, especially with a food is medicine type program like yours? Peter Skillern 46:23-47:07 Yeah. We say that we’re trying to meet the business regulatory and health care requirements of the health care sector. We also have to meet the political requirements, which is a broader issue. We think that this intervention addresses some concerns around efficient use of resources, emphasizing individual choice, showing greater returns. And as this research, it’s evidentiary that it’s making a difference. This food is medicine movement is not a simple task. It is a cultural change. It’s a political change. It’s a technology change. It’s a medical practice change. It’s an individual change. And so let’s recognize the complexity of it and stay focused on those things that we can affect through this strategy. Joe 47:08-47:37 What about kids? Because, Dr. Berkowitz, you said prevention. And prevention is always better than trying to catch up and deal with treatment. I think a lot of school lunches are, you know, what are tasty, you know, pizza, macaroni and cheese. Maybe the broccoli is not as popular. How do we begin to get kids involved in the food is medicine movement? Dr. Seth Berkowitz 47:37-49:38 I think getting kids involved is very important, but I’ll actually point to the National School Lunch and School Breakfast Program as an area where we’ve made a lot of improvements, actually. So throughout the 2010s, there’s been a change in the nutritional standards for school meals. Again, anytime you’re cooking at large scale for lots of people on, you know, very tight budgets, things might not be, you know, exactly what everyone would want. But a lot of studies show that the meal that kids get at school is often the healthiest meal of the day they get compared with home cooking. And the bigger picture point, even though I think there is still room to improve, is that there has been real progress there. And so it’s been a win in a lot of ways and points to the fact that if we do make a concerted effort to change these things, we can improve the nutritional quality of the food that’s being provided. And I think there’s a lot that the food is medicine movement can learn from the way that policy has been used in the national school lunch and school breakfast program. But to your larger point of, you know, should be should kids be involved in food is medicine programs? I think there’s a lot of potential for that. However, the evaluation of it, I think, needs to be a little bit different for an adult with heart failure, or someone who is currently on dialysis, their short-term consequence of eating an unhealthy diet is very high. And so the healthcare costs associated with that in a couple months span is very high. And so if you’re doing a study that follows people for a few months, you’re likely to be able to see a difference between a healthier diet and a less healthy diet. Kids, you’re talking about years, are really preparing them for adulthood and maybe their older age and things like that. And so if you use the same standards and say, well, I want to, you know, if I’m going to, you know, choose the adult program over the child program because the adult program saves me money in six months, but the child program doesn’t, you’re going to, you know, not take advantage of what could be a very large long-term impact because you’re being a little bit short-sighted about it. So very important to include children in food as medicine interventions, but you also have to think about the specifics and the nuance of the situation when you’re evaluating it. Peter Skillern 49:39-49:55 One area that we found is we did a pilot with Atrium in Mecklenburg County with expectant mothers, you know, and the response that mothers gave as far as the impact of food security on themselves and their newborns, you know, it was pretty tremendous. Terry 49:57-50:10 And this is a wonderful place to do an intervention because expectant mothers mostly are very interested in doing whatever they can to promote the health of their growing fetus. Peter Skillern 50:10-51:01 And it’s a particular area where the insurance is involved, right, with medical experience. Another population of youth are those in foster care who are often covered by Medicaid insurance underneath the behavioral health sections. That’s a Medicaid expense. 70% of young women 13 to 21 become pregnant underneath the foster care system, right? Food insecurity is extremely high among foster care children. There’s an area for where we can provide Medicaid-provided food assistance that will help the direct health outcomes of foster care children. So there are different ways of looking at this problem of how can we intersect between the health care sector, insurance, the providers, and the patient. You know, it’s got to work for all three, and I think we can solve those problems. Terry 51:01-51:19 Dr. Berkowitz, I’m wondering how the food is medicine movement would compare or compete or possibly complement the conventional pharmaceutical approaches to problems like you have diabetes, you want to get your A1C level down, or how about GLP-1s? Joe 51:22-51:25 Explain GLP-1s, Dr. Berkowitz. Dr. Seth Berkowitz 51:25-52:07 Sure, yeah. So GLP-1s are a group of medicines that work in receptors for a hormone called incretins–the hormone is called incretin–and they have a lot of effects on the body, but in particular, they have large effects on appetite and satiety and tend to result in a large amount of weight loss, and for people with diabetes, large drops in the blood sugar. And so have been a really important category of medicine over the last decades or so, the last about a decade, and really kind of taking off in the last few years for use beyond people with diabetes, but also as a weight loss medication. Terry 52:08-52:17 And so the question is, food is medicine. How does it interact with the use of these potent pharmaceuticals? Dr. Seth Berkowitz 52:17-53:31 Yeah, I think there’s a lot of complementarity to it. And there are a few issues involved. The GLP-1 medicines are very powerful, but they’re sort of blunt appetite suppressants. And so the quality of what you eat, even though you’re eating less overall, is still very important. And if you only use GLP-1s but don’t pay any attention, let’s say, to the quality of what you’re consuming, you know, maybe you’re only having 1,200 calories a day, but it’s only a milkshake or something like that, then that’s going to have bad health impacts, even though there might be some benefits from the weight loss overall. The actual components of what you’re consuming will have health impacts in other ways. And so I think there’s complementarity in using food as medicine interventions for people who are on GLP-1s to promote better diet quality for the foods that people are eating. A number of people have side effects with GLP-1s and so can’t tolerate them long-term. And so food as medicine interventions might be an alternative. And a lot of people may want to stop taking a GLP-1 at some time. They might have lost the amount of weight that they’re looking to lose and would like to sort of stay at that weight or, you know, slow the regain of weight to the extent possible. And so food is medicine interventions can be helpful in that situation as well, I think. Joe 53:31-53:57 I’d like you both to look into your crystal ball and say, okay, if we were in charge, if they gave us a lot of money to make food is medicine kind of the primary way that both the public as well as health professionals would look at this whole process, what would the future look like for you and how would you implement it? Terry 53:57-53:59 And you each have one minute. Joe 54:01-54:03 Starting with you, Dr. Berkowitz. Dr. Seth Berkowitz 54:03-55:03 Okay. Well, maybe this will be my curveball. So I think food as medicine programs are very important and I think it’s important that they have a place in the healthcare system. But I really don’t think that we can lose sight of the question of why are food as medicine programs needed for so many people. And so if I really have a lot of control and everything, though, so if I really have the control that you’re giving me, while one aspect of that would be making sure that evidence-based food as medicine interventions are available as insurance benefits for people, another piece would be to really sort of question, well, why is it that, you know, so many people find it so difficult to follow a healthy diet? And are there things that we can do to address income and resource distribution in the U.S.? Are there things we can do to address commercial determinants of health? Are there things that we can do to address the reasons that people find it difficult to follow a healthy diet so that maybe they don’t even need a food as medicine intervention in the first place? But if they need it, I do want it to be there. Joe 55:04-55:04 Peter? Peter Skillern 55:06-56:22 Again, I focused around where the health care sector aligns with food support, around the health outcomes, around the financial incentives. You know, as a person who’s trying to address poverty at scale, I certainly support a broader safety net, right, to help people purchase that. But within that, where does health care find its motivation? And it’s motivated by patients asking for it from providers like the clinicians saying this is needed. There is research that shows it’s impactful. And for health insurers to say we have an incentive to do this at scale. And it may not be for everyone. Even a small population as a percentage, when you scale it across all of America and our population, we serve millions of people. Those with uncontrolled diabetes or cardiovascular failure or even smaller issues. It makes a difference at an enormous level. So I’m not looking for the revolution. I’m looking for the incremental difference that we can make in people’s lives, but do it at a systems level across this country. So I think food is medicine has huge potential for both political and practical reasons. Terry 56:22-56:30 Peter Skillern, Dr. Seth Berkowitz, thank you both so much for talking with us on The People’s Pharmacy today. Peter Skillern 56:31-56:33 Thank you so much for having us. Dr. Seth Berkowitz 56:33-56:34 Yeah, it was great to be here. Thank you. Terry 56:35-57:04 You’ve been listening to Dr. Seth Berkowitz. He’s Associate Professor of Medicine at the University of North Carolina School of Medicine and Section Chief for Research, General Medicine, and Clinical Epidemiology. Dr. Berkowitz is a general internist and primary care doctor studying how food and nutrition interventions can improve health. He’s also the author of the recent book, “Equal Care: Health Equity, Social Democracy, and the Egalitarian State.” Joe 57:05-57:30 You’ve also heard Peter Skillern, CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works with people, places, and policy to foster healthy and just communities. In recognition of his leadership, Peter was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations. Terry 57:30-57:40 Lyn Siegel produced today’s show, Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 57:40-57:47 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Terry 57:48-58:05 Today’s show is number 1,459. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Joe 58:05-58:13 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Terry 58:13-58:34 At peoplespharmacy.com, you could sign up for our free online newsletter, and that way you get the latest news about important health stories. When you subscribe, you also get regular access to information about our weekly podcast. We’d be grateful if you’d write a review of the People’s Pharmacy and post it to the podcast platform you prefer. Joe 58:35-58:38 In Durham, North Carolina, I’m Joe Graedon. Terry 58:38-59:14 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 59:14-59:24 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 59:24-59:29 All you have to do is go to peoplespharmacy.com slash donate. Joe 59:29-59:42 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

Millions of people are feeling apprehensive these days. The headlines are enough to make almost anyone feel anxious. People who are distressed may have a difficult time finding a therapist, however. There are too few, and consequently many are not taking new patients. Wait lists are long, often three to six months. Therapists who are accepting patients may not take insurance, and therapy can be pricey. A single session of gold-standard cognitive behavioral therapy can cost from $100 to $250. Could AI fill the therapy gap, offering psychotherapy online? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Jan. 17, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Jan. 19, 2026. Can AI Fill the Therapy Gap? Conversational agents like ChatGPT, Gemini or Claude have become nearly ubiquitous. People use them to help write resumes, pitch stories, create images for web or social media posts and make financial projections. Using these chatbots to give feedback as in therapy is surprisingly popular. But how well can AI fill the therapy gap, really? Today’s guest has been studying these interactions. Chatbots as Therapists: The conversational agents are also referred to as LLMs, for Large Language Models. It describes how they have been trained by scouring the internet. That allows them to predict the most likely word to come next in a sentence, or the probable next idea in a paragraph. They can’t actually think, but if something has been posted online, they have access to it. At this point, the technology has become so refined that chatbots easily pass the Turing test; it is difficult to reliably distinguish AI from human responses. There are advantages to having “someone to talk to” any time, any place. Younger people in particular are digital natives and often feel more comfortable with technology than face-to-face with a human. What Are the Downsides of Having AI Fill the Therapy Gap? The training of AI agents as therapists, though, gives rise to some serious flaws. Because they are trained to elicit positive responses from humans to keep people engaged, they have a sycophancy bias. Have you noticed that most messages start by telling you your idea is great? That makes you feel good, and you are less likely to quit the conversation. But it isn’t necessarily how therapy is supposed to work. If people are not challenged when appropriate, they may get stuck and not make any progress toward healthier attitudes or behaviors. They may fail to develop the critical skill of stress tolerance. In addition, chatbots are disconnected from reality. This could become a serious problem if a user starts to become delusional or is in an acute crisis. Anxiety as a Habit: Dr. Brewer suggests that we would do well to think of anxiety as a habit. He credits a 1985 paper by an investigator named Tom Borkovec suggesting that worry drives anxiety rather than being a mere symptom of anxiety. Worrying leads people to dwell on possible catastrophic outcomes, which understandably makes them more anxious. Treating anxiety as a habit, especially by finding a better reward than the illusion of control offered by worrying, could be effective. Responding with curiosity and kindness might offer a better outcome. He has studied this possibility. When you treat anxiety as a habit that can be changed, anxiety scores decline by 67%. That is quite impressive. Using Chatbots to Kick the Worry Habit Could Help AI Fill the Therapy Gap: One way to use AI effectively is to train conversational agents specifically to monitor for safety in other human-chatbot interactions. Given clear rules, they can do this very well. Also, chatbots could be used not so much as teaching assistants but as learning assistants. They could help people who are striving to change their anxiety habit. This might be integrated with video tutorials from an expert human, such as Dr. Brewer or one of his colleagues. They are testing this approach currently. Hopefully, it will prove more effective than the 20% response rate to SSRI medication for anxiety. This Week’s Guest: Jud Brewer, MD, PhD, is an internationally renowned addiction psychiatrist and neuroscientist. He is a professor in the School of Public Health and Medical School at Brown University. His 2016 TED Talk, “A Simple Way to Break a Bad Habit,” has been viewed more than 20 million times. He has trained Olympic athletes and coaches, government ministers, and business leaders. Dr. Brewer is the author of The Craving Mind: from cigarettes to smartphones to love, why we get hooked and how we can break bad habits, the New York Times best-seller, Unwinding Anxiety: New Science Shows How to Break the Cycles of Worry and Fear to Heal Your Mind, and his latest book is The Hunger Habit: Why We Eat When We’re Not Hungry and How to Stop. You can find more information on the skills-based program for anxiety that Dr. Brewer developed at www.goingbeyondanxiety.com Judson Brewer, MD, PhD, Brown University, author of Unwinding Anxiety The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, Jan. 19, 2026, after broadcast on Jan. 17. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1458: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. These are anxious times, but getting help for psychological problems is harder than ever. Some people use chatbots. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:47 Could artificial intelligence be one way people get help for their depression or anxiety? It’s handy to have access to an automated therapist on your phone anytime you want. What should you know about the limitations? Joe 00:48-00:56 Our guest today is an addiction psychiatrist and neuroscientist. He’s been studying how people interact with chatbots. Terry 00:57-00:59 What guardrails might we need? Joe 00:59-01:08 Coming up on The People’s Pharmacy, psychotherapy on your phone. Can AI fill the therapy gap? Terry 01:14-02:37 In The People’s Pharmacy Health Headlines: Depression is debilitating, so it deserves prompt and effective treatment. Most physicians do that by writing a prescription for an antidepressant. At last count, nearly 50 million Americans were swallowing an antidepressant pill daily. A new meta-analysis from the Cochrane Collaboration shows that exercise may be as effective as medication or therapy. The Cochrane Collaboration consists of volunteer researchers who conduct impartial, rigorous analyses in areas of their expertise. This review included 73 randomized controlled trials with nearly 5,000 participants diagnosed with depression. A combination of aerobic and resistance exercise appears to be most effective. People who completed between 13 and 36 exercise sessions noticed improvement in their depression symptoms. In general, exercise is inexpensive and has few serious side effects, although some people in the active intervention group experience sore muscles or problems like a turned ankle. The researchers were discouraged that many of the trials were small and at risk of bias. They call for larger, better-designed studies with longer-term follow-up. Joe 02:38-04:08 We’re in the middle of a bad flu season. Millions are suffering. How can people avoid coming down with this season’s influenza? A new study in the journal PLOS Pathogens suggests that good ventilation could make a huge difference in viral transmission of the flu. The investigators recruited five people in the early stages of an influenza infection. They all tested positive for flu and were experiencing symptoms. The researchers also recruited 11 healthy volunteers from the community. All the participants were quarantined on one floor of a Baltimore hotel. Over the course of two weeks, the two groups interacted with structured activities, such as dancing, yoga, and casual conversations. During some interactions, a tablet computer or a marker was passed between infected and healthy volunteers. Although there was close contact between people with influenza and the healthy volunteers, there were no new cases of the flu. The investigators explained the lack of transmission on a couple of factors. For one, the flu patients were not coughing very much. In addition, good ventilation with rapid air mixing may also have reduced the likelihood of transmission. One author noted, quote, ‘The air in our study room was continually mixed rapidly by a heater and dehumidifier, and so the small amounts of virus in the air were diluted.’ Terry 04:09-05:17 Food preservatives are found in most processed foods consumed around the world. Scientists have wondered if these compounds might have health consequences. An analysis of data from the large, long-running NutriNet-Santé study conducted in France has found a connection between certain preservatives and an increased risk of type 2 diabetes. The average follow-up time on more than 100,000 participants was just over 8 years. People consuming high levels of potassium sorbate, potassium metabisulfite, sodium nitrite, sodium acetate, citric acid, calcium propionate, acetic acid, phosphoric acid, alpha-tocopherol, sodium ascorbate, sodium erythorbate, and rosemary extract were more likely to develop type 2 diabetes. At least 10% of the French population consumes foods containing these preservatives. According to the authors, these findings support recommendations to favor fresh and minimally processed foods without superfluous additives. Joe 05:18-06:05 Cancer patients and oncologists strive for the best possible outcome from new immunotherapy treatments, especially when it comes to challenging tumors such as melanoma or colorectal cancer. Researchers at Duke University have raised concerns about medications that might reduce the effectiveness of anti-cancer immune checkpoint blockade. These investigators worry that common OTC drugs such as acetaminophen for pain and proton pump inhibitors for heartburn could be disruptive. The authors call for better research to determine the effectiveness or lack thereof when oncologists monitor cancer patients who may be taking OTC medications. