The Dr. Hyman Show - How Food Marketing is Making Us Sick and Fat with Dr. Sean Lucan

Episode Date: October 31, 2018

So often doctors tell their patients, just eat less and exercise more. The patient who is overweight is often blamed and called a lazy glutton who doesn’t have enough willpower. Well, willpower is not enough. Patients aren’t simply lacking in self-discipline. They are not weak and lazy. Most of them are biologically addicted to sugar, and it’s no wonder! Willpower is not enough to stand up to easy, cheap, convenient food. We need more than willpower. We need solutions.   My guest on this week’s episode of The Doctor’s Farmacy is Dr. Sean Lucan, a practicing family physician in the Bronx treating children and adults. He is an award-winning NIH-funded investigator who has published numerous articles on food-related issues. Dr. Lucan and I talk about food environments—essentially how our surroundings dictate our food choices, and how OSBs (other storefront businesses, places like gyms, laundromats, the barbershop, etc…) are becoming a huge source of providing junk to both children and adults. It all comes down to this: grazing vs. grocery environments.   We also talk about food and beverage marketing to youth, and Dr. Lucan’s campaign to protect youth from dangerous marketing which led to a ban on alcohol advertising.   I hope you enjoy this episode as much as I did.

Welcome to the doctor's pharmacy. I'm Dr. Mark Hyman and that's Pharmacy, F-A-R-M-A-C-Y, a place for conversations that matter. And today we have a great conversation that really matters about food, the food environment, the politics of food, the science about food as medicine, and lots more with our guest, Dr. Sean Lucan. Now he's a practicing family physician in the Bronx. He treats kids and adults. He's an award-winning National Institute of Health funded investigator who's published numerous articles on food-related issues.

He's co-authored one textbook on nutrition and another on stuff that I don't really like, which is biostatistics and epidemiology is okay, preventive medicine and public health. Now, he earned his MD and MPH, his master's in public health, at Yale before completing residency in family and community medicine at the University of Pennsylvania. After residency, he completed a fellowship in the Robert Wood Johnson Foundation Clinical

Scholars Program, which is a big deal, where he earned his master's in health policy research. He's currently a fellow at the National Academy of Medicine, formerly the Institute of Medicine. And that is a big deal, guys. The National Academy of Medicine is the epicenter and the epitome of the best in science and medicine. And you only get in if you know what you're doing. Dr. Lukens' research focuses on how different aspects of urban food environments can influence what people eat and what the implications are for obesity and chronic diseases, particularly in low-income and minority communities, which unfortunately are really targeted by the food industry. And some of

your work was fascinating. We want to get into that about how deliberate targeting is made to low-income minority groups, even when they're not the highest volume, they're targeting them. Another focus of his work is the critical examination of the clinical guidance and public health initiatives that are related to nutrition. In other words, how do we make science into policy? All right, welcome Dr. Liu Ken. Thanks for being here. Thanks for having me. Thanks for the intro. Okay, so you're a family doc. You're interested in community medicine. I'm a family doc. How did you get interested in this issue around food? Because clearly, we don't learn about food in medical school, in residency,

and we certainly don't learn about health policy. We don't learn about the politics of food. And yet, you've made this your life's work to really show the connections between the food environments that we live in and the behaviors that lead to obesity, diabetes, and chronic disease, and particularly in communities that are affected far more than others, communities of color, minorities, the underserved, the poor. This is just striking to me how this actually is so deliberate. Yeah, so I'm a family doctor. I treat children and adults. And the patients that I see predominantly are obese and suffer from diet-related chronic diseases. And it's frustrating as a physician, as a provider, treating patients one-on-one,

talking yourself blue in the face, giving the same advice over and over, and then seeing patients really struggle and not being able to succeed. Which is what doctors get told to do. Eat less, exercise more, come back in three months, and if you're not better, I'll give you medication. That just doesn't work. Well, that doesn't work. And part of the reason it doesn't work, especially in the communities where I work, is that there are such environmental obstacles or contextual barriers to people doing the things that they would otherwise want to do, you know, be motivated to do and just are challenged in getting done. So, you know, I, you know, routinely counsel patients on diet and nutrition and making good healthy choices and

optimizing their eating. And then they go out into a world where that, um, you know, becomes a, uh, a real difficulty for them. So during residency, I remember we did this community survey where we went out and just kind of looked at the neighborhoods and saw where our patients were living and, um, tried to understand, you know, uh, try to see life through their eyes. And one of the, you actually, try to see life through their eyes. And one of the... You actually went out into the community. Yeah, we