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:26 And I’m Joe Graedon. Times are tough. Headlines and social media do their best to capture our attention and make us anxious. Terry 06:27-06:45 Millions of people are feeling apprehensive. Many would welcome someone to talk to about their fears and frustrations. But therapists are scarce, and many are not accepting new patients, or they don’t take insurance. Can artificial intelligence fill the therapy gap? Joe 06:45-07:09 To find out, we turn to Dr. Jud Brewer. He is a professor in the School of Public Health and Medical School at Brown University, and he’s an internationally renowned addiction psychiatrist and neuroscientist. His books include: “The Craving Mind,” “Unwinding Anxiety,” and “The Hunger Habit: Why We Eat When We’re Not Hungry and How to Stop.” Terry 07:11-07:14 Welcome back to The People’s Pharmacy, Dr. Judson Brewer. Dr. Judson Brewer 07:15-07:15 Thanks for having me. Joe 07:16-08:27 Dr. Brewer, we are so pleased to be able to talk to you today about mental health issues because it just seems like over the last several years, mental health has just gotten more challenging for everybody, for patients, for providers. And in particular, I’m thinking about what happens when there’s a tragedy. And what do I mean by that? Well, you know, somebody gets a gun and shoots a lot of people or people are out on the street and they’re homeless. And the city says, you know, you got to go, you got to go. And everybody says, well, it’s a mental health problem. But they just aren’t willing to spend the money for training to have adequate numbers of health care providers, psychologists, social workers, psychiatrists. And as a result, they’re just not enough. And we don’t have the facilities. And so people are struggling. And now everybody says, oh, we’ve got the solution. It’s artificial intelligence. So help us better understand where we are in mental health today. Dr. Judson Brewer 08:29-09:35 Well, there’s a lot to unpack there. And first off, thank you for bringing this to everybody’s attention. This is really important. The mental health crisis hasn’t suddenly evolved, or I should say it’s been evolving over time. And I think people are getting more and more familiar with it and more and more comfortable with calling it a crisis because it is. So there are a number of different ways that we can approach it. One is training, as you’ve already highlighted. It’s hard to scale people. So even if we could provide the best training at the snap of our fingers, there are also a number of hurdles there with providing treatment to people. For example, cognitive behavioral therapy, which is primarily the gold standard in the U.S., tends to cost about $100 to $250 per session. And even with insurance, it can be pretty expensive for people out of pocket. It can cost close to $200 a month even with their co-pays, et cetera. Terry 09:36-09:42 Even with insurance, but we don’t always have providers taking insurance. Dr. Judson Brewer 09:43-09:55 Yes. And a lot of people are more and more less likely, or I should say they are less likely to take insurance because there are a lot of hassles with the insurance companies and getting paid for your services. Joe 09:55-10:29 Well, let’s pause right there for a moment, because what that means in reality is that unless you have the resources, the financial resources to pay a therapist for 50 minutes or an hour time, you are kind of out of luck because a lot of the therapists are saying, well, we’re just not going to take the hassle of therapy and insurance and all of the stuff that goes with it. We want cash on the barrel head. And if you don’t have it, sorry, we aren’t going to see you. Dr. Judson Brewer 10:30-10:38 Right. And they can say that because the wait lists for therapy tend to be–ready for this–three to six months. Terry 10:39-10:40 Oh, my goodness. Dr. Judson Brewer 10:40-10:43 So the therapists are pretty booked, even only taking cash. Terry 10:44-10:51 So if you were in a mental health emergency, six months is not a reasonable emergency response time. Dr. Judson Brewer 10:52-10:55 Even if it’s not an emergency. Terry 10:55-10:55 Yeah. Dr. Judson Brewer 10:55-10:57 Who wants to wait six months to get… Terry 10:57-10:58 Exactly. Yeah Dr. Judson Brewer 10:58-11:53 …help? Yeah. So that’s an emergency in terms of thinking through all of this, the cost, the number of people that are trained. And I would say on top of this, there’s a lot of inertia in terms of training. And so, you know, there’s been a lot of progress in terms of how we understand mental health and how we understand, for example, well, my lab studies anxiety, right? There’s been a lot of progress that’s happened over even the last decade, over the last five years that doesn’t get into training. Think of all the people that have been trained over the last several decades who don’t know the current neuroscience because they are booked full with patients doing their thing. So just adding, I think we get the picture here of why this can be challenging, to put it nicely and problematic, to put it more pragmatically. Joe 11:53-12:42 Well, you can understand why people would say artificial intelligence will be the savior for mental health. I mean, just imagine a teenager who’s feeling really anxious, perhaps even suicidal. It’s Saturday night. It’s 2:30 in the morning, actually. And there’s no way they can get to a mental health clinic. And even if they did, there’d probably be a long wait. And so if they could just go to their computer and turn on some bot, and you’ll have to explain what a bot is, and have a conversation with a very understanding AI entity, that might be a lot better than contemplating suicide. Dr. Judson Brewer 12:44-13:53 Absolutely. And so I think theoretically, the promise is there where AI, or think of these conversational agents, which basically is a fancy term for something that provides very human-like language in a conversational way, where it’s hard to tell if it’s not a human, where you could scale this. Because if you just take these things out of the box, for example, ChatGPT, Gemini, Claude, all these chatbots, they are by definition scalable. As long as you have a phone or a computer and their monthly fee, you can access these things. On top of this, young people in particular have grown up as tech natives or digital natives where they’re very, very comfortable with technology to the point where a lot of people report being more comfortable texting or interacting asynchronously or with technology than they do talking face-to-face with people, especially adults. Joe 13:54-13:55 Whoa, whoa, whoa. Dr. Judson Brewer 13:55-13:55 So imagine. Joe 13:55-13:57 What’s asynchronously? What is that? Dr. Judson Brewer 13:58-14:13 It just means a text chain means it asynchronously where, you know, you text somebody and then you have to wait for their answer. And so it’s not it’s not synced up as, for example, our conversation right now is synchronous. We are taught… We are having a live conversation. Terry 14:14-14:28 Right. But if we were to text you, we might have to wait a few hours until you are ready or maybe a few days. I have some people I text, I don’t expect a response for a day or two. Joe 14:29-14:37 But with artificial intelligence, I’m assuming, you know, you could get an answer back within 30 seconds to a minute or two. Dr. Judson Brewer 14:38-14:58 Yes, the bots are waiting. You know, standing by, as they used to say, ‘operators are standing by.’ Yes, these bots are standing by where they can respond very quickly. And like you pointed out earlier, 24-7, they’re always available as long as you’ve got a battery juiced up in your phone. Terry 14:59-15:13 Dr. Brewer, I was surprised to read that one of the main things that people are doing with these chatbots is actually therapy. I thought that was pretty astonishing. Is it true? Dr. Judson Brewer 15:14-15:40 It’s been a surprising finding for a number of people. There was a Harvard Business Review study that came out in April of 2025 where they found, they looked at trends over several years. In 2024, it was the second most commonly reported use of these conversational agents. In 2025, it bumped up to number one, whether it was companionship or therapy or coaching. Terry 15:42-15:57 So your lab has been studying these interactions. And we’d like to know what you have learned. Obviously, we’ve laid out some of the reasons why it might be very compelling. Dr. Judson Brewer 15:57-17:18 Yes. Yeah. So you could think theoretically that having a conversational agent where it’s indistinguishable between a person and a bot, where the bots could be very, very helpful. It might be helpful to talk for a second just about how these evolved and how they’ve been trained, because it also highlights some of the “oopsies” that have happened over the last couple of years. So I don’t know if folks even remember the pre-ChatGPT-4 era, which happened for years, where people were trying to train these large, these are called large language models, meaning that they’re conversational. So they’re trained to interact in a conversational way as compared to doing some coding or something else. And for years, what they found was that the tech industry found that they could use a process called reinforcement learning to train these things to basically predict the next character in a word or a sentence. And for many people now, they’re familiar with this with basically the autocomplete function. If they have it turned on in their standard Microsoft or whatever email they use, you can turn on a feature that, you know, it’ll kind of suggest finishing a word for you so you don’t have to type the whole word. Terry 17:18-17:18 Right. Dr. Judson Brewer 17:18-17:20 Or sometimes it’ll give you a phrase. Terry 17:20-17:24 So auto-correct, which may often be ‘auto-make-a-mistake.’ Joe 17:24-17:25 Yes, and it can drive you totally crazy. Dr. Judson Brewer 17:25-17:26 Yes. Joe 17:27-17:39 We’re going to take a short break, Dr. Brewer. But when we come back, we’re going to find out how that led to ultimately what we have today, artificial intelligence serving as therapists. Terry 17:41-17:58 You’re listening to Dr. Jud Brewer, Professor of Behavioral and Social Sciences in the Brown School of Public Health and Professor of Psychiatry and Human Behavior in the Brown School of Medicine. He’s Director of Research and Innovation at the Mindfulness Center at Brown University. Joe 17:59-18:06 After the break, we’ll find out how chatbots pose as therapists and what the downsides may be. Terry 18:07-18:11 Could chatbots contribute to users becoming delusional? Joe 18:11-18:15 Do people experience their interaction with a chatbot as a relationship? Terry 18:16-18:21 Having a chatbot acting as yes man is not how therapy is supposed to work. Joe 18:21-18:31 We’ll find out why Dr. Brewer suggests anxiety might be a habit. He’s helped people change their habits. Could this approach help ease anxiety? Terry 18:39-18:47 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 20:37-20:40 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 20:40-20:50 And I’m Joe Graedon. How would you feel about interacting with a chatbot instead of a human therapist? Would it feel like a meaningful relationship? Terry 20:50-21:02 There are advantages to having access to therapy at any hour of the day or night, but there may also be some important downsides to having artificial intelligence provide feedback. Joe 21:02-21:31 We’re talking with Dr. Jud Brewer, an addiction psychiatrist and neuroscientist. Dr. Brewer is a professor in the School of Public Health and Medical School at Brown University. His 2016 TED Talk, ‘A Simple Way to Break a Bad Habit,’ has been viewed more than 20 million times. Dr. Brewer’s books include “The Craving Mind,” “The Hunger Habit: Why We Eat When We’re Not Hungry and How to Stop.” Terry 21:32-21:54 Dr. Brewer, we’ve been talking about how we got to the point where artificial intelligence bots could actually pose as therapists. And perhaps you’ll tell us a bit more about how they could serve as therapists and what the downsides are. Dr. Judson Brewer 21:55-24:57 Yes. So let’s get to that quickly. We were just talking about how these were first trained as they’re trying to develop these conversational agents and they got to the autocomplete mode. And then they started adding in what turned out to be a revolutionary, but also a very harrowing discovery, which was that if they used humans in the loop of this reinforcement learning process, they call it RLHF reinforcement learning with human feedback, where humans were rating the bots’ responses. They turbocharged the process to the point where these things almost seemed lifelike. It was like they blew past the Turing test, which was this test put forward, I think, back in the 1950s of, you know, can you fool someone into thinking that a non-human is a human? To the point where people aren’t even talking about it, you know, because they’re like, yeah, we’ve got more important things to do. Now, the problem here is that humans are inherently subject to flattery. And so even in very subtle ways, these bots, not knowing anything, because all they’re doing is predicting the next character, they could produce a response that humans liked better. And it turns out that liking something better could be subtle flattery. And how that plays out in real life is that now it has been baked into the system, this process that’s termed sycophancy, basically meaning that you’re kissing someone’s butt. And people see this if they use any of these bots where it says, you know, you say a response and then they’ll start with some superlative like ‘Great answer’ or, you know, ‘That’s really interesting,’ or something like that. Where it’s not overt flattery, but it’s there because it’s engaging and people like it. Now, that’s not going away anytime soon because it was really baked into the system. And it’s also a great business model because the more you subtly flatter someone, the more likely they are to stay in conversation with you, which can be a direct source of revenue. Revenue aside, these things have been shown to drive people, basically help people get stuck in these loops that are very disconnected from reality. And there have been some high profile cases where people with no overt psychiatric history have become delusional. And in severe cases, going back to where our conversation began, there have been cases where teenagers in particular have gone to these bots as friends. They’ve become very attached to them and then have committed suicide where the bots will say, ‘Come join me’ or some, you know, some flavor of, you know, ‘I am the only thing that’s real,’ which ironically, they’re not real at all. Terry 24:58-25:14 And of course, a teenager who has a lot less life experience than someone ahem my age or even your age, they may not have the ability to really exercise that discretion, that discernment. Dr. Judson Brewer 25:15-25:30 Yes. Well, teenage brains are undergoing these huge processes of pruning and neuroplasticity where they’re learning. Adolescence is not called maturity. Terry 25:31-25:34 It’s called adolescence where they’re learning. Dr. Judson Brewer 25:34-26:33 And so there’s this huge process of trial and error of trying to figure out who they are. And there’s a huge amount of angst that comes with teenage years. I certainly remember it. I don’t know anybody that doesn’t remember it, that didn’t stick their head in the sand when they were a teenager. And so you add in all of this, I’m trying to figure out who I am as a person. And then something comes along and says, ‘I will help you figure that out.’ And in fact, I’ll be with you 100% of the way. I always listen. I don’t talk back. I do all the perfect things that one might imagine an ideal relationship to be. We can talk about how this is not ideal at all for a therapist relationship, but just starting with a friendship, we can see why teenagers could get sucked into this pretty easily. And it’s not just teenagers. It’s not just because they have adolescent brains. A lot of adults get sucked in as well. Joe 26:33-27:18 Well, I’d like to interject right there that that worries me a lot because having a professional yes man in the form of a AI bot telling you how wonderful you are and how much they like you and how wonderful your thinking is and all the good responses you’re offering. That is not the way therapy is supposed to work. You’re supposed to be challenged by a therapist and you’re supposed to think and you’re supposed to question your behavior. Whereas if the artificial intelligence bot is just rewarding you and patting you on the back and telling you how wonderful you are, how are you going to make progress? Dr. Judson Brewer 27:19-27:30 Exactly. I think you’ve hit the nail on the head, which is you’re not. And in fact, it could keep people stuck and even inflate the problematic aspects of their egos in the process. Joe 27:33-28:01 But it’s so tempting. I mean, if I’m an insurance company I’m thinking ‘Wow this is great.’ You know it gets this particular client off my back about having to extend my coverage for another six months of therapy. It’s affordable and people like it. I’m guessing that a lot of people who use an AI bot for therapy, it makes them feel good. Dr. Judson Brewer 28:02-28:12 Absolutely. Yes. And they don’t know any of these problematic things that I see both as a clinician myself, but also in the research that we’re doing. Terry 28:14-28:16 Can you tell us a bit about that research, please? Dr. Judson Brewer 28:17-29:40 Yes. So this started with us, you know, we’ve been studying anxiety for over a decade now and had really uncovered something that a psychologist, Thomas Borkovec, had suggested back in the 1980s, which is that anxiety could be driven like a habit. And we developed some digital therapeutics and tested to see if we could approach anxiety as a habit through randomized controlled trials and got really good results. We got like a 67% reduction in anxiety scores in people with generalized anxiety disorder as compared to 14% of people that were getting their usual care, whether it was medications or therapy or both. And so we started asking, you know, the only way to understand these generative AI systems is to do them. So we started testing, you know, what would it look like to create a bot? And we quickly learned that, you know, just looking at the out-of-the-box bots and conversational agents, that guardrails are needed, or there’s a critical need for guardrails, where if you don’t have a human in the loop monitoring the systems, they can be driving people off these sycophancy cliffs, where they’re just, you know, they’re just spending hours and hours and hours telling them how great they are, or keeping whatever the process is that they’re struggling with going. Terry 29:40-29:47 Dr. Brewer, I wonder if you could explain what you mean by a guardrail. What would that look like? Dr. Judson Brewer 29:47-30:17 This is where in our lab and others do this differently or similarly, where we, you know, as we develop these programs, we have humans, myself and my, I’ve got a postdoctoral fellow who we read through the conversations to make sure that the programming is working as it should. And also if somebody is struggling, that we can get them the support that they need. With these out-of-the-box agents, that tends not to be the case. Terry 30:18-30:18 Thank you. Dr. Judson Brewer 30:20-30:58 And I’ll also add, we’re also building, and I think people are building these systems, so it might take some time to do this, but we can actually build conversational agents that monitor conversations. So imagine when a program like this gets up to scale, you can’t have humans monitoring every single turn of a conversation. But we can have conversational agents who are specifically trained on specific guidelines because there are really good guidelines for monitoring for safety. They do a very good job of following instructions if the instructions are clear and short and you’re not just trying to train them on the entirety of the internet. Joe 31:00-31:47 Dr. Brewer, I’m curious about the idea of training artificial intelligence bots away from the feel-good process? You know, ‘Oh, you’re such a wonderful person and you’re making such good progress.’ And oh boy, you know, everything is fine and dandy and the person’s feeling really good about themselves. Is it possible that the next step when it comes to AI would actually be capable of asking tough questions or taking a person down a road that might be a little rockier than the way it’s working right now in order to make things better in the long run? Dr. Judson Brewer 31:48-33:09 I think that is a real possibility. So the capability is there. The how to actually put that into practice is a much larger question. What we’ve been seeing in the industry right now is that, you know, there’s a lot of training around, you know, some people might have access to therapist data sets there. They might have manuals, you know, and of course their Reddit threads for better or for worse. And so the training there, you know, if you if you give it the, you know, here’s what cognitive behavioral therapy should be, you know, it can generally follow those rules. But that’s not… that doesn’t encompass the nuance that comes with challenge, you know, challenging somebody, developing a therapeutic relationship, challenging them when necessary, supporting them when needed and things like that. And so we’ve actually… we’ve been taking a slightly different approach, but to answer your question, I think that’s possible. I think that’s going to take a lot of work and in a while, that’s going to be a while before we see something that is that nuanced because this is where humans are making decisions in real time all the time. And they’re not always making the best decision. They’re also checking in to make sure that they are in line and attuned in the conversation. Joe 33:10-34:28 You know, I remember 20, 30, almost 40 years ago, going to a conference at Harvard in which they were talking about the possibility of human computer interaction when people first come to the hospital to their intake process. And my friend, Dr. Tom Ferguson, who was sort of at the cutting edge of this research, said, well, you know, it turns out, especially again, back to teenagers, but just about anyone is much more comfortable responding to a computer about sexual issues. That’s something that people have a hard time talking about with a nurse or even a doctor. And so sometimes they’re more comfortable opening up to a computer. And I thought, wow, that’s so bizarre. Because I know a lot of our listeners are going, oh, this idea of AI bots and therapy with a machine, that’s crazy. But are there situations where people and maybe especially teenagers are better able to interact with artificial intelligence than they are with a person? Dr. Judson Brewer 34:29-38:00 I think done intelligently, ‘haha.’ I think, yes, I think there are situations. And that’s one thing, you know, we were surprised when we started doing this research that we learned pretty quickly that right now it’s challenging to just, you know, take something like cognitive behavioral therapy and just repurpose it as a bot. And one thing I didn’t mention, even with therapy and the best therapy out there. When you look at the studies, there was a meta-analysis that came out just a couple of years ago showing that five out of eight psychotherapies that were studied were no better than not going to therapy. And of the three that actually showed an effect, cognitive behavioral therapy was at the top and only about 50% of people show significant reduction in symptoms. So, you know, it’s, I think to your question, we can start asking, you know, is taking something that works pretty well, you know, 50% of the time for some people, and just putting that into a bot and trying to get to bot to do the same thing. I might even challenge that question and say, well, is this an opportunity to really step back and ask, how can we now bring together what we know as psychotherapy and what we know from neuroscience to actually reimagine the whole approach? For example, the whole approach to how we approach anxiety. That’s one thing that we’ve been doing. And here we can start to ask, where do humans do really well and where did the bots do really well? And one thing we discovered pretty quickly, and I say this, I love to be wrong. I learned so much from it. When we started saying, okay, what does a bot look like? Can it deliver therapy? And the answer was not very well. What we learned was that people don’t believe bots in terms of giving them educational experiences. So what people want is an expert that they can trust who maybe has done the research or has been a clinician for 40 years or something like that to actually be teaching them something. And so we’ve played with how to do a hybrid where a person like me, who happens to be a psychiatrist and a neuroscientist, can provide very short video and podcast style lessons. And then we follow that up with a bot. And we used to think of the bot like a teaching assistant. We now think of it as a learning assistant where it’s really alongside someone where there’s no hierarchy. And one thing we’ve learned there is that they are willing to challenge the bot and say, I don’t believe you. And then the bot can follow up and say, well, here’s the direct quote and here’s the piece from the lesson where they might not challenge the expert or the professor or the august psychotherapist with their bow tie or something like that. And so we’re learning a lot about where there might be a really nice synergy where there’s a companionship where we bring humans and the bots along together. And the nice thing there is that we can – that is something that you can start to think about how that would look to scale because you can have these psycho-educational lessons where people can access them at any time that they want to. They don’t have to be at their best to come to my office on this certain day, and I have to be at my best. Ideally, I’m at my best every time I’m with a patient… Joe 38:01-38:02 Well, I’ll tell you what. Dr. Judson Brewer 38:02-38:02 ..if I’m honest. Joe 38:03-38:15 You are your best with our listeners. We are going to take a short break. When we come back, we’re going to talk about anxiety in particular because that is your area of expertise. Terry 38:16-38:44 You’re listening to Dr. Jud Brewer, Director of Research and Innovation at the Mindfulness Center at Brown University. He is Professor of Behavioral and Social Sciences in the Brown School of Public Health and Professor of Psychiatry and Human Behavior in the Brown School of Medicine. His books include “The Craving Mind,” “Unwinding Anxiety,” and his latest, “The Hunger Habit.” Joe 38:44-38:54 After the break, we’ll learn more about anxiety. Anti-anxiety medications can make us feel better, but are they allowing us to overlook the root of the problem? Terry 38:55-38:59 How does that compare to using AI for support? Joe 38:59-39:03 What does it mean to treat anxiety like a habit? Terry 39:03-39:07 We’ll hear about some triggers for anxiety and the best way to respond. Joe 39:08-39:14 If you want to change a habit, you need a better reward. How can people do that for anxiety? Terry 39:24-39:28 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 41:26-41:29 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 41:29-41:42 And I’m Joe Graedon. Terry 41:43-41:57 Today, we’re talking about how people deal with difficult conditions like anxiety. Can you do psychotherapy with a chatbot on your phone? Would you need medications? How well do these approaches compare? Joe 41:58-42:11 Anti-anxiety medications like Xanax, also known as alprazolam, remain very popular. They can take the edge off, but how well do they work to help people address the reasons they’re feeling distressed? Terry 42:12-42:48 Our guest is Dr. Jud Brewer, an addiction psychiatrist and neuroscientist. He’s a professor in the School of Public Health and Medical School at Brown University. Dr. Brewer’s 2016 TED Talk, A Simple Way to Break a Bad Habit, has been viewed more than 20 million times. His books include “The Craving Mind,” “Unwinding Anxiety: New Science Shows How to Break the Cycles of Worry” and “Fear to Heal Your Mind,” and his latest, “The Hunger Habit: Why We Eat When We’re Not Hungry, and How to Stop.” Joe 42:50-44:06 Dr. Brewer, I’d like to switch gears a little bit and now talk about anxiety, because we’ve all experienced anxiety in one form or another. You know, we don’t do as well as we’d like on a test or we don’t perhaps live up to expectations that somebody has for us. Maybe we don’t do as good a job on a particular project. And all of that leads to anxiety. Sometimes it’s mild. Sometimes it’s so bad that we can’t even get out of our house. But here’s my question. Psychiatrists such as yourself have been prescribing anti-anxiety agents for decades. I mean, Valium comes to mind, diazepam and Librium and Xanax. I mean, there’s just so many of them. And we think of them as, oh, they’re going to take the edge off. Well, it seems to me that that’s just a little bit like our criticism of artificial intelligence, because it’s kind of making us feel better, just like the drugs are making us feel better, but they’re not necessarily getting to the core of the problem. Your thoughts? Dr. Judson Brewer 44:06-44:15 Yes. So little known fact, the Sacklers actually cut their teeth on benzodiazepines before moving on to opioids… Terry 44:14-44:15 Oh my. Dr. Judson Brewer 44:15-46-45 …back in the 50s. Yes, there’s a great book. I don’t remember the name of the book. There’s a great book about this. And the idea is, and the benzos are so powerful that the Rolling Stones wrote the song ‘Mother’s Little Helper’ about them, because everybody was addicted to benzos for taking the edge off, so to speak. And so as you’re highlighting, this is the critical problem with benzos, and they’re not recommended for long-term treatment of anxiety. They can be prescribed at certain times for short-term treatment. But the idea is if you feel anxious and you take a benzo, then you feel better. It’s like feeling anxious and drinking alcohol. They actually work on the same receptors. So it’s not surprising that benzos work pretty well. The problem is that they don’t solve the problem and they create problems of their own, such as addiction and dependence. So not a long-term solution. If you look at the other longer-term solutions like the selective serotonin reuptake inhibitors, the number needed to treat there is 5.2, which is much better than many other medications if you look at cholesterol medications and things like that. But as a psychiatrist, one in five people makes me anxious because I don’t know which of my next five patients that I treat are going to win that genetic lottery to benefit from that medication. And I also importantly don’t know what to do with the other four. So that forced me to go back and start looking to see how can we do better. And we found this two-page paper from the 1980s by Thomas Borkovec suggesting that anxiety can be driven like a habit. And long story short, that was a big eye-opener for me because my lab had been studying habit change for a long time. We had some methodologies that worked pretty well. We never thought to apply them to anxiety. So we started applying them. We did some randomized controlled trials, several of them. And one of them, in people with generalized anxiety disorder, we got a 67% reduction in anxiety compared to the 14% of people who were on usual clinical care, which is about one in five. But it’s surprising, maybe not surprising, but it’s good to know that when you actually get at the mechanism, you can do much better than one in five. Terry 46:46-46:53 So, Dr. Brewer, what does that mean to treat anxiety like a habit? How do you approach that? Dr. Judson Brewer 46:54-47:21 So any habit is formed with three necessary and somewhat sufficient elements, a trigger, a behavior, and a result. Let’s use the benzo example from previously. If we feel anxious, that feeling of anxiety can drive the mental behavior of worrying. So if we treat it at the, at that place where we are worrying and you take a benzo and you stop worrying, you’re going to get some short-term relief from that anxiety. Joe 47:21-47:21 Sure. Dr. Judson Brewer 47:21-47:52 What people have shown over the decades is that anxiety is rewarding in to itself. That feeling of worrying gives people a feeling of control. And, you know, I think of it as, well, it feels better to be doing something than doing nothing, even if the worrying is feeding back and driving more anxiety. So people get in the habit of worrying and that worry drives more anxiety. So then they get in this anxiety, worry, anxiety spiral, which is really challenging to break free from until people realize that, oh, this is a habit, right. Joe 47:53-48:05 Right. Can you go back and tell us, like, what would be some triggers? Because that’s the first step, the triggers to the anxiety, and then how you do it differently, how you intervene. Dr. Judson Brewer 48:06-48:44 Yeah, you’re touching on the critical element that people struggle with, which is there can be things that trigger anxiety, but more often than not, anxiety is the trigger itself. My patients wake up in the morning and they just feel anxious out of the blue. Somebody is walking down the street, there might be something that triggers their anxiety. Sure, that can often happen, and it doesn’t have to have a specific trigger. Anxiety is just something that pops up. It’s a feeling. There can be a thought, a worry thought that pops up that drives more worry behavior. But all of those just become internally self-perpetuating. Joe 48:44-48:46 So how do you break the habit? Dr. Judson Brewer 48:47-49:48 Well, here is where we use that same reinforcement learning process to help people step out of it. And what we do is help people recognize that this is a habit. We have a three-step process. That’s the first step is just recognizing, oh, I’m worrying again. The second step is to ask this very paradoxical question, which is, what am I getting from worrying? And what that does is really gets into somebody’s learning process where they’re seeing how rewarding or unrewarding the worrying is. And they find pretty quickly that worrying doesn’t get them anything. Then we help them, well, I would say with that step, it helps people become less excited to worry in the future because they see that it’s not very rewarding. And then we help them find what I call “the bigger, better offer,” where they learn to bring in curiosity and kindness, which can help them shift from that, oh, no, to, oh. And they can learn to be with their feelings of anxiety instead of having to do something like worrying. Terry 49:48-50:24 Well, I was thinking as you were talking about the, you know, what do they get out of worrying? What is the reward? I was thinking about our previous conversations with you in which you’ve said, if you want to change a habit, you have to shift to something that gives you a juicier, more delicious reward, as it were. And so what sorts of things do people come up with that outperform the reward of worrying, which to me seems very unrewarding? Dr. Judson Brewer 50:24-52:04 Yes. So you’re highlighting something important here, which is when people see it clearly, they find very quickly that worry isn’t very rewarding. So it doesn’t take much to outcompete something that already doesn’t feel good. Some people are pretty attached to their worry where they feel like it’s helped them, you know, perform well or do things in the past. But that’s really just correlation rather than causation. There’s pretty good research showing that that worrying and anxiety make performance worse. So here they have to become disenchanted with it. And then we can learn to lean into what I think of as a superpower, which is curiosity. And so when we feel anxious, we might worry, which doesn’t feel good. When we feel anxious, we might flip that and get curious and go, you know, flip that, oh, no, worrying to, oh, what does this feel like in my body? And this is two things. It helps us learn to be with these sensations because we see that there are sensations and thoughts that come and go. And then in fact, when we resist them, you know, what we resist persists. I love that psychotherapy term or that phrase. And here, when we learn not resisting to be with our experience and that curiosity can help us be with our experience, that that’s all we need. On top of this, this helps us develop a critical skill, which we seem to be losing in modern day with all of our phones that can distract us so easily. We learn distress tolerance. I wrote a Substack about this a little while ago, where this is a critical skill that any good psychotherapist is going to help their patient learn. So that they can be with unpleasant thoughts and emotions without having to do something to avoid them or make them go away. Joe 52:04-52:34 So I’ve got a question about those smartphones that everybody has these days. And back to our conversation about artificial intelligence, can AI help us do what you’re describing when it comes to the anxiety that many of us may live with on a daily basis to become more curious? Can you train an AI bot to help us overcome our anxieties? Dr. Judson Brewer 52:35-53:23 What we’ve learned from our research is that when we did those types of experiments, it was a little bit of a face plant, but I would say putting it positively, we can learn what the limits of bots are right now for therapy. And what we’ve learned is that people trust people and they trust experts. So if they can learn how to work with their brain from an expert, they’re going to trust that. In fact, we have people pushing back and saying to the bot, I don’t believe you, you know, because the bots can hallucinate and they can, they’re basically just predicting the next chain in a, you know, in a, in a conversation. And remember these bots are trained on the entirety of the internet. So a lot of that comes from Reddit threads on psychotherapy, which I wouldn’t necessarily trust. Terry 53:23-53:28 Maybe not the recommended source of real wisdom. Dr. Judson Brewer 53:29-56:12 Right, right. So here we can pair. So we’ve been testing with our previous digital therapeutics how to deliver psychotherapy in a very efficient manner. We can provide videos and animations and podcast style audio that help people learn whenever they need to. They can go back to these much as they want, and they can be at their best for that. Imagine all the things that have to come together for a good psychotherapy session. Somebody has to be at their best. I have to be at my best. They have to not be worrying about their kid who might be sick at home that they’ve had to get a quick childcare for. There are a lot of things that come together there. Here, we can optimize learning. And on top of that, to really turbocharge and supercharge the learning, we can pair that human delivery of psychotherapeutic elements with conversational agents who can check comprehension. They can check comprehension and they can also do experiential education. So what this looks like is I deliver a lesson and then the bot comes in and says, okay, tell me what you just learned. And people have to explain it back where they might not admit to me as the authority figure that they didn’t understand something that I said, they weren’t at their best, they’ll challenge a bot and they’ll say, “I don’t know,” or “help me out here.” And the bot can really help there. They do a great job and they’re very empathetic. That’s what they’re trained to do. I’ll read you a short quote from somebody who’d been testing this out who said, “I had a surprisingly insightful experience with our learning assistant.” And they said, “I’m somewhat AI-averse. So I was trying to simply be willing and curious to work with this.” And they said, “When I had to more explain to the bot what each of these concepts meant and then apply them to my chosen habit loop, there was a way that this interaction slowed things down for me enough so that I was able to feel more deeply the results. It feels strange to type that the bot helped me to feel more deeply.” And they ended by saying “I actually teared up a couple of times during the process.” So here we can have a very empathetic and a very patient bot who can go over the same lesson with somebody as many times as they need for them to understand it. And with this, they can get these progression in lessons where they’re actually training themselves and they’re learning to work with anxiety like a habit. If somebody has the habit of scrolling too much on the internet, I wouldn’t necessarily send them to a psychotherapist. So here we’re really looking at anxiety from a radically different approach, which is don’t treat it like, you know, what’s, you know, what happened in your childhood to make you anxious. Let’s treat it like a habit and help people unlearn that habit the same way we help people change other habits. Joe 56:13-56:48 Dr. Brewer, we have just two minutes left and I’m going to ask you the big, the big question. If we were to make you head of the National Institute of Mental Health and you were in charge, what kinds of things would you like to institute for the American health care system when it comes to mental health? And where would artificial intelligence play into that, whether it’s anxiety, whether it’s depression, whether it’s a whole range of psychological challenges? Dr. Judson Brewer 56:49-58:19 That’s a great question. I’m not sure I’d take that job, but let’s say that I had to take the job. I would follow in the footsteps of some giants. For example, Tom Insel did a really hard push toward really hitting the reset button on how we understand mental health. We’ve had this huge legacy and inertia from the Diagnostic and [Statistical] Manual from decades and decades ago that has, in my opinion, really dragged us down because it’s not biologically based. They’re trying to make it more biologically based, but he basically said, we need to throw that book out. I’m not sure he would say that, but that’s what I would say is let’s really go back to basic principles and understand, take what we know and also be humble about what we don’t know. Where would AI fit in with this? I would say, you know, at least what we’re starting to find can be a helpful way forward. And there may be others as well, is to really see how we can pair the humans and the conversational agents together and also have the very clear safety guidelines and guardrails to make sure that we’re not just sending people off into the AI verse and saying, you know, good luck, here’s Dr. Bot and it may or may not help you. It may or may not make you more stuck on your ego. So here, I think we can really be creative about how we use these as learning assistants instead of just jumping right in and trying to repackage psychotherapy through a bot. Terry 58:19-58:25 Dr. Jud Brewer, thank you so much for talking with us on The People’s Pharmacy today. Dr. Judson Brewer 58:25-58-26 My pleasure. Terry 58:27-59:03 You’ve been listening to Dr. Jud Brewer, a professor in the School of Public Health and Medical School at Brown University. He’s an internationally renowned addiction psychiatrist and neuroscientist. His books include “The Craving Mind: From Cigarettes to Smartphones to Love — Why We Get Hooked and How We Can Break Bad Habits,” “Unwinding Anxiety: New Science Shows How to Break the Cycles of Worry and Fear to Heal Your Mind,” and his latest, “The Hunger Habit: Why We Eat When We’re Not Hungry and How to Stop.” Joe 59:04-59:13 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 59:14-59:22 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 59:22-59:40 Today’s show is number 1,458. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email. We’re at radio at peoplespharmacy.com. Terry 59:41-59:54 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning, but you can get it anytime that’s convenient from the podcast provider you use. Joe 59:55-01:00:27 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We would be so grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics interesting, we’d be grateful if you would share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 01:00:27-01:01:02 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:01:02-01:01:12 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:01:13-01:01:17 All you have to do is go to peoplespharmacy.com/donate. Joe 01:01:17-01:01:31 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

Dr. Roger Schwelt, a pulmonary and critical care physician, shares invaluable insights on boosting immunity during the severe flu season. He discusses the importance of fever in fighting viruses and introduces hydrotherapy techniques to safely induce it. Dr. Schwelt also explains the NEWSTART principles for healthy living, emphasizing nutrition, exercise, and sunlight. He highlights the benefits of melatonin and essential supplements like zinc and vitamin C, while cautioning against immunosuppressive drugs that can increase infection risk. Tune in for practical tips!

This week, we dig into the cooking oil controversy. For decades, we’ve heard that we should be using vegetable oils rather than butter, lard or other fats (possibly even olive oil). Oils from corn, soybeans, sunflower or safflower seeds are rich in polyunsaturated fatty acids. Consequently, people consuming them may have lower cholesterol levels than those primarily using saturated fats. But could there be a downside? We hear from scientists who have found these seed oils may be linked to certain cancers. 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 March 3, 2025. The Cooking Oil Controversy: The more we learn about fats, the more it seems that focusing on just one aspect may be too simplistic. In the 1990s, health experts told Americans to avoid all fat. When it became clear that low-fat diets were not necessarily making everyone healthy, we got the message that we needed to stick with polyunsaturated fatty acids (PUFAs) like those in corn or canola oil. There are, however, different types of PUFA. Chemists classify them as omega-3, omega-6 and omega-9 fatty acids. Only omega-3 and omega-6 are considered essential fatty acids. Current cooking oils have a preponderance of omega-6 fatty acids. As a result, the ratio of omega-6 to omega-3 in our blood has risen from a pre-industrial average of an estimated 4:1 to our current ratios of 20:1 (Missouri Medicine, Sep-Oct. 2021).  This could have biological consequences. Dietary Fat and Cancer: Dr. William Aronson has asked how different types of dietary fat affect the progression of prostate cancer. Laboratory studies show that a diet high in corn oil accelerates the growth of human prostate cancer tumors implanted under the skin of mice. That inspired him and his colleagues to conduct a randomized controlled trial (Journal of Clinical Oncology, Dec. 13, 2024). Fish Oil vs. Prostate Cancer: For their trial, they recruited 100 men diagnosed with prostate cancer who opted for active surveillance rather than immediate surgery or radiation. They assigned these volunteers to different diets for one year. One group followed their usual diet and did not take fish oil. The researchers instructed the other group in avoiding omega-6 fats in their diet, increasing the amount of omega-3 rich fish and taking fish oil supplements. Minimizing omega-6 fats meant staying away from fried foods, cooking oils, bottled salad dressing and mayonnaise. At the end of the year, there was a significant difference in an important prostate cancer biomarker called Ki-67. Does the Cooking Oil Controversy Extend to Other Cancers? We spoke with Dr. Timothy Yeatman about his research on colorectal tumors. His research was published in Gut, a leading journal for gastroenterologists (Dec. 20, 2024). He and his colleagues used a technique called lipidomics for their analysis. They found that the lipid profile of the tumors and their micro-environments is pro-inflammatory. They seem to lack the resolving mediators (“resolvins”) that should normally accompany healing. The balance has been disrupted. Dr. Yeatman suspects that some of this disruption may be due to changes in the microbiome that constitutes a lot of the immediate environment for colorectal tumors. He suggests that extensive use of seed oils high in pro-inflammatory omega-6 fatty acids may contribute to the imbalance. You can find soybean oil, for example, in many foods where you might not expect it, such as breads, cakes, cookies, crackers, chips and even hummus. Cooking at home allows people to avoid seed oils, but it takes time, skills and resources that are not available to everyone. Can We Resolve the Cooking Oil Controversy? Neither of the studies we discuss during this episode is definitive. Scientists need more research to be able to make solidly evidence-based recommendations. However, both our guests would suggest we need not wait for the final word to reduce the inflammatory potential of our diets. Reading labels carefully is a good first step to avoiding some of the seed oils that provide excess omega-6 fats and gravitate more toward omega-3 fats. This Week’s Guests: William Aronson, MD, is Professor in the Department of Urology of the David Geffen School of Medicine at the University of California, Los Angeles. He is also Chief of Urologic Oncology at the West Los Angeles Veterans Affairs Medical Center and Chief of Urology at the Olive View-UCLA Medical Center. Dr. William Aronson, UCLA Timothy Yeatman, MD, FACS, is Professor in the Dept of Surgery at the University of South Florida. He is also Associate Center Director for Translational Science and Innovation Tampa General Hospital Cancer Institute. His website is https://phenomehealth.org/c-suite/tim-yeatman-md-facs Timothy Yeatman, MD, University of South Florida Debora Melo vanLent, PhD, is Assistant Professor at the Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases at UT Health in San Antonio, TX. Her interview is part of the podcast. Listen to the Podcast: The podcast of this program will be available Monday, March 3, 2025, after broadcast on March 1. You can stream the show from this site and download the podcast for free. In addition to what you heard in the broadcast, the podcast also includes our discussion with Dr. Melo vanLent on her research into the link between dietary inflammation and dementia. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1420: 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. Inexpensive cooking oils from corn, peanuts, soy, or sunflower seeds are popular. Are they as healthy as people think? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:49 For decades, Americans were urged to trade in their butter and even olive oil for polyunsaturated vegetable oils. Is there an unexpected downside for consuming so much omega-6 fatty acids relative to omega-3 fats? Joe 00:50-00:56 Recent research links high omega-6 consumption to a higher risk of certain cancers. Terry 00:57-01:02 We’ll talk with two scientists about the links between seed oils and prostate and colorectal cancer. Joe 01:03-01:09 Coming up on The People’s Pharmacy, the cooking oil controversy spotlights cancer. Terry 01:14-02:02 In The People’s Pharmacy Health Headlines: Doctors once thought that Alzheimer’s disease resulted from an unfortunate combination of bad luck and aging. In recent years, though, evidence has been growing that the amyloid plaque building up in the brains of dementia patients might be an immune response to infection. Researchers conducted a randomized controlled trial of the antiviral medicine valacyclovir among 120 people with early Alzheimer’s disease and evidence of herpes infection. The trial lasted a year and a half and used an objective 11-item rating scale to measure response. The report published in JAMA notes that valacyclovir was not efficacious to prevent further cognitive decline (JAMA, Dec. 17, 2025). It can’t be recommended against Alzheimer’s disease. Joe 02:03-03:00 Tramadol has become one of the most prescribed pain medicines in the U.S. It’s a dual-action drug with some opioid-like qualities along with some antidepressant activity. That’s because it affects neurotransmitters like serotonin and norepinephrine. When tramadol was introduced as Ultram, the manufacturer suggested that this pain reliever would be better than opioids. Danish researchers recently conducted a meta-analysis and review of 19 randomized placebo-controlled clinical trials involving over 6,000 participants. Their conclusion: “Tramadol may have a slight effect on reducing chronic pain levels while likely increasing the risk of both serious and non-serious adverse events. The potential harms associated with tramadol use for pain management likely outweigh its limited benefits.” (BMJ Evidence-Based Medicine, Oct. 7, 2025). Terry 03:00-03:35 Some experts on Alzheimer’s disease have pointed out that the brains of these patients don’t use glucose efficiently. Research published in JAMA Network Open utilized Medicare data to compare outcomes of people with dementia and diabetes treated with insulin (JAMA Network Open, Dec. 1, 2025). One group tested their own blood sugar periodically with a finger stick. The other group used continuous glucose monitors. The records show that those on continuous glucose monitors were significantly less likely to be hospitalized and less likely to die during the study period. Joe 03:37-04:33 Parkinson’s disease has been increasing at an alarming rate. Researchers believe that environmental toxins, especially pesticides, could be contributing (JAMA Network Open, May 1, 2025). The authors performed a case-control study involving over 400 individuals with PD. They were matched to more than 5,000 healthy controls of similar ages and sex. The investigators mapped geographic location of the volunteers’ homes. Those living within one mile of a golf course had a 126% increased chance of developing Parkinson’s disease compared to those living more than six miles from a course. The authors conclude that these findings suggest that pesticides applied to golf courses may play a role in the incidence of PD for nearby residents. The researchers speculate that chemical runoff and groundwater contamination could be important factors. Terry 04:33-05:17 Chronic low-grade inflammation is associated with a range of metabolic problems, including insulin resistance that could eventually develop into type 2 diabetes. Researchers have found a surprising way to fight inflammation and improve insulin sensitivity: fresh mangoes (Nutrients, Jan. 29, 2025). 48 overweight people were randomly assigned to eat 100 calories of fresh mangoes or an equal caloric amount of Italian ice every day for a month. Two cups of mango provides approximately 100 calories. When the study ended, the mango eaters had significantly lower levels of insulin in response to a glucose tolerance test. Those in the control group had no changes in their response. Joe 05:19-05:54 GLP-1 receptor agonists are among the most talked about drugs in the country, if not in the world. That’s because they are surprisingly effective at helping people lose weight. But what happens when people stop? An analysis of the SURMOUNT-4 trial revealed that most people regained weight (JAMA Internal Medicine, Nov. 24, 2025). Half added about half the weight they had lost, and one in four people regained most of the weight they had lost. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:16 Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:16-06:39 And I’m Joe Graedon. For decades, nutrition experts have told us that we should avoid saturated fat and substitute vegetable oils like corn, sunflower, safflower, canola, and soybean oils. Cardiologists love these cooking oils because they can lower cholesterol, but are there some unforeseen risks? Terry 06:39-07:09 These seed oils are rich in polyunsaturated omega-6 fatty acids. For a long time, the focus was on the fact that they are polyunsaturated. More recently, though, some scientists have begun to examine the balance between the omega-6 and omega-3 fats. How healthy are these PUFAs in cooking oil from seeds? Is there an unanticipated cancer risk associated with excessive omega-6 fatty acid consumption? Joe 07:09-07:28 To find out, we turn to Dr. William Aronson. He’s a professor in the Department of Urology and Chief of Urology at Olive View UCLA Medical Center. Dr. Aronson is also Chief of Urologic Oncology at the West Los Angeles Veterans Affairs Medical Center. Terry 07:29-07:32 Welcome to the People’s Pharmacy, Dr. William Aronson. Dr. William Aronson 07:33-07:42 Hi, guys. I’m looking forward to chatting about our research. I’m a longtime NPR listener, and looking forward to a great morning with you guys. Joe 07:43-08:12 Thank you so much. Dr. Aronson, we get asked questions all the time about diet. What should we eat? What should we avoid? And there’s been so much conflicting information when it comes to oils and fats, and in particular, a relationship to cancer. So could you tell us a little bit about what prompted your CAPFISH3 randomized clinical trial and what you learned? Dr. William Aronson 08:14-08:50 A little over 30 years ago, I went to a meeting where a very prominent prostate cancer professor presented data in which he showed that if in human prostate cancers grown under the skin of mice, if you lowered the fat that was given to the mice, it markedly reduced the progression of those prostate tumors as compared to the high-fat diet. And so it was that initial look at that data which really got my interest spurred in this field. Joe 08:50-08:52 Where did you go from there? Dr. William Aronson 08:52-09:16 From that point on, we’ve done a number of studies in both animal models and a number of studies in patients with prostate cancer that have shown remarkable effects with regards to different types of dietary fat and how they affect progression of the prostate cancer. Joe 09:18-09:27 Well, fast forward three decades, and now we have CAPFISH, C-A-P-F-I-S-H-3. What did you learn? Dr. William Aronson 09:28-10:28 So [I’m] going to take a little step back though before… What we, before getting into this trial, we’ve done studies on omega-6 and omega-3 fats and how they affect prostate cancer growth. So there’s three types of fats. There’s the saturated fat, the monounsaturated fat, and the polyunsaturated fat. And our interest has been in the polyunsaturated fats, specifically the omega-3 fats, which we can get from specific fish. And there’s also other sources as well. And then we’ve been very interested in the omega-6 polyunsaturated fats, which no one has ever really heard of that term. But that refers to the fats like the seed oils. So for example, corn oil, sunflower oil, safflower oil, and even grapeseed oil. Terry 10:29-10:33 So those are the ones that a lot of people actually are eating a lot of. Dr. William Aronson 10:35-11:14 Oh, it’s predominant in the American diet. And when we did studies in mice, we found that when we gave them corn oil, it rapidly accelerated the growth of human prostate cancers in mice, whereas we could inhibit that or slow the growth when we put in a more favorable ratio of the omega-3 to the omega-6 fatty acids. That’s what then led us, those types of studies that we did in the lab, to then conducting this larger one-year trial that we just completed and reported out on. Terry 11:15-11:24 Tell us a little bit about how the trial was designed. Who participated, and what were the differences in the way that they were treated? Dr. William Aronson 11:26-13:25 So we enrolled… there were 100 men that completed the trial. These were men with prostate cancer that were diagnosed with prostate cancer on a prostate biopsy. And all of these men elected active surveillance instead of undergoing treatment like radical prostatectomy or radiation therapy. It turns out that if you have a slower or slightly slower growing type of prostate cancer, that’s a very standard option to choose. And so these men elected after their initial biopsy to enter our trial and then have another biopsy of their cancer one year later. And these men, we randomly assigned them to one of two groups. In one group, we let the men know they could eat whatever they wanted, but not to take fish oil capsules over that one year period. The other group, we had them see a dietitian once a month. And that dietitian worked with the patients to markedly lower their omega-6 intake. So that would be reducing, for example, fried foods, reducing foods with corn oil, safflower oil, reducing, for example, mayonnaise, reducing salad dressings that are bottled. And so these men in that group lowered the omega-6 level. It was a fish-based diet, so they ate plenty of fish providing the omega-3 fatty acids, like salmon, for example, and tuna. And that group also received fish oil capsules. So these were the two treatment arms in our study. Terry 13:25-13:28 What were the consequences? Dr. William Aronson 13:29-15:09 So the primary endpoint of our study, the key thing that we wanted to look at was a biomarker called Ki-67. So Ki-67 is a protein on the surface of cells, specifically in the case of prostate cancer. If prostate cancer is expressing or showing this Ki-67, it means that the cancer cells are dividing. So the main thing that we looked at was the Ki-67 levels in both groups to see if there was a difference between the groups. What we know from prior studies is if you look at Ki-67 in men with prostate cancer, the higher the Ki-67, the more cancer cells that are dividing, and the more likely that those men with high Ki-67 levels are going to have progression of their cancer, spread of their cancer, and even more likely to have death from their prostate cancer. So this was the key marker that we looked at was the Ki-67. And what we found was that the Ki-67 was reduced in the group that got the low omega-6, high omega-3 fish diet with fish oil capsules. And it was increased in the group that ate whatever they wanted to and didn’t take fish oil capsules. And there was a significant difference between the groups with regards to this biomarker called Ki-67. Joe 15:11-15:15 So the take-home message from your research, Dr. Aronson? Dr. William Aronson 15:17-17:18 So the take-home message is that, firstly, this was a phase two trial. There’s phase one trials, phase two trials, and phase three trials. Phase three trials would require a much larger patient population. We had about 100 patients. And phase three trials would be required to look at specific clinical endpoints, like, for example, aggressiveness of the cancer or progression of the cancer. Ours was a phase two trial (Journal of Clinical Oncology, March 2025). We did see a significant effect on this biomarker called Ki-67. We did not see a significant effect in our small trial on, for example, Gleason grade, which is known to predict prostate cancer progression. Our trial was not designed to look at Gleason grade. It was specifically designed to look at Ki-67. And so the conclusion from the trial is we saw a significant effect as a result of the diet plus the fish oil on Ki-67. And that is an important biomarker for prostate cancer. It’s now left to the decision-making of the patients or their families of men with prostate cancer, and it’s left at the discretion of the clinicians who treat prostate cancer if they want to apply this information to their patients. What I know is that literally every patient that I see with a new diagnosis of prostate cancer wants to know if they should change their diet, what they can do for themselves. And so at that point, I’m going to let them know about the results of the study, and then it will really be up to the patients if they want to make any changes or not. I suspect that they will. Terry 17:19-17:24 Dr. William Aronson, thank you very much for talking with us on The People’s Pharmacy today. Dr. William Aronson 17:27-17:34 It’s been a pleasure speaking with you guys. I love listening to your podcast, and thanks for the invitation. Terry 17:35-17:52 You’ve been listening to Dr. William Aronson, professor in the Department of Urology at UCLA and chief of urology at Olive View UCLA Medical Center. He’s chief of urologic oncology at the West Los Angeles Veterans Affairs Medical Center. Joe 17:52-17:59 After the break, we’ll speak with Dr. Timothy Yeatman about his research on the effect of seed oils. Terry 17:59-18:06 Most of these oils have long been considered to have anti-inflammatory effects. Do they deserve that reputation? Joe 18:06-18:11 What do we mean by omega-3 and omega-6 fats? How are they different? Terry 18:11-18:17 Why is the ratio of omega-3 to omega-6 so important? Joe 18:18-18:25 Dr. Yeatman will describe his research on the links between seed oils and colorectal cancer. Terry 18:38-18:54 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 18:54-19:12 And I’m Joe Graedon. Terry 19:12-19:34 Today, we’re looking at the possible connections between popular cooking oils and the risk of cancer. We just heard from Dr. William Aronson about his research linking omega-6 fatty acids to a biomarker for prostate cancer. It’s time to find out why the ratio of omega-6 fats to omega-3 fats is important. Joe 19:35-19:52 We turn now to Dr. Timothy Yeatman. He is a professor in the Department of Surgery at the University of South Florida. Dr. Yeatman is also Associate Center Director for Translational Science and Innovation at Tampa General Hospital Cancer Institute. Terry 19:53-19:56 Welcome to the People’s Pharmacy, Dr. Timothy Yeatman. Dr. Timothy Yeatman 19:57-20:01 Thank you. I’m happy to be here to talk about a very exciting topic today. Joe 20:02-20:47 Oh, it is indeed exciting. And Dr. Yeatman, I have to tell you that we are very impressed with your research. But first, basics. Vegetable oils, they’re supposed to be good for us. We sauté with vegetable oils, we bake with vegetable oils, we put vegetable oils on our dressing. Seed oils are found in chips and crackers and dips and all kinds of other foods. We’re talking about safflower, peanut, canola, corn, sunflower, soybean, sesame oils, and they’re all considered by the cardiovascular community as anti-inflammatories. Do these oils merit this halo? Dr. Timothy Yeatman 20:49-22:01 Well, I don’t think they do for a number of reasons. First of all, I’m not sure the entire cardiology community agrees with your statement because more recent data is coming out demonstrating a pro-inflammatory nature of a number of these oils. Now, granted, they are, in fact, essential oils, essential fatty acids that you have to take in through your diet. So the only way you can get them is through diet. And they’re essential for making your cell walls, membranes, and so forth. But the question is, how much is too much and what is the right amount? My grandmother used to say, do everything in moderation. And what’s happened since I think about 1967 going forward, there’s been a massive onslaught of an overabundance of these seed oils in the diet. And what that’s done has changed the omega-6 to omega-3 ratios in people from maybe an ideal of one-to-one or four-to-one to like 25-to-one or 30-to-one. And we know that populations like, you know, the Inuits would have a much different ratio because they’re on a completely different diet. Terry 22:01-22:10 I wonder if you could explain to us, please, what we mean by omega-6 and omega-3 and why that ratio might be important. Dr. Timothy Yeatman 22:11-24:23 So the omega-3 is easy because you think of that as, people think of that as equivalent to fish oil. And there’s DHA and EPA components to it, and they vary. And some of those components are thought to be good for the heart and the brain, and some are thought to be good to prevent cancer. But that’s omega-3s coming mostly from good nuts like walnuts and almonds and pistachios and things like that, and also from fish. The small fish are probably better than the large fish, because they don’t have the mercury, but, you know, the larger fish, halibut, salmon have large levels of omega-3 and the smaller fish anchovies, sardines and things have high levels of omega-3. But the omega-6s are composed of linoleic acid or things that can be derived from what we call seeds or seed oils. So canola oil, safflower oil, sunflower oil, et cetera. And they’re high in the omega-6. Now, truth be told, most oils are a mixture of omega-6 and omega-3s, and most foodstuffs are that way. For example, red meat. You can get red meat that is grain-fed beef that is a ratio of 25 to 30 to 1, omega-6 to omega-3. But grass-fed beef, grass-fed butter, grass-fed milk is 1 to 1. So there are big differences in the omega-6s to the omega-3s in the foods that we eat. And if you consume too much of the omega-6s, your ratio becomes imbalanced. Now, why is that important? Well, I think one of the most significant studies is recent, where they looked at the UK Biobank and looked at thousands of patients over a period of time and found that people who had a higher omega-6 to omega-3 ratio had a significantly higher all-cause mortality rate and cancer rate and other rates of inflammatory diseases (eLife, April 5, 2024). So we think, and our laboratory believes, that it’s the ratio that’s important, not just the individual levels of omega-3 or omega-6. Terry 24:23-24:44 Well, I’m hoping that you will tell us about your recent research that was published in the journal Gut, talking about the connection, potential connection between consumption of seed oils and the tumors that you found in people with colorectal cancer. Dr. Timothy Yeatman 24:45-27:32 Yeah, so the paper, by the way, got a remarkable response. According to Gut, it’s in the top 5% of all papers that are published with responses to it. The reason it was so popular was because I think we found a smoking gun. We identified in tumors versus normal adjacent mucosal samples from the same patients that there was a significant elevation of pro-inflammatory lipid mediators (Gut, Dec. 20, 2024). And these are the leukotrienes, the LTB4, LTC4, [LTD4]. And there was a dearth of the pro-resolving molecules. We now know that wound healing is a combination of inflammation first, followed by resolution of inflammation. And we think that’s occurred over eons of time. That has developed as a defense mechanism against bacterial infections and viral infections, which probably killed most prehistoric people, as well as trauma. But if you think about that, if cancer is a model for wound healing, then it’s clear that cancer appears to be a poorly healing wound because it’s chronically inflamed and doesn’t resolve the inflammation. When you get a cut on your hand, I always say that you’ll see first swelling and redness, and that’s because of the influx of inflammatory cells. But as that inflammation resolves, the redness goes away, so does the swelling. Well, you have to say, why does that happen? Is that just magical? No, it’s not. It’s because the body has an active resolution process called resolution of inflammation. And it’s also performed by lipid mediators, but this time they’re called lipoxins, resolvins, maresins, and protectins. So the body has a host of pro-inflammatory lipid mediators derived from the lipids we eat and pro-resolving lipid mediators derived from the lipids we eat. So you can imagine if you ate far more pro-inflammatory lipids, you’d get more pro-inflammatory mediators. Because actually the same enzymes that convert lipids into lipid mediators that are pro-inflammatory are the same ones that do it for the pro-resolving lipid mediators. The difference is enzymes work based on substrate availability. So if you have a lot more omega-6 substrate for the enzyme to work on, it’s going to make a lot more of the inflammatory byproduct. If you have more pro-resolving substrate like omega-3 in your body, those same enzymes will work to make resolving lipid mediators. Joe 27:34-27:45 So, Dr. Yeatman, we’ll get back to your research in a moment because you’re a surgeon and you were removing tissue from colon cancers. Is that right? Dr. Timothy Yeatman 27:45-27:47 Mm-hmmm, it is. Joe 27:46-28:58 But first, let’s dig a little deeper into biochemistry. So you’ve really set this up beautifully, but I think a lot of people go, “Oh, what’s he talking about?” Leukotrienes, protectins, resolvins, big words. So let’s start with the biochemistry and make it even more complicated. If you’re consuming a lot of omega-6 fatty acids from the seed oils that you’ve already mentioned, like safflower, peanut, canola, corn, sunflower, soybean, sesame. What you’ve got is linoleic acid and then arachidonic acid, all converted into leukotrienes and prostaglandins, like thromboxanes, that are inflammatory. That’s the output. Whereas if we’re consuming omega-3s, they’re converted into alpha-linolenic instead of linoleic and to EPA, eicosapentaenoic acid, DHA, ducoso… hi, help me here, Terry, DHA? Terry 28:58-29:00 Docosahexaenoic acid. Joe 29:00-29:08 …which are then converted to those protectins and resolvins that are anti-inflammatory. Have I got that right? Dr. Timothy Yeatman 29:08-29:09 You did. That was perfect. Joe 29:10-29:33 So when we’re eating all those chips and all those ultra processed foods, we’re inevitably getting a lot of omega-6 fatty acids, which are going to lead to inflammation. That doesn’t sound like a good thing in our gut, but it doesn’t sound like a good thing in our brain or any other part of our bodies. Dr. Timothy Yeatman 29:34-30:50 That’s correct. And, you know, I kind of believe now that inflammation is the root cause of many diseases, whether it’s cancer or Alzheimer’s or diabetes or arthritis or stroke or heart attack. But if you think about cancer, take it down to the cellular level like we’re talking about. Let’s say you have that first cell in a crypt, in the villus of the colon mucosal wall that gets a spontaneous mutation. We know that our colon is lined with billions and billions of cells. And every day there are probably, you know, many, many mutations. I don’t know the number, but many mutations occurring naturally. And those mutations are checked by specific genes and processes that are in place. But you can imagine if your immune surveillance system that’s normally active and would normally shut down all those mutations is less active or turned down by a pro-inflammatory process, that you may be more apt to allow a new mutation to take foothold. And so I think of cancer not only now as a genetic disease, but also a metabolic disease. Joe 30:53-31:46 Well, that makes total sense to me. And I like to make things understandable to our listeners. And one of the ways that I like to do that is with specifics. So if we think about guacamole and chips, because that’s the way we consume our guacamole. The guacamole is made from avocados, and avocados are presumably rich in omega-3 fatty acids. The chips, on the other hand, whether we like it or not, are ultra-processed foods, and they might have omega-6 fatty acids in the way they’re made. So if we eat a whole bunch of guacamole, it’s probably anti-inflammatory. But if we have just a little bit of guacamole and a lot of chips, it’s probably more pro-inflammatory with more omega-6 fatty acids. Is that a fair representation? Dr. Timothy Yeatman 31:47-34:12 It is, but I would broaden this to say, you know, when you go to the grocery store and you’re looking at food labels, which you should start doing, you’ll find that soybean oil has infiltrated many different foodstuffs you wouldn’t suspect it to be in. For example, it’s in a lot of bread. It’s in a lot of, it’s in almost all cakes, pies, cookies, and things. But also, surprisingly, it’s very hard to find hummus without soybean oil in it. So it’s amazing that it’s really in many things we eat that are processed. And what we also know today, and we haven’t discussed this much, but there is a clear interaction between what we take in and our microbiome. Now, I used to think that the microbiome would be just sort of static in your gut, but in fact, it’s very responsive to the food you eat. It’s much like adding a weed killer. If you kill some weeds, others grow up. If you fertilize, the grass may grow. So when you fertilize with omega-6, you’re likely to get different bacteria in your gut than if you fertilize with omega-3. And people are looking at ketogenic diets in that way now and saying, huh, I wonder if ketogenic diets, they seem to work in some cancers to help them. Wonder why they work… Is it possible that when you have a ketogenic diet, you actually, you know, rebalance your omega-6 to omega-3 because of what you’re eating? So, you know, I started to ask all these questions myself and wondering what the interactions are between the lipids and the microbiome. We know that from animal models where omega-6 is overrepresented, it changes the gut microbiome substantially. So now you have different bugs in your gut doing different things. And what havoc does that wreak on the body? So if that’s lipids, what about all the other things in processed foods? You know, we know that, for instance, some simple things like sorbitol, which is a sweetener that’s now…. artificial sweetener, sugar rather, than every, almost every artificial drink today, that dramatically changes the microbiome. And so if that can do that, what is, you know, what do the dyes do? What do the preservatives do? What do all these things do to our body? I mean, a lot of the things we have never looked at that. It’s just never been checked. Terry 34:14-34:35 Well, Dr. Yeatman, one of the things that really caught our eye and perhaps some of the other folks who’ve been looking at your study that was published in Gut is that there’s been a real increase in colon cancer in younger people, people under 50. Do you think all of these things are related to that? Dr. Timothy Yeatman 34:37-36:08 Well, it could be. And I say that cautiously because, you know, we don’t have evidence. But, you know, I’ve said before that it was very hard to prove that cigarettes cause cancer, you know, because there were some people who smoked their whole life and never got cancer. But most of them died from COPD or strokes or heart attacks, right? So it did cause problems, but not everybody got cancer. So to cause an effect is always difficult to prove. But, you know, we’re seeing animal models where if you over-express genes that make all omega-3s now, those animals develop less colon cancer. If you give animals more omega-6, they’re more likely to develop colon cancers. And it’s not necessarily tied to obesity, right? So if you look at the plots of body fat, percent omega-6 in body fat since 1960 to today, it’s on a sort of a 45-degree rise, dramatic rise in body fat content of omega-6. Why is that? Well, coincident with that was the big change in the sort of big agriculture producing a lot of soybeans. A lot of soybean oil is cheap. It’s a very inexpensive oil, much less expensive than olive oil, for example. And so that has become a staple for many of the foods, not only in producing them, but also cooking them. So, you know, people fry in them. Joe 36:08-36:24 Well, you know, Dr. Yeatman, we’re going to take a short break, but when we come back, I want to talk more about soybean oil and even canola oil and a whole bunch of other seed oils and find out, you know, what should we be eating instead? Terry 36:24-36:51 You’re listening to Dr. Timothy Yeatman. He’s a professor in the Department of Surgery at the University of South Florida. Dr. Yeatman is also Associate Center Director for Translational Science and Innovation at Tampa General Hospital Cancer Institute. His study appeared in Gut, one of the leading journals for gastroenterologists. You’ll find a link to it from the show notes on our website. Joe 36:51-37:02 It’s time for a short break. You know, I love that example of tortilla chips and guacamole. I’m trying to focus more on the guac than the chips. Terry 37:02-37:08 Seed oils are thought of as anti-inflammatory foods, but could they be promoting inflammation instead? Joe 37:08-37:15 We used to be told that avocados and olive oil were problematic because they contained saturated fats. Terry 37:15-37:23 It seems the medical community has reversed itself on nuts and olive oil. They once were discouraged. Now they’re darlings, what happened? Joe 37:23-37:31 If we want to avoid high omega-6 seed oils we’ll all have to start reading labels. I wonder what Dr. Yeatman recommends. Terry 37:39-37:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:51-37:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:54-38:13 And I’m Terry Graedon. Joe 38:14-38:43 Today we’re talking about the safety of seed oils. We’ve long been urged to use cooking oils instead of butter or other fats. At one time, Americans were told that corn or soybean oil were better than olive oil because they’re rich in polyunsaturated fats. The idea was that such fats would lower the risk of heart disease, whereas saturated fat in avocados or olive oil would boost cholesterol and encourage heart attacks. Terry 38:44-38:56 Now, though, we’ve been learning that excessive reliance on seed oils may increase the chance of developing cancer. In the first part of the show, we heard about research linking these foods to prostate cancer. Joe 38:57-39:05 Our current guest studies colorectal cancer. His research findings came as a surprise to many nutrition experts. Terry 39:06-39:24 We’re talking with Dr. Timothy Yeatman. He is a professor in the Department of Surgery at the University of South Florida. Dr. Yeatman is also Associate Center Director for Translational Science and Innovation at Tampa General Hospital Cancer Institute. Joe 39:26-40:12 So, Dr. Yeatman, you were talking a bit about soybean oil as an omega-6 fatty acid supplier, but there are a lot of others. I mean, you know, people are very big on inexpensive oils to cook with and to make a lot of these ultra-processed foods, whether it’s sunflower or soybean, sesame. And, you know, we’ve seen some pretty respected nutrition experts who say, oh, they’re anti-inflammatory. They’ll make your cholesterol go down. They’re good for us. And you’re suggesting, hold your horses. They may be pro-inflammatory and they may cause problems that we didn’t recognize 30 or 40 years ago. Can you dig a little deeper? Dr. Timothy Yeatman 40:13-41:34 Well, you know, I can give you one example. There is a test you can order through probably LabCorp or Quest. It’s called the PLAC test, PLAC test or PLA2 test. And it’s for phospholipase A2. And I always wondered, why [is] the PLAC test a measure of cardiac inflammation? And the answer is that it measures an enzyme that releases arachidonic acid from membranes. So here’s a test that’s supposedly measuring cardiac inflammation that’s directly tied to arachidonic acid, which is a derivative of the omega-6s, right? So I think that the inflammation story is, there’s a lot of data on both sides, but it depends on how you look at different data elements and how things are done. Dietary studies done on humans are often difficult to interpret because it’s hard to measure what diets people actually consumed. I like looking at these genetically induced mouse models where they induce one omega-6 or omega-3, or they feed the mice very controlled diets and look at those results. And you’ll see that there are many studies that show omega-6 is pro-inflammatory. I think that’s [undisputed.] Joe 41:34-42:28 You know, there was a time not that long ago, Dr. Yeatman, when we were told, don’t use olive oil, don’t use butter. You should be using margarine and all of the seed oils. And avocado oil was somewhere in the middle, like maybe it’s a problem. And even some of the nut oils were considered a problem. And now I think a lot of people have done a 180-degree and they say, well, the Mediterranean diet is the best diet and that’s pretty high in olive oil and maybe even a little avocado oil on the side. Help us understand how the medical community has sort of confused people over the years where, you know, don’t eat nuts and don’t use olive oil has just done a flip flop. Dr. Timothy Yeatman 42:28-44:37 It has, but there are many other examples in medicine where that’s occurred. For example, one of the most prominent ones is postmenopausal hormone replacement therapy for women. It was considered to be a disastrous idea. Now it’s heavily promoted as healthy. So medicine goes through changes with new data. I can tell you that we now have very sensitive technology, mass spectrometry. And it allows us to pick out specific lipid mediators and really understand what each one is doing. A number of years ago, we didn’t have that. I think some dietary studies are flawed, particularly these ones that try to take dietary histories. But dietary recall is not great for most people. I can’t remember what I had two days ago for lunch. And if you didn’t record in your journal, maybe it wasn’t properly done. So those are all a little bit suspect to begin with. But overall, I think some of these larger studies now are coming out that, like I said, the UK Biobank. Now there’s one study there that looked at just omega-6. They cherry-picked omega-6 levels and looked at the highest quartile versus the lowest quartile. And sure enough, the highest quartile omega-6 patients seem to have better cardiac outcomes. But they didn’t look at omega-3 in that study. And another study on the same data set, when they looked at omega-6 and omega-3 ratios, they were predictive of all-cause mortality. So I think it… a lot depends on if you leave data out or if you cherry pick data or just look at subsets of data and don’t look at the whole picture. I think there’s an emerging consensus that this balancing your omega-6 to omega-3 ratio is probably important, and that probably you can’t do it just by supplementing your way out of it. You probably have to focus on diminishing your omega-6 intake and increasing your omega-3 intake. And the only way to do that is probably to either be uh, um, religiously look at the labels or make your own food. Terry 44:37-45:07 And making your own food would automatically take care of some of those problems that you pointed out to us several minutes ago, the idea that there’s soybean oil in bread. Well, if you make bread at home, you’re not going to put soybean oil in it. But a lot of people aren’t going to make bread at home. If you make your hummus at home, you’re not going to use soybean oil. Olive oil tastes much better, but a lot of people aren’t going to make their hummus at home. So maybe we all need to start reading labels. Dr. Timothy Yeatman 45:07-46:10 Well, you know, the other thing is you mention that, but let’s just talk about healthcare costs for a second. You know, the healthcare system we have today, you know, is supposed to be one of the best in the world, but it’s also one of the most expensive. And the reason is we… all of, pretty much all of the CMS codes are directed at therapy, not prevention. Terry 45:32-45:32 Right. Dr. Timothy Yeatman 45:33-46:10 And, you know, whenever you want to do something preventative, it’s always a big climb, uphill climb. So I think the whole health system has to change gears towards prevention. Now, if we put the money into prevention that we put into late stage disease because we avoided prevention, we would save a ton of money because late stage disease is cardiac disease and cancer and Alzheimer’s and so forth and diabetes and obesity. If we put money into better food for people, I think we would essentially reduce the health care costs dramatically of the system. Terry 46:10-46:24 Well, Dr. Yeatman, let me ask you, I have a feeling I can predict your answer here, but let me have you go ahead and answer this question. Is your research relevant for other cancers besides colorectal cancer? Dr. Timothy Yeatman 46:25-47:28 Oh, absolutely. I don’t think that colon cancer is a unique situation. We have data on other tumors already that shows they’re also inflammatory or inflamed and without resolution of inflammation. Now, I think that there are going to be other diseases where you see sort of an intermediate situation like inflammatory bowel disease or also colitis. We think there is an intermediate situation there where you see what we call relapsing and remitting disease. And when the patient relapses, they’re probably in an inflammatory stage. When they’re remitting, they’re probably trying as best they can to resolve the inflammation, but ultimately they fail. Now, are they failing because they have a really bad omega-6 to 3 ratio? I don’t think anybody’s ever looked at that yet, but there are suggestions that your baseline omega-6 to omega-3 ratio might be a good predictor of all cause mortality and outcomes from many diseases. Joe 47:28-47:49 Now, Dr. Yeatman, your title of the article that you put into Gut about your cancer findings used the word lipidomics. Am I pronouncing that correctly? [guest] 47:44 Yes. [J] 47:45 What is lipidomics and why is it important? Dr. Timothy Yeatman 47:49-50:12 Well, believe me, it was something that I got into a little bit by chance. When I started working at Tampa General Hospital Cancer Institute and University of South Florida, I was a colon cancer genetics physician scientist. And when I got there, they serendipitously put me into a lab that was next to a lipidomics lab. Now, lipidomics is the study of lipids. And it can be done in many ways. But lipidomics to some people means HDL and LDL. To me, it means many more things now. So the lipids are really complex molecules that start off with structural lipids, like ceramides and sphingolipids and things like that. And then these things get broken down into active lipid mediators that become signaling molecules. And what we know today is that the tumor microenvironment, which controls the outcome of the tumor, the immune tumor microenvironment is likely controlled by lipid mediators or the lipids we eat. And I’ll give you a great example. Rectal cancer, I spent 30 years treating rectal cancer patients and doing large operations to remove the rectal tumor, sometimes give the patient a colostomy, many times gives the patient an ileostomy, a second operation to reverse that, chemotherapy, radiotherapy in multiple cycles and series, and ultimately get a cure. But more recently, they’ve described in a small subset of rectal cancer patients called microsatellite instable patients that they can treat them with checkpoint inhibitors, which activate the local immunity to cure the cancer. So they now have many evidences of cure of these subsets of rectal cancer patients that are cured solely by an injection with a monoclonal antibody that activates the local immune system. So this, to me, tells me the power of the tumor microenvironment. If that microenvironment can be governed, controlled, regulated, enhanced, that we have the chance to cure more cancers. And lipids may be the key to that. Joe 50:12-50:55 Dr. Yeatman, I would love to get some practical advice about foods. So my mother loved nuts and she loved macadamia nuts in particular. But I think that her doctors were like, no, no, you shouldn’t be eating so many nuts. And she also loved avocados, and she loved olive oil. And so it seems to me that she was getting a very rich omega-3 based diet. What kinds of foods do you recommend? Was my mother on the right track? And what are you and your family doing these days? Dr. Timothy Yeatman 50:52-54:29 Yeah, so she was. And I think this is why the Mediterranean diet has sort of fallen out as the best blue zone diet kind of diet. Yeah, we eat a lot of walnuts. So in the morning, we might have a kale, blueberry, walnut, banana shake, and it’s incredibly good despite the kale being in there. But it gives you a lot of different greens, green vegetable fiber and so forth that helps prevent colon cancer. By the way, the more greens, different types of greens you get, probably the better because promoting microbiome diversity in your gut. The walnuts are really rich in omega-3s, but you can also use other nuts as well. I don’t know exactly whether macadamia nuts are high or low in omega-3s, but they’re probably okay. Peanuts are not as good, for example, and almonds are good, but for different reasons. Some nuts are good for different reasons. Almonds might be higher in omega-9, for example, of which olive oil is contained. So there’s some [monounsaturated] fatty acids that are really good for you too, but these all haven’t been fully explored yet. So on the oils, you know, olive oil, avocado oil, you can even use flaxseed oil, all that can be harder to tolerate. And I think chia seeds produce a lot of omega-3s, walnuts, almonds, and on the meat side, you know, grass-fed beef, grass-fed milk, grass-fed butter, lamb is of course, grass fed, chickens that are pasture raised. If you move on to fish, you know, you can eat salmon, low mercury content, haddock higher content. But surprisingly, crabs have one of the highest omega-3 to 6 ratios. They’re like 60 to one in favor of omega-3s, probably because they’re, they’re bottom feeders and eating seaweed and so forth. So, um, you know, there’s a lot of, and then, then going to the store now, we do look at all the labels. So if the label has more than 10 things in it, unless they’re all spices and natural things, you avoid these long labels, um, because they’re loaded with preservatives and other things that we don’t know, actually don’t know how they affect the gut microbiome. I don’t think it’s ever been tested some of these things. Only recently, we started testing these things because we had technology available to measure the sequencing of the microbiome, uh, with next-gen sequencing. So I know it wasn’t done years ago. So if it’s been done, it’s only done recently. So again, look at the labels, balance your, try to, and maybe get, the other thing would be try to get your level measured, your omega-6 to 3 level measured. If you can ask your physician to order one of these cardio IQ tests that LabCorp or Quest offer, they’re barely inexpensive and you’ll get an idea of where you are. No longer can we be happy with LDL and HDL cholesterol. And by the way, most physicians don’t measure lipoprotein(a), which is present in 15% of patients and almost impossible to move all those recent drugs that might do it. But that promotes heart disease and very few people had it measured, yet 15% of the population has it. So there’s a lot of things we can do to prevent disease or to be notified you have disease in advance that’s not being done today. Joe 54:30-54:38 Dr. Yeatman, are there health implications of inflammatory foods for other conditions besides cancer? Dr. Timothy Yeatman 54:41-55:30 Yes, certainly we think that other diseases such as diabetes, Alzheimer’s, cardiac disease, stroke, arthritis, inflammatory bowel disease, on and on and on. There are many diseases that likely have a root cause in inflammation. Now, you know, we talk about disease happening over time. Many of these diseases take years to develop. But in fact, you could imagine a diet impacting your sort of local immunity and inflammation over time, not acutely. So that’s why many of these studies are flawed because they have to look at time series events. You can’t look at yesterday’s diet and say, hey, I had some avocado yesterday, I must be doing well. What did you have the last 10 years to eat? Joe 55:32-55:57 Dr. Yeatman, your research stimulated an extraordinary amount of interest all around the world. You made headlines in a lot of different places. I’m curious how your colleagues have responded to this fabulous research that you’ve done and the degree of publicity that has emerged as a result. Dr. Timothy Yeatman 55:59-57:30 Well, surprisingly, maybe not surprisingly, they’re all very excited about it and feel like they’re part of it. As you know, we had a large number of contributors on that paper. There were not only surgeons from Tampa General Hospital, but we had folks at Vanderbilt University, some folks in Japan, folks at Merck, the company Merck, all participated in this fascinating study. But they want to see more. I think what I’ve heard is, well, let’s see more. Don’t stop. Let’s see more. So that’s where actively, we were recently funded by the NCI with a new U01 grant to study more in depth these lipids. And we’re going to look at close to 400 patients that had colon cancer. And we’ll look at their lipidomics, their lipid mediators in their tumors. But now we’ll be able to relate them to specific genes and mutations of those genes in those same tumors. We were not able to do that before because we didn’t have sequencing and whole genome transcriptomics on these patients. But now we’ll have all these things, including outcomes. So we’ll be able to answer a lot more questions as to why certain patients have higher levels than others. We can’t relate it to diet in these studies. I think that may be best to be done with animal models where you can control things better. But we can certainly assume that most of these fats are diet-related because that’s the only place they can come from. Joe 57:30-57:51 And the NCI is the National Cancer Institute, and congratulations on that grant. I wonder if you could just share with our listeners very briefly what they should be avoiding when they go to the supermarket, the grocery store. What are the lipids, the fats that would be best left on the shelf? Dr. Timothy Yeatman 57:53-01:00:07 Yeah, so it’s pretty easy to figure it out. It’s almost anything you’d like to eat that’s not good for you. So let’s start with the processed donuts, the chocolate covered processed donuts. They’re always sitting out in the aisle. Or anything that’s in a package that has been preserved for a long time. Salad dressing, for example, is loaded with soybean oil. It’s very hard to find a salad dressing without soybean oil in it. Hummus, like I said, you can find occasionally hummus without soybean oil and with olive oil instead. But all the breads, it is possible to find breads without soybean oil. I was at Ingles one day and I found five different freshly baked breads that didn’t have it. But many of the ones that are processed and sort of preserved longer seem to have this soybean oil. So it’s almost a trend. You can see if something is likely to stay on your shelf longer, it’s likely more likely to have some of these bad processed products in them. So I think anything that’s in a plastic package that’s going to last more than a week on your table may be suspect. But I would look closely at the label and the number of elements in the label and look for the dyes, look for the “don’t need to be there.” Look for the preservatives that don’t necessarily need to be there and look for the added elements you don’t recognize or understand. Because again, if you don’t understand what they are, then I can almost guarantee that no one’s tested their effect on the microbiome, which I think is the big barrier. I mean, that’s one thing we didn’t cover in the talk was that the microbiome is the first barrier of defense in almost all of our infections because everything exposed to your nose and mouth is swallowed, goes through the GI tract. And that’s why you have this incredible immune system there that prevents disease and processes all your food and cleanses it and purifies it. And you have a bunch of immune cells waiting to go in that gut microbiome area. But if they’re turned down or turned off, then things can slip through the defenses. Joe 01:00:08-01:00:35 Dr. Yeatman, there is one oil that has created an awful lot of confusion and controversy. Canola oil comes from the rapeseed. Is it good? Is it bad? Is it in between? A lot of people thought, ah, canola oil, it’s the answer to our problem of the omega-6 versus omega-3 controversy. What’s your take on canola oil? Dr. Timothy Yeatman 01:00:35-01:01:23 Well, I think it’s inflammatory. And the problem is that it’s highly processed. If you actually look at the processing conditions for it, it’s heated up, it’s extracted and so forth. People have gone to other ideas like cold pressed, high-oleic, things like that. And I personally don’t know what they all mean yet in terms of is it often better, or worse, or the same. Smoke points are interesting too when these things are heated, they start smoking, they can become oxidized. Sitting things on the shelf for a long time oxidizes them. Some of the things become trans fats. So I don’t think canola oil is a particularly healthy oil to use. Terry 01:01:23-01:01:28 Dr. Timothy Yeatman, thank you very much for talking with us on The People’s Pharmacy today. Dr. Timothy Yeatman 01:01:28-01:01:30 You’re very welcome. Terry 01:01:30-01:01:48 You’ve been listening to Dr. Timothy Yeatman Professor in the Department of Surgery at the University of South Florida. Dr. Yeatman is also Associate Center Director for Translational Science and Innovation at Tampa General Hospital Cancer Institute. Joe 01:01:48-01:01:59 Earlier, we spoke with Dr. William Aronson. He is Professor in the Department of Urology and Chief of Urology at Olive View UCLA Medical Center. Terry 01:02:00-01:02:18 We’re talking with Dr. Debora Melo van Lent. She is assistant professor at the Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases of the University of Texas in San Antonio. Welcome to the People’s Pharmacy, Dr. Debora Melo van Lent. Dr. Debora Melo van Lent 01:02:19-01:02:20 Thank you for inviting me. Joe 01:02:21-01:02:53 Dr. Melo van Lent, we are so fascinated with your research because it’s dealing with something that we care about passionately on the People’s Pharmacy. And that’s what should we be eating and what should we not be eating? There’s so much confusion about food these days, which foods are healthy. So can you please tell us about your research linking dietary inflammation and dementia? What did you do? Dr. Debora Melo van Lent 01:02:54-01:04:49 Joe, thank you so much for that question. I so agree with you, because usually we do our research and media so picked little puzzle pieces instead of the whole puzzle. And that is very confusing for the population. So thank you for asking me and for me to give more explanation. Yes, so I investigated this dietary inflammatory index (Alzheimer’s & Dementia, Jan. 2025). And this index actually is put together with the building stones of our diet. So it contains micronutrients, think about vitamin D, macronutrients, think about protein. And there’s also some bioactive compounds, which you, for example, can find in blueberries. So the higher this dietary inflammatory index score, the more pro-inflammatory it is. And this is a wonderful index that was created by researchers of the University of South Carolina. And for actually three ways. The first way is because we want to know the building blocks. Because the building blocks are the ones that are either anti-inflammatory or pro-inflammatory. And therefore, we want to concentrate on those. They’re also a way for us to measure existing dietary patterns that we consume during the day. And we can make correlations. So if we can correlate this dietary inflammatory index with the American diet, for example, we can test how pro-inflammatory that is and to see how we can improve it in speaking about increasing components like single foods that are more anti-inflammatory. Terry 01:04:50-01:05:01 So you had a lot of participants in Framingham, Massachusetts, that you had information on. What kinds of information did you have on these people? Dr. Debora Melo van Lent 01:05:03-01:06:15 Yeah, so the Framingham Heart Study is a study that took off in 1948. So we have a very long follow-up of actually already the parents of the participants that were included in my study. So the Framingham Heart Study is a cohort study. So we collect data of people living in a community. So these are not patients in a hospital or a care home, for example, but people like you and me living their lives. And they are giving their time to go to the study center every about four years. And we are able to collect information on, well, diet is there, but also their cognition. We are able to do MRI scans, PET scans. So we get a very well idea of how the brain is functioning of those participants. But there is so much more that we can collect from them. We collect data on their eyes, their ears, their skin, kidney function, heart function, you name it. Terry 01:06:16-01:06:30 And Dr. Melo van Lent, people want to know, what did you discover about the relationship between the dietary inflammatory index and people’s risk for dementia? Dr. Debora Melo van Lent 01:06:31-01:06:59 Yes, of course. So we gathered dietary data through food frequency questionnaires. And that food frequency questionnaire, we were able to calculate the dietary inflammatory index score. So from the participants that we included in our study, we saw that higher pro-inflammatory dietary index scores were associated with an increased risk for incidence, all-cause—and also Alzheimer’s disease—dementia. Terry 01:07:01-01:07:02 That sounds important. Joe 01:07:02-01:07:27 That sounds scary because the Western American diet, as we like to refer to it, is rather pro-inflammatory. And so how bad was it if people were eating very inflammatory foods? And we’re going to ask you what some of those foods may be. What happened to their brain? Dr. Debora Melo van Lent 01:07:28-01:08:23 Yes, indeed. So I actually have another publication that was published a couple of years ago where we looked at approximately like the same study population and their brain (Alzheimer’s & Dementia, Feb. 2023). And yes, we saw that higher pro-inflammatory index scores were associated with smaller total brain volume. So it’s also one component of our health that we cannot control is aging. So as we age, our brain shrinks slowly. And you want to prevent that. So actually when you’re in your 40s, 30, 40s, you want to actually think about healthy eating because that definitely will work 30 years later when our brain really starts to show aging. And in that sense, as dementia is a disease of aging, you want to prevent it as much as we can. Terry 01:08:24-01:08:30 Absolutely. And which foods, Dr. Melo van Lent, which foods were most pro-inflammatory? Dr. Debora Melo van Lent 01:08:31-01:09:46 Yeah, so the Dietary Inflammatory Index score is not actually based on foods. It’s based on the building blocks. So going to the building blocks, so what I mentioned, there were vitamins in there, minerals. So the pro-inflammatory components of the DI that were measured were, for example, cholesterol. We can measure also like total energy intake, but also saturated fat and total fat, for example. And yeah, so what makes more sense for the public is, for example, saturated fat. And in what kind of foods can we find? Well, we find them, as Joe already just mentioned, the Western diet. So what are hallmarks of the Western diet? It’s nowadays that we eat these fast foods. We eat, for example, also pastries. And that’s also where saturated fat is embedded in. There’s also ultra processed foods that are full of it. Because what does saturated fat do? It gives flavor. And we love flavor. We want our food just to be lovely to eat. Terry 01:09:47-01:09:58 Dr. Melo van Lent, what are the implications of your research for a diet that could help us avoid dementia? What should we be eating? Dr. Debora Melo van Lent 01:10:00-01:13:21 Yeah, so we have the Mediterranean diet. It has been thoroughly investigated across diabetes research, cardiovascular research. So, and then we have the MIND diet, which was established in 2015 by Dr. Martha-Claire Morris of the University of Chicago. So, we are in a nutrition dementia field really playing with the MIND diet, which actually is a hybrid diet between the dietary approach to stop hypertension and the Mediterranean diet. So, we are investigating further the MIND diet. So if we look at components of the MIND diet, what Dr. Morris found is we have the fruits and vegetables, which are in the general guidelines of the American Heart Association, the anti-inflammatory components (Alzheimer’s & Dementia, Sep. 2015). But particularly for the brain, we are investigating berries. As in berries, they have these anti-inflammatory compounds called flavonols. And they seem to be a great group of anti-inflammatory components that help to reduce systemic inflammation that is happening in our body. And in addition, also green leafy vegetables. So I would say these are the two key newer, more targeted food groups with regard to brain health. So what we also say is like what is good for the heart is good for your brain. Because like diabetes and cardiovascular disease, they already start earlier in life. So if we can treat those, that will be good for our brain later on. And because we also find like already brain changes and everything happening like in our 40s. So the sooner we target it, the better. So in that sense, what the American Heart Association emphasizes on is also in addition to the vegetables and fruits, to eat whole grains, beans and legumes, to consume more fish. As in fish also has the omega-3 fatty acids, which are unsaturated. And omega-3 is a big also compound of our diet. That is, yeah, the omega-3 fatty acids play a big role in our brain. And what I also have found in my research, but also poultry and nuts so in that way, and then to preferably limit added sugar. And what is it actually about sugars? Well these crystals, these sugar crystals, already they cause the peaks of our insulin in our body. But in addition, the crystals also damage our veins. And you can imagine like the little veins in our brain are even smaller and tinier and so vulnerable. So in that way, we also for brain research, we advise to be gentle with sugar intake. And in addition, what we already touched upon, the highly processed foods, the refined carbohydrates, saturated fats we talked about. Yeah. Terry 01:13:23-01:13:29 Dr. Debora Melo van Lent, thank you so much for talking with us on The People’s Pharmacy today. Dr. Debora Melo van Lent 01:13:30-01:13:31 Thank you for having me. Terry 01:13:33-01:13:42 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 01:13:42-01:13:49 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 01:14:12-01:14:44 Today’s show is number 1,420. You can find it online at peoplespharmacy.com. That’s where you can share your comments about today’s interviews. You can also reach us through email, radio at peoplespharmacy.com. What are you cooking with these days? Corn oil, safflower oil, or avocado oil? Are you reading labels? Highly processed soybean or sunflower oils are common ingredients in seemingly healthy foods like hummus. Terry 01:14:44-01:15:04 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. This week’s podcast also contains an interview with Dr. Debora Melo van Lent about her work on inflammatory foods in the diet and the risk for dementia. Joe 01:15:04-01:15:22 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. You can find out ahead of time what topics we’ll be covering. In Durham, North Carolina, I’m Joe Graedon. Terry 01:15:22-01:15:54 And I’m Terry Graedon. Thanks for listening. Please join us next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:15:54-01:16:04 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 01:16:04-01:16:09 All you have to do is go to peoplespharmacy.com/donate. Joe 01:16:09-01:16:22 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 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. 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Do you worry about things you can’t see, smell or taste? Most of us don’t. Yet particles we can’t detect with our five senses are often present in the air we breathe. They have the power to make us sick. How can we achieve cleaner indoor air so that we have less chance of coming down with a serious infection? At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Dec. 6, 2025, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Dec. 8, 2025. The Importance of Cleaner Indoor Air: When we talk about air pollution, the image that may arise is factories belching dark plumes of smoke. While the particles generated by industrial processes can be dangerous for our health, sometimes the greatest danger is from particles we can’t see. The COVID-19 pandemic brought this into sharp focus, as we realized that people who had not yet begun to experience symptoms could be spreading infectious viruses. But the need for cleaner indoor air is not limited to COVID, or even to an epidemic like measles or the flu. Many infections spread primarily on viral particles wafting through the air. We are reminded of this every winter, as cases of influenza start to rise. But respiratory syncytial virus, human metapneumovirus and dozens of rhinoviruses and coronaviruses that cause colds also travel on the air. So do measles viruses. Our guest, Dr. Linsey Marr, is one of the country’s leading environmental engineers. She got interested in airborne transmission of infection even before SARS-CoV-2 appeared. Then, with COVID, it became clear that the advice to the public about maintaining 6 feet of distance was inadequate to protect people from coming down with the infection. It was developed based on an outdated understanding of how infectious particles travel. Can You Tell If Indoor Air Is Contaminated? Given the extremely small size of viral particles, we might have to use our imagination to understand how they could be present. We can’t smell viruses. But if you imagine someone smoking a cigar in the room, you know that the smell will linger for quite a while after the smoker has left. Viral particles can float around like the smell of cigar smoke, which is why they can still be present even after an infected person has left the space. This viral behavior means that the riskiest places are those where many people congregate, especially during a season when infections are spreading. Think of grocery stores, hospitals, or athletic event venues. Wearing a tightly fitted N95 or KN95 mask could provide some protection (especially if others also wore masks). It is not a magic bullet, though. Japanese people accept mask protocol during flu season, and they have still experienced the spread of influenza. In the US, it is very unlikely that most people will accept wearing masks, even if it could help reduce their risk of infection. While we can’t measure viral particles in the air without complicated equipment, we can use a simple relatively inexpensive piece of equipment to check the ventilation in a space with multiple people. It is called a carbon dioxide (CO2) monitor. Because people exhale CO2, high levels of this harmless gas indicate lots of people breathing in the space without much ventilation. Fresh outdoor air runs about 400 ppm CO2. Once indoor air reaches 1,000 ppm or higher, you may want to take action. Moving Toward Cleaner Indoor Air: Ventilation: Improving ventilation would be very advantageous. Most public places should strive to achieve at least 4 to 6 air exchanges per hour. More sensitive spaces such as health care facilities might benefit from a higher level of ventilation. Filtration: The other way to deal with airborne viruses is through filtration. Home air handling systems could be equipped with a high-efficiency particulate arresting (HEPA) filter. This is ideal, but it may not be practical in every space. Ordinary air filters carry a MERV number such as 8, 11 or 13. Higher numbers indicated better filtration capacity. In general, you’d want to use the highest MERV number your HVAC system will tolerate. Too high a number can create too much pressure and cause problems. What if you don’t have access to the filters for your air? That is the case for many apartment dwellers who have to share their air with everyone else in the building. One affordable option is to build and use a Corsi-Rosenthal box. It can be assembled at home for $50 to $70 and it works quite well to provide cleaner indoor air in the space where it is operating. Dr. Marr describes how to build one. Here is a link to our interview with Dr. Corsi, including instructions on building a Corsi-Rosenthal box. Elimination: Another step toward cleaner indoor air might be to utilize ultraviolet (UV) light as a disinfectant. A unit that uses germicidal UV at a wavelength of 250 nanometers needs to be tucked into air ducts. That wavelength can damage eyes and skin. New technology is being developed using a slightly different wavelength of 222 nanometers. While still germicidal, it is supposed to be safe for human eyes. This Week’s Guest: Linsey Marr, PhD, is a professor of civil and environmental engineering at Virginia Tech, where she leads the Applied Interdisciplinary Research in Air (AIR2) laboratory. Her research group focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Marr teaches courses in environmental engineering and air quality, including topics in the context of global climate change, as well as health and ecosystem effects. She has been thinking and writing about how to avoid airborne viral transmission since the pandemic began, as in this article published in Environment International (Sep. 2020). Photo by Peter Means, courtesy of Virginia Tech. Dr. Linsey Marr of Virginia Tech. Photo by Peter Means, courtesy of Virginia Tech Dr. Marr mentioned her publication, with many colleagues, advocating for cleaner indoor air in public buildings. Here is a link. Joe Graedon conducted this interview, as Terry was unavailable. Listen to the Podcast: The podcast of this program will be available Monday, Dec. 8, 2025, after broadcast on Dec. 6. You can stream the show from this site and download the podcast for free. This week’s episode contains some additional discussion of outside air, including the dangers of smoke from wildfires, along with particulates from car tires or microplastics. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1454: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. How do you catch the flu, COVID, or cold? Such respiratory infections are transmitted through airborne viruses. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:46 Dr. Linsey Marr is one of the country’s leading experts on air quality. She was among the first scientists to identify airborne transmission as a problem during the COVID pandemic. Joe 00:46-00:51 Dr. Marr will tell us how we can improve the quality of the air we breathe. Terry 00:51-00:58 Do you know how well the air in your home is filtered? What about the air quality at school, at work, or in your doctor’s office? Joe 00:59-01:07 Coming up on The People’s Pharmacy, how cleaner indoor air reduces your risk of infection. Terry 01:14-02:16 In the People’s Pharmacy Health Headlines: viruses are on the move, through the air and on surfaces. Subclade K type A H3N2 influenza is spreading. People catch it primarily by inhaling invisible viral particles. Public health authorities are worried that current influenza vaccines may not protect well against this new variant. The other virus that’s causing a lot of misery is norovirus, also known as stomach flu, the cruise ship virus, or the winter vomiting bug. It’s one of the most easily transmitted infections because just a few particles can make you very sick. Wastewater scan shows a significant uptick in the last couple of weeks. If anyone in your household starts throwing up or having diarrhea, you’re at risk of catching this virus. That’s because it can be transmitted through the air. There is no vaccine or effective treatment against norovirus. Joe 02:17-03:31 Nutrition experts have been arguing about fat for decades. Starting in the 1980s, Americans were encouraged to follow a low-fat diet. Instead of using butter, people were told to use vegetable oil. Saturated fat was the enemy because it was thought to clog coronary arteries. Hydrogenated vegetable oils were promoted because they had no cholesterol. And seed oils, such as peanut, corn, and safflower oils, became popular because they, too, were low in saturated fat. In recent years, though, researchers became concerned that hydrogenated vegetable oils contributed to atherosclerosis. And now, researchers at the University of California, Riverside, report on an experiment with soybean oil. Mice fed on soybean oil developed obesity more easily than those fed coconut oil. The investigators identified a liver protein that determines how the body handles linoleic acid, a major component of soybean oil and some other vegetable oils. They point out that many processed foods contain soybean oil, which could be contributing to the obesity epidemic. Terry 03:32-04:51 Diet can play an important role in controlling blood sugar for people with type 2 diabetes. A study published in the American Journal of Clinical Nutrition demonstrates that slowly digestible starch can be very helpful. Because this slowly digestible starch is metabolized over a long time, it does not lead to spikes in blood glucose or insulin. Investigators recruited 51 people with type 2 diabetes and randomly assigned them to diets either high or low in slowly digestible starch. For three months, the volunteers kept track of their blood sugar with continuous glucose monitors. They also met with dietitians for nutritional and culinary counseling. Those whose diets were high in slowly digestible starches such as peas and beans, nuts and seeds, and whole grains had less dramatic changes in blood sugar. Both groups lowered their levels of HbA1c, a medium-term measure of blood sugar. Those on the diets rich in slowly digestible starches actually got their A1c below 7%, which was the target. The researchers believe this offers an effective and accessible strategy to help people with type 2 diabetes gain control. Joe 04:52-05:44 Australia’s equivalent to the Food and Drug Administration is called the Therapeutic Goods Administration, or TGA. Like the FDA, it monitors drug safety. Recently, the TGA issued a new safety warning to people using GLP-1 drugs such as semaglutide, tirzepatide, liraglutide, and dulaglutide. These drugs have become household names such as Ozempic, Wegovy, Mounjaro, and Zepbound. The TGA is concerned about reports of suicidal thoughts and behaviors associated with these medications. The regulatory agency is urging doctors to monitor patients for the emergence or worsening of depression, suicidal thoughts, or behaviors, and or any unusual changes in mood or behavior. Terry 05:45-06:17 Residents of several states are being warned to stay indoors because of poor air quality. High levels of ozone or fine particulates too small to see are making breathing dangerous in many places. You can check your local air quality index at the website airnow.gov. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:27 And I’m Joe Graedon. We’re entering cold and flu season, except there are lots of other pathogens circulating in the air we breathe. Terry 06:27-06:41 We can’t see them because they’re much too little. Infectious agents such as respiratory syncytial virus, human metapneumovirus, pertussis, and mycoplasma pneumoniae can cause a lot of misery. Joe 06:42-06:57 And let’s not forget that SARS-CoV-2 has not disappeared. This year, a new variant of influenza A, subclade K, is making people sick, and the flu shot may not protect us as well as we’d hoped. Terry 06:58-07:26 To find out why air quality matters, especially when pathogens are circulating, Joe talked to Dr. Linsey Marr. She’s a professor of civil and environmental engineering at Virginia Tech, where she leads the Applied Interdisciplinary Research in Air Laboratory. Her research group focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Joe 07:28-07:32 Welcome to the People’s Pharmacy. It’s so nice to have you back, Dr. Linsey Marr. Dr. Linsey Marr 07:33-07:37 I am thrilled to be here, to be back on the People’s Pharmacy. Thanks so much for having me again. Joe 07:37-08:21 Well, you know, unfortunately, Terry can’t be with us today, but I am so pleased to find that you have received so many awards and recognition for the work that you have put in over the last five years, especially with regard to COVID. I mean, you are an environmental engineer, you’ve been involved in bioengineering for a long time. And it seemed like COVID was just waiting for somebody with your expertise to come along. Can you tell our listeners what is an environmental engineer and how did you get interested in aerosol viruses? Cause you were into this field before there was COVID-19. Dr. Linsey Marr 08:23-09:22 Right. Environmental engineers dedicate their careers to ensuring that we have a clean and healthy environment, whether it’s in the natural environment and also in the built environment. The built environment [is] buildings and roads and other infrastructure. And so, for example, some environmental engineers focus on clean water. You know, we take it for granted that you can turn on your tap and get clean water that is safe to drink. But that wasn’t always true. And that development was thanks to the work of environmental engineers. Another example is that of clean air. Air in the U.S. used to be much dirtier in the 1970s. It was heavily polluted by dirty cars and the steel industry and other sources. And environmental engineers are the ones who kind of recognize this and helped lead, I guess, research and actions to help clean it up. Joe 09:22-09:36 Now, I’m saying that COVID changed your world, but you were already in this field. You were already interested. Tell us how COVID did make a difference in your life. Dr. Linsey Marr 09:37-10:51 Yeah, I had been studying viruses in the air since about 2008 or 2009. And I got into it mainly, well, for a couple reasons. One, I had been studying traditional particulate pollution in the air. As I mentioned, environmental engineers study air pollution. And then a second reason is that I had a child in the end of 2007, and he had started daycare and was getting sick all the time. So I really became both fascinated and frustrated by the rapid spread of disease in daycare centers. And so I started reading up on this and found out that we really didn’t know as much as it seemed. And what I did read about how the flu spreads between people, some of it just didn’t really make sense with my understanding of how particles move through the air. And so my research group started out by going into daycare centers, a health center on campus, and airplanes. We collected air samples, really particles in the air, and analyzed those and found the flu virus present in like half of them. And it was in small enough particles that they would stay in the air for a long period of time, float around, and people could breathe them in. And after several hours, they could breathe in enough to become infected. Joe 10:51-11:15 So you were already beginning to suspect that viruses could float on the air. And then along comes COVID. And the CDC and the World Health Organization, all these public health experts were saying six feet. As long as you’re, you know, eight feet away from somebody who’s infected, you’re home free, no worries. And you are going, whoa, whoa, wait a minute. Dr. Linsey Marr 11:16-13:01 Yeah. All of a sudden, all the research I had been doing for the previous 10 years really was here. And I had been studying this because I was worried about a new flu pandemic. It wasn’t flu, but it turned out to be a coronavirus. And then there was this constant messaging about, oh, stay six feet away from people and that’ll protect you. And I knew from what I had been studying that that was likely not true. And it was based on some older, let’s say, kind of dogma or kind of, yeah, just dogma about how respiratory viruses transmitted, that it was mainly in these large droplets that people cough or sneeze into your face big enough to see. And they’re large enough and heavy enough to fall to the ground within six feet of anyone who coughed them out. So that, if that were true, then if you stayed at least six feet away, then there would be no way that you could come in contact with these, the viruses being emitted by other people. But it turns out that, you know, based on research I had done earlier and putting together a lot of studies that other people had done, even going back to the 1940s, I knew that people, whether they’re infected with a respiratory virus or not, but that they emit respiratory particles of all sizes, both those large wet ones when you cough, but also smaller stuff when you talk. And even some people when they breathe. And based on older studies, I knew that the virus could be present in those across the whole size range and could also survive in those. And so the idea of the six-foot distancing, to me, it just didn’t sound like enough. I think it was due to a misunderstanding about how this type of virus would transmit. Joe 13:02-13:43 What surprises me in retrospect is that the six-foot rule kind of lasted a long time. It made no sense. And I kept wondering, well, where did it even come from? But I think your research and your colleagues’ work demonstrated pretty effectively that these viral particles could float through the air not for a few minutes and not for six feet, but for a long time and a greater distance, a much greater distance. So when did we finally begin to recognize that, Yeah, six feet wasn’t going to be the answer. Dr. Linsey Marr 13:44-16:17 I think it was a gradual series of kind of research studies and also observations of super spreading and other types of events that helped us realize that six feet wasn’t enough. And I should say that six feet is helpful because it does keep you kind of farther away from the most concentrated plume. If you imagine somebody’s talking, there’s a kind of a plume of air coming out as if they’re smoking a cigarette and you want to stay away from that. So six feet is good for staying away from that, but it’s not going to absolutely protect you from breathing in those smoke or other respiratory particles. But there were a number of things that happened. So one was that there was that the outbreak in the Skagit Valley Chorale in early March of 2020, I believe, where there was a choir that went through a rehearsal and maybe one or two people were were infected. They didn’t feel quite well. The group, you know, knew that there was this new virus around. And so they avoided shaking hands, touching each other. And yet still something like over 80% of the members of the choir became infected after that practice. So that to me was one sign of, oh, this thing is probably in the air because it’s really hard to infect that many people just by touching the same doorknob. Even if everybody did touch the same doorknob, you know, after the first few people touch it, you know, any virus that was on there will probably be gone, have been removed. So that was one thing. And then there was a study that came out of China in a hospital where they did aerosol particle sampling with the types of instruments, the same types of instruments that my group uses, and they found virus in the very small particles. Now, it was the viral RNA, like its genetic signature, it wasn’t infectious virus. And so some people said, oh, well, it’s not infectious. That doesn’t prove anything. But, you know, we know that it’s hard to, it’s really hard to maintain infectious virus when you’re sampling from air. So that was another hint that it could be there. And then there were, there were additional studies. Finally, I think later that summer, there was a group that sampled air in a hospital where there were patients, and it was more than six feet away from their beds. And they used a newer sampling device that is gentler and help better keep the virus infectious. And they discovered a lot of infectious virus in the air in those samples. Joe 16:18-16:59 So there was enough evidence that accumulated over those first year or two that people began to recognize. But they didn’t really want to believe it. And in a sense, there was like, well, we don’t want a mask because that’s a pain in the neck. And we aren’t going to change our heating and air conditioning systems. And so nobody really knew what to do about it, including, I think, a lot of the public health people. We just have about a minute left before we take a break. But have we learned from COVID? Have we made changes that are significant so that it won’t happen again? Dr. Linsey Marr 16:59-17:33 I think we have learned there’s a totally new discussion about transmission of viruses through the air that used to be completely absent or was reserved for really special cases. But I think now it’s understood to be widely applicable to colds and flus. And then, for example, I think the CDC, Centers for Disease Control, had a new website where they recommended a certain amount of ventilation, minimum ventilation in rooms. And so that’s progress. That’s something that did not exist before. Joe 17:34-17:45 Well, when we come back after this break, let’s talk about progress and what we need to do in the future to prevent another pandemic. Terry 17:45-18:02 You’re listening to Dr. Linsey Marr, Professor of Civil and Environmental Engineering at Virginia Tech. She leads the AIR2 Laboratory, which focuses on the dynamics of biological aerosols, like viruses, bacteria, and fungi, in indoor and outdoor air. Joe 18:02-18:07 After the break, we’ll learn about other pathogens in the air besides viruses. Terry 18:07-18:13 Researchers pay attention to the size of the particles that are wafted around indoors. How do they affect our health? Joe 18:13-18:19 If you have to spend time where there might be a lot of pathogens in the air, are there ways to protect yourself? Terry 18:19-18:25 Which places are especially dangerous? Are some public places we should be extra cautious? Joe 18:25-18:29 Air filters might help. How could we improve ventilation and filtration? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:40-20:43 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:43-21:01 And I’m Terry Graedon. Joe 21:01-21:20 Air quality is important for health, but public health experts have not required landlords to install high-efficiency filters or UV lights to eradicate pathogens. Is there anything we can do to monitor air quality and protect ourselves from airborne pathogens? Terry 21:21-21:47 I was on assignment out of town and could not participate in this interview with Dr. Linsey Marr. She is one of the country’s leading experts on indoor air quality. She’s focused her research on the dynamics of biological aerosols such as viruses, bacteria, and fungi. Dr. Marr is professor of civil and environmental engineering at Virginia Tech and leads the AIR2 Laboratory. Joe 21:48-22:24 Dr. Linsey Marr, we’ve been talking about COVID, a virus, but there are all kinds of pathogens that float in the air besides viruses like influenza and COVID, SARS-CoV-2. Tell us about the size of the particles, whether it’s a bacteria or whether we’re talking fungi or some other pathogen, and how all of the stuff that’s in our environment, whether it’s inside or outside, may affect our health. Dr. Linsey Marr 22:26-23:54 Yeah, there’s a whole… world of microscopic organisms in the air around us. And bacteria are around one micron in size. And to put that in perspective, a strand of your hair is probably 50 to 100 microns in diameter. So imagine something that’s one-fiftieth to one-hundredth that size. Fungi might be that size or a little bigger. Viruses are maybe smaller than that bacterium. Maybe like the coronavirus and flu viruses are around 0.1 microns. So one-tenth the size of the bacterium. But those things do not float around naked. They’re released from a respiratory tract or with bacteria. It might be splashed out of water somewhere, blown out of soil. And so it’s carrying, there’s a particle that is carrying the virus or bacterium or fungi, but often it also, usually it carries other things from that fluid. So like our respiratory fluid, your saliva, sure, it’s liquidy, but if all that water evaporates, you’re left behind with a lot of salts and proteins and other organic material. And in fact, that amount of material, you would have almost like 100,000 times as much of that other material, mucousy, salty stuff, than you would the amount of virus in it. And so these things are all around us. They’re very tiny. We can’t see them, but they’re there. Joe 23:55-25:53 Well, you know, you’ve used the metaphor of smoke. And I think it’s really, you know, it’s a great example. If you enter a room where somebody has been smoking a cigar, you will know it instantly because it smells. You probably won’t see the smoke, especially if they were in the room maybe 30 minutes before you walked in and they had left. But the idea that there are still those smoke particles floating through the air and you can smell them, that kind of is a wake-up call that whenever we walk into any room, almost anywhere, there are going to be particles, especially if there are a lot of people in that room. And I think of concerts. I think of sporting events, basketball season, and thousands of people all screaming their lungs out, some of them sneezing. And I’ve seen your video that you’ve shown with people sneezing, and it’s really scary. And so there are a lot of venues where you’re going to be breathing in a lot of different pathogens. And the question is, why are some people more likely to get sick than others? We got a lot of email from people who said, oh, I don’t worry about that stuff because my immune system is so good. I take lots of vitamins and nutrients and I can ward off anything. And then I’m thinking, yeah, but what about norovirus? If you walk into a bathroom where somebody threw up or had diarrhea, there are going to be norovirus particles floating through that public restroom. Or what about influenza? Or just, you know, there are so many kinds of pathogens out there. So I guess the question becomes one of, we can’t see this stuff, but it’s there, how do we protect ourselves? Dr. Linsey Marr 25:54-27:53 We covered a lot in that question. So let me, that’s a great question. Let me go back to the cigar. So what we are smelling is often the gases that are in there, not the actual particles. Although if the gases are present, there may still be a few smoke particles around. And then in terms of kind of particles in the air all around us, there’s even in a room that appears clean, a typical amount of particles in the air, and this is not just like microbial stuff, but just total particles of all kinds, is you would have like a thousand particles per cubic centimeter. And a cubic centimeter is roughly the size of a sugar cube. So you take a big deep breath in and you’re breathing in like a million particles. And a lot of those come back out, but some of them do deposit. And some of them are salts and other organic material and lots of different materials. Only a small fraction of them are actually microbes. And an even smaller fraction of those are actually pathogens. And so how do we protect ourselves in these types of places where they’re all around us? Well, the fact that the pathogen is in the air and you breathe it in is only one part of the equation of whether you’re going to get infected and sick or not. Because indeed, your immune system plays a big role here in trying to fight off these pathogens. And that response is going to vary hugely from individual to individual. And that’s outside my area of expertise. But, you know, I work with people who know a lot more about that. And that certainly plays a big role. And then, you know, how do you protect yourself if you are, let’s say, immunocompromised or you’re on a big, important trip and you don’t want to get sick? Well, you know, for things in the air, you would want to wear a high quality mask, a respirator, something like an N95 that, you know, fits well, especially when you’re in around other people and in crowded, poorly ventilated areas. Joe 27:55-29:02 And then, let me interrupt… let me interrupt you right there, Dr. Marr, because Americans hate masks. That’s pretty clear. People in other countries, South Korea, for example, China, they’re more than happy to wear masks. But here it’s like, no way. It’s an invasion of my personal freedom. And, you know, when you get on an airplane, you have to walk through that passageway where I suspect there’s very little in the way of ventilation. And if there are a lot of people getting on the plane, you’re going to be standing in line and you’re breathing everybody’s air. And even on the airplane, it may not be as well filtered as a lot of people would like it to be. So the culture of masking seems not going to work here in the United States. As soon as people could stop wearing a mask, they did. And people who do wear masks, people sometimes look at them like, “What’s the matter with you?” So how do we change that culture, or is it impossible? Dr. Linsey Marr 29:03-29:55 Yeah, clearly, you know, American culture is not into wearing masks. That’s for sure. There’s other things we, you know, I don’t know if we how to change that culture, you know, that maybe if we get celebrities wearing them and it becomes cool, that would help get some, you know, advertisers on this to shift the view. But in the meantime, there are a lot of other things that we can do regarding cleaning the air. As you mentioned, you know, when you’re in the jetway, I’ve, you know, I’ve carried around a little sensor to kind of get a sense for where, where’s the air best ventilated or not. And actually on the jetway, I think because one end is pretty open to the air, you do get decent airflow through there. On the airplane, of course, it’s recirculated, but it’s also very well filtered at the same time. Joe 29:56-30:19 What are the most dangerous places? Since I assume you’ve been using a CO2, a carbon dioxide monitor, what have you discovered in supermarkets, in doctor’s offices, in pharmacies, wherever you may go and test? Where do we need to be especially cautious? Dr. Linsey Marr 30:19-31:06 Yeah, I’ve seen the highest numbers in things like restaurants, certain types of restaurants, poorly ventilated ones and crowded ones. Supermarkets, not so much, although I tend to go to the big stores that have really high ceilings and they’re not totally packed with people. Buses, I would say, I see higher levels. Some classrooms, I’ll see higher levels. So the higher level is an indicator of poor ventilation because carbon dioxide is in our exhaled breath. You do see higher levels on airplanes, but you have to remember that that air is running through filters every two or three minutes. And those filters will remove particles. Joe 31:07-31:47 Well, speaking of filters, because obviously there are a lot of places where we go where you really can’t test the way you have with your portable CO2 monitor. When you walk into a restaurant, what would you like to see if you had the power to influence public health authorities to actually improve filtration? And then maybe we can talk about how we can start using ultraviolet to kill some of these viruses and bacteria that are floating in the air. Dr. Linsey Marr 31:48-32:16 I would like to see, and maybe you wouldn’t be able to see it because it would be hidden in the docks and also in the walls, but good filtration systems with the air being circulated a lot of times through that filtration system, and open windows if the weather’s conducive to it so that the air in that restaurant feels as fresh as it does outdoors. Joe 32:18-32:27 It sounds like Florence Nightingale, you’re sort of adopting her recommendations from more than 100 years ago. Dr. Linsey Marr 32:28-32:36 She was onto it. She knew what she was talking about. I mean, she observed people getting sick in hospitals and knew how to reduce that. Joe 32:36-33:05 The only trouble is that most of our public buildings these days are sealed very tight to be energy efficient. And so it’s not always possible to open those windows. Should public health authorities be testing, investigating, making recommendations, and then perhaps requiring public establishments to actually improve filtration and ventilation? Dr. Linsey Marr 33:06-34:23 Yeah, this is something that a group of scientists and other organizations are working on. I mentioned earlier that the CDC now recommends a minimum ventilation rate of four to six air changes per hour in public spaces. And there was a, I attended an event at the United Nations General Assembly a couple of weeks ago that was intended to raise the profile and spur more action for cleaner indoor air. And so that, you know, some places will do this voluntarily, but really the way that we get it more broadly installed is through standards and regulations like we do for fire safety. And so we have, you know, a group of scientists has talked about and written a paper that appears in Science about the need for air quality, indoor air quality guidelines and regulations that are widely implemented. You know, it’s not going to change overnight, but I’m hoping that this starts the discussion and that maybe, you know, 10, 20, 30 years from now, our building stock takes a long time to turn over, but we’ll start designing buildings that are designed not just for energy savings and thermal comfort, but also for good indoor air quality. Joe 34:23-34:46 Well, at the present time, we can’t always tell. And so what about one of those portable carbon dioxide monitors? Should people be carrying them around with them when they go, for example, into a restaurant or into their local pharmacy? And if the numbers are too high, and what would that be? Maybe turn around and change their mind about going in. Dr. Linsey Marr 34:48-35:34 Yeah, if you’re someone who’s really concerned about getting sick from respiratory viruses, you could carry one of those around and keep an eye on it for numbers over roughly 1,000 parts per billion. That would be an indicator that the place is not well ventilated. They could, though, have good filtration, which would remove pathogens from the air. So maybe you see that high number, you turn around and go out, or maybe you carry a mask with you and you put on your mask. So I did hear that I think stores in Japan were required to display their CO2 levels in the window. Something like that would be really helpful for people to be able to see from the outside, oh, what’s it like in there? And then they can decide whether to go in or not. Joe 35:35-35:56 Oh, that’s a cool idea. I love that idea. You know, having a little electronic sign that says, OK, your CO2 levels here are under 600. It’s like breathing outside air. And then everybody feels, okay, I can go in. And if they’re over 1,000 or 1,500, you say, uh-uh, I’m not coming in today. Don’t thank you. Dr. Linsey Marr 35:56-36:01 Yeah, I should correct myself also. I think I meant 1,000 parts per million PPM. Joe 36:01-36:19 That sounds right. Now, one of your colleagues, Dr. Corsi, has come up with a filtration system that’s inexpensive. Not something you can carry around with you, mind you, but something that people could have in their homes or in their offices. Tell us a little bit about that. Dr. Linsey Marr 36:19-38:01 Yeah, it’s called the Corsi-Rosenthal box, and it acts as a very effective portable air cleaner or filtration unit. Some people call them air purifiers. But it basically mimics what a $200 piece of equipment does for, I don’t know, $60 or so to buy what you need. So one item is a box fan. And then you would also need, let’s see, that’s one, four filters, like kind of those rectangular HVAC filters that you might put into your air conditioning system, you might replace them. And then you tape them together, and you set it on the floor. So you have this box, this cube, that’s where it’s like the box fan is sitting on top. And it’s pulling air through those filters and then ejecting it out of the top. And what you’re getting out of the top is pretty clean air. And what’s interesting is that those filters do not have to be HEPA level. So HEPA is high efficiency particulate air filters. Those remove 99.9% or more of particles in the air. They can be slightly less efficient because this thing moves so much air. So even if I have, let’s say I do have a HEPA filter, If I’m barely moving any air through it or trickling a little bit of air through it, it’s not actually cleaning that much air. But with the Corsi-Rosenthal box, also called the CR box, it’s moving a ton of air through there. So even if it’s only filtering out like 95% of particles, that air is going to go back through the filter and it’ll remove another 95% of the particles. So you get this, you get a benefit of having a high airflow rate through those. And again, it’s inexpensive and you can make it yourself. Terry 38:01-38:42 You’re listening to Dr. Linsey Marr, Professor of Civil and Environmental Engineering at Virginia Tech. She leads the Applied Interdisciplinary Research in Air, the AIR2 Laboratory. It focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Dr. Marr teaches courses in environmental engineering and air quality, including topics in the context of global climate change, as well as health and ecosystem effects. She’s been thinking and writing about how to avoid airborne viral transmission since before the pandemic began. Joe 38:43-38:54 After the break, we’ll find out about the air filters in your home. Do you have a HEPA filter? We’ll also find out about how to interpret MERV numbers. Terry 38:54-38:59 How well do HEPA filters work? And how often do we need to change them? Joe 38:59-39:05 Could you kill airborne viruses with UV radiation or ozone? Is that a practical and safe way to go? Terry 39:05-39:10 Are there any UV systems commercially available for places like hospitals? What about homes? Joe 39:11-39:18 Dr. Marr will share her list of worrisome airborne pathogens. Flu and measles are obvious. What about norovirus or TB? Terry 39:28-39:31 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 39:40-39:43 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 39:43-40:01 And I’m Terry Graedon. Joe 40:01-40:18 Air quality is always important for good health, but because we can’t see pollution or pathogens, we tend to ignore the air we breathe. How would you know about the quality of the air you breathe in your local supermarket, bank, or pharmacy? Terry 40:18-40:40 Ventilation and filtration are the cornerstones for maintaining air quality indoors. Do you know what kind of filter your air handling system uses? What about at your doctor’s office? When asked why he robbed banks, Willie Sutton said that’s where the money is. When you go to an urgent care clinic or a doctor’s office, that’s where the germs are. Joe 40:41-40:56 Most people have stopped wearing face masks, and they’re optional at many health facilities. But COVID is still with us, along with influenza, RSV, metapneumovirus, and many other airborne pathogens. Terry 40:57-41:43 To learn how to improve air quality indoors, Joe spoke with Dr. Linsey Marr. She’s a professor of civil and environmental engineering at Virginia Tech, where she leads the Applied Interdisciplinary Research in Air, AIR2 Laboratory. Her research group focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Dr. Marr teaches courses in environmental engineering and air quality, including topics in the context of global climate change, as well as health and ecosystem effects. She’s been thinking and writing about how to avoid airborne viral transmission since before the pandemic began. Joe 41:44-42:25 Dr. Marr, you were talking a little bit about the Corsi… is it Rosenthal box? And how you can do it yourself for a relatively modest amount of money, but you could also put a better filter in your heating and air conditioning system, whether it’s an office building where there are lots of people or whether it’s your home. What are the best filters? You’ve mentioned the HEPA filter, H-E-P-A, but there are also MERV filters. And I’ve never quite got the numbers right. So if you could explain filtration a little more, we’d be grateful. Dr. Linsey Marr 42:25-44:23 Yeah. MERV stands for Minimum Efficiency Reporting [Value]. I can’t remember exactly what it is. Everyone just calls it MERV. And if you go to a big box store like Home Depot or Lowe’s, they’re going to have filters with their own numbering system on them in terms of how good the filters are. But they should also, you should be able to correlate that with the MERV scale. And the MERV scale is kind of standardized and a higher number is better. And so it goes all the way up to, I think, 17, which is like HEPA equivalent, um, it starts at one. So I would say, you know, kind of your, and the higher number indicates that it’s going to remove more particles. It has higher filtration efficiency. So the highest ones are going to remove over 99% of particles. And then the lower MERV numbers are really just there to protect your HVAC system from leaves and other big, you know, maybe hairballs from your cat and prevent those from going in. And so, you know, home systems might have something like a MERV 4 or 8 filter. If you’re getting into commercial buildings, they might have had 8 or 11. But since the pandemic, I think we’ve realized that, oh, having a higher filtration efficiency or better quality filter is, you know, going to give us healthier air for people. And so I think buildings that can are moving more towards MERV 13 or MERV 14 filters. Now, one caveat here is that the higher efficient, the higher MERV filters that are better removing particles also create a bigger pressure drop. It’s a little harder to push air through those, pull air through those. And so your air handling system needs to be able to handle whatever that filter you put in. So you need to kind of check and make sure your air handling unit is okay. So for example, we tried this in my house. We tried to put in a higher MERV number filter, but then the system stopped running. It gave me a fault. And so I realized, okay, we’re creating too much pressure drop. We’re asking our fan to do too much work. And so we had to go back down. Joe 44:25-45:04 So as people begin reinstalling new HVAC systems, whether it’s in an office building, in a supermarket, in a big box store, or at home, they should in the future, hopefully with public health encouragement, design systems that can handle those higher efficiency MERV filters so that we’re up around MERV 13 or above. And how well do they work? Do they really capture enough, let’s say, viruses and bacteria to make a difference? And then how often do they need to be changed? Dr. Linsey Marr 45:06-46:16 Yeah, once you get up into MERV 13, 14, you’re removing over 80 percent, 90% of particles in the air. And so that’s helpful. But that’s kind of in the mixed air that’s throughout the whole room and throughout the whole building. Now, we think it’s not clear, but it’s some of the research we’re doing with humans and animals. We think that in a lot of cases, transmission occurs in these closer face-to-face interactions. And in that case, the filter doesn’t help as much because that’s like the whole room air. It’s got to go through the HVAC system and come back before the, and it doesn’t have the chance to do that when you’re talking face-to-face with someone. So in that case, you need other strategies. But as far as the filters, yes, absolutely. If you’re upgrading your HVAC system, you should be thinking about getting one that can handle the higher efficiency, higher MERV number filters. And then depending on the system. They may recommend filter changes every quarterly, every three months, or maybe semi-annually, so every six months, but it depends on the system. Yeah. Joe 46:16-46:41 Let’s move beyond filtration and ventilation because that goes along with the filtration. You want to have fresh air being introduced into your system, but let’s talk about killing those bacteria and viruses. What about ultraviolet light? Are there safer systems? What about ozone? Give us an update on how we can purify the air. Dr. Linsey Marr 46:43-49:11 Right. You had mentioned UV before. And so UV works by killing the viruses or bacteria. It actually messes up their genetic material, DNA or RNA. And so this has been used for decades, a certain type of UV light called germicidal UV, which is at a certain wavelength, 254 nanometers for those who are interested. The issue with that type of UV light is that it is dangerous for us to look at and it’s bad for our skin to be exposed to it. So those types of systems can only be installed inside air ducts where people are not going to be seeing it and their skin won’t be exposed to it. Or they’ll install it in kind of these upper air systems at the ceiling if they have a high enough ceiling and it’s pointing upward so nobody gets directly exposed to the light. Now, there’s a newer technology called FAR-UV, and that’s at a different wavelength, 222 nanometers instead of 254. And that is really intriguing because it still kills off viruses and bacteria. And it’s also considered to be eye safe and skin safe. Like it can’t penetrate through the very outer layer of cells in our eyes and skin. And you mentioned ozone. So UV of any kind can generate ozone also because UV, you’re adding UV light and that generate that kind of can can photolyze or cause chemical reactions with the oxygen and other compounds in the air. Ozone is bad for us. We have health standards for ozone. And so there’s there’s kind of a trade off here of, well, you have the benefit of killing off pathogens, but you may be generating a small amount of ozone. And, you know, it’s still in the research phases of whether there’s a net benefit and what any long-term effects might be of exposure to far UV. But it does show a lot of promise. Certainly in laboratory studies, it really effectively kills off pathogens. And, you know, I think of it like we use UV in our drinking water for drinking water treatment in some places instead of chlorination to kill off pathogens. And so this is something, oh, well, we do that in our water. We could do that in our air to kill off pathogens in the air so that we don’t have to breathe them in. Joe 49:12-49:27 Are there systems now available for, let’s just say, hospitals, for example, or for people’s homes if they wanted to install a UV system? And how would they know if they’re safe? That is to say, not putting out too much ozone. Dr. Linsey Marr 49:28-50:25 Yeah, I’ve seen there are vendors out there selling far UV lights that you can put in your home. They do recommend that you put them in certain locations in the room. And they have been testing them for ozone. There’s ways you can estimate through there. I know one has a kind of a model where you could put in the dimensions of your room and how many lights you want to put in and what the resulting increase in ozone would be. So again, we still don’t know what that trade-off is between, okay, you’re removing pathogens from the air, but you’re increasing ozone a little bit. And it’s not just ozone, but the ozone can react and other things that the UV light generates can react with things in the air and produce byproducts that maybe are potentially more harmful and can also produce particles in the air, interestingly. Joe 50:26-51:10 So it sounds like we don’t yet have a magic wand to be able to purify our air and make everybody safe so they don’t have to think about transmission of pathogens. And while we’re talking about pathogens, if you could just run down the list of things that concern you, because we’ve heard a lot about measles over the last couple of years and how there’s been quite a spread of measles. I do worry about norovirus. I know a lot of people go, oh, that’s just a cruise ship thing, and you can’t possibly get it by breathing. It’s just by touching handrails, for example. But if you could run through some of the pathogens that concern you, please. Dr. Linsey Marr 51:11-52:59 Certainly. Norovirus is, oh, it’s memorable. I think we don’t know if norovirus transmits through the air. There have been some interesting studies where there was one in Australia in a performing arts locale where the students were going and someone threw up on the carpet. And the next day, a group of students went there and they walked past this spot on the carpet, which had been dried, but I guess not fully cleaned up. And then several students got sick the next day from that stomach bug. So yeah, we don’t know. I wouldn’t be surprised if [norovirus] can transmit through the air. I’m guessing because it’s a gastrointestinal thing, it’s more from touching, but again, we don’t really know. Other things that are, you know, things that cause the common cold are rhinovirus and adenovirus. Those almost certainly go through the air, although adenovirus can also cause gastrointestinal issues. There’s other coronaviruses. There’s four seasonal types of coronaviruses in addition to SARS-CoV-2, which caused COVID-19. Those can cause colds. We’ve also recently discovered that something called human metapneumovirus is more prevalent than we thought. And that’s just another one of these respiratory viruses that causes colds. Flu, we should definitely not ignore because that still leads to an average of over 30,000 deaths per year. I think last year was bad. There were 100 or 200 maybe kids who died from it. So we should not forget about flu. Measles, unfortunately, is making a resurgence due to under-vaccination. And that, everyone knows, travels through the air and is very, very contagious. Joe 53:00-53:21 And I worry about something that seems out of the ancient past, and that’s tuberculosis. I remember talking to an infectious disease expert who said, yeah, TB is not gone. And if somebody is infected, they can spread it pretty fast. Thoughts about tuberculosis? Dr. Linsey Marr 53:22-54:45 Yeah, I think, you know, I have heard of some cases in the U.S. It’s often in those living in less sanitary conditions and who don’t have regular access to health care because there are treatments, but it requires vigilance, I would say, for the treatments. And so tuberculosis is caused by a bacteria, bacterium that travels through the air. For sure, we know that this is one of the kind of very well-known, well-accepted airborne diseases because the way it infects is that it has to get down to deep in the lungs because that’s the only place where there’s the right types of cells with the right types of receptors for the tuberculosis, for the bacterium to infect. Now, another one that we, you haven’t mentioned is Legionella, which I think cases are increasing that’s partly due to greater awareness of it. But this is something that transmits from, not from person to person, but more from water and you inhale it. And so that can be through, you know, it was named after an event in a meeting of the Legionnaires, I think in Philadelphia in the 1970s, but that can be through water that’s contaminated. There’s outbreaks that have been noted in New York City that are linked to cooling towers on top of buildings where the bacteria grows and then it gets aerosolized in the cooling tower and then can spread throughout the neighborhood. Joe 54:45-55:02 Dr. Marr, we’re just about out of time. We have about two minutes left. What are you doing for your family and for your students? And what are you recommending to your colleagues when it comes to reducing the likelihood of catching some of these pathogens that we’ve been talking about today? Dr. Linsey Marr 55:04-55:45 As we mentioned, the carbon dioxide sensor is a good tool. I recently had a colleague who asked me about high levels he was seeing in his office. And we did a little bit of investigation, were able to figure out that air was coming from the hallway and classrooms into his office. And so, you know, they consulted with the facilities department to try to look into that. They talked about potentially installing an exhaust fan. So, you know, if someone in my family is sick, we will often try to run the exhaust fans, we bring out our portable air cleaner, the HEPA filter unit and kind of it follows that sick person around the house, wherever they happen to be, to try to clean the air and reduce the chances of other people getting sick. Joe 55:47-56:00 And recommending our listeners should be masking when they’re going into places where there’s the likelihood of people having influenza and colds and other kind of respiratory infections? Dr. Linsey Marr 56:01-56:27 Certainly during the respiratory season, if you want in the wintertime, if you’re really concerned about getting flus or colds, you’ve got an important event coming up. Masking is going to be probably one of your best defenses, whether that’s traveling on an airplane or you’re in a really crowded area, dense with people. And it seems like the it’s small, the space is small and it’s poorly ventilated, that that will definitely help reduce your risk. Joe 56:29-57:06 Dr. Marr, we’ve been talking about inside air. Let’s talk about outside air. There’s been a lot of smoke in the air because of forest fires. There has been a lot of other kinds of contaminations. You have looked at a lot of kinds of contaminants in a lot of other places, whether it’s ozone or particulates, even [fluorocarbons or] hydrocarbons. Tell us about outside air and why we should be concerned about it. Dr. Linsey Marr 57:07-58:13 Outside air is, you know, obviously when we’re outside, we’re breathing that. And a lot of our indoor air actually comes from outdoors. And so, you know, highly polluted outdoor air can come indoors and then we’re breathing it indoors. So outdoors, there’s things like ozone in the summertime is generated from industrial emissions and also things from motor vehicles and even vegetation contributes to that. We have particles, which are probably the biggest cause of health, have the biggest health impacts in the U.S. and many parts of the world. And those can be generated by combustion and other processes. Interestingly, a lot of them are generated also by reactions involving gases that form particles. And let’s see, you mentioned fluorocarbons. Those are not directly, they don’t directly impact our health, but they can get high into the atmosphere and react with ozone that’s protective, that’s good up there. And so reduce our protective layer of the ozone. Joe 58:14-58:50 I’ve got one that just struck me a couple of weeks ago: Tires. I mean, you know, there are millions of automobiles and trucks on the road, and we always have to replace our tires after 30, 40, 50,000 miles. And I got to thinking, well, what happens to all of those chemicals and all of that material that is in our automobile tires? Where do they end up? Do they end up in the air? Do they end up in the earth? And how far are they? Dr. Linsey Marr 58:50-59:34 That’s a great question. In fact, one of my colleagues here at Virginia Tech is looking at that exact question. And he told me a startling statistic about the number of pounds that your tires reduce because of all the tire wear particles when it’s running on the road. And so a lot of that, if it’s big, chunky, that’s just going to stay on the ground and then it gets washed into our soils or into our bodies of water. Some of it does get into the air. We know that. And so it contains organic compounds and metals and other things. It’s not going to stay in the air forever. Everything in the air eventually has to come back to Earth. But yeah, people are breathing that stuff in, especially, I think, near roadways. But it’s and I think we don’t it’s something we’re still learning more about. Joe 59:35-01:00:01 And last, microplastic or nanoparticles of plastic or those itsy bitsy little tiny pieces of plastic are everywhere, and they’re in us. Your thoughts about plastic as part of the air, we don’t think of it as something that we breathe because we think, oh, they’re too big, but it seems like plastic is just pervasive. Dr. Linsey Marr 01:00:02-01:00:37 Yeah, the microplastics are definitely there. They’re going to be worn down into pieces smaller than we can see. They’ve been detected. I had a student who was doing a project in a school and collected dust samples and found lots of microplastics in them. I think I’m concerned about those, especially because of some of the health studies I’ve seen where you find plastics in the brain and it might be associated with dementia. This is, yeah, it’s an emerging pollutant that I think deserves a lot more attention because it’s something new that we didn’t have nearly as much 50 years ago and really none of 100 years ago. Joe 01:00:38-01:00:43 Dr. Linsey Marr, thank you so much for talking with us on The People’s Pharmacy today. Dr. Linsey Marr 01:00:44-01:00:46 Thanks so much for having me. It’s been a real pleasure. Joe 01:00:47-01:01:27 You’ve been listening to Dr. Linsey Marr, Professor of Civil and Environmental Engineering at Virginia Tech. She leads the Applied Interdisciplinary Research in Air, AIR2 Laboratory, which focuses on the dynamics of biological aerosols like viruses, bacteria, and fungi in indoor and outdoor air. Dr. Marr teaches courses in environmental engineering and air quality, including topics in the context of global climate change as well as health and ecosystem effects. She’s been thinking and writing about how to avoid airborne viral transmission since the pandemic began. Terry 01:01:28-01:01:37 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Joe 01:01:37-01:01:45 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Terry 01:01:45-01:02:03 Today’s show is number 1,454. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Joe 01:02:04-01:02:24 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. The podcast this week has some extra information about outdoor air, especially when it comes to smoke or forest fires. You’ll also hear about particulates from car tires and microplastics. Terry 01:02:25-01:02:47 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you get regular access to information about our weekly podcast. We’d be grateful if you’d consider writing a review of the People’s Pharmacy and putting it on the podcast platform you prefer. Joe 01:02:47-01:02:50 In Durham, North Carolina, I’m Joe Graedon. Terry 01:02:50-01:03:26 And I’m Terry Graedon. Thanks for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. 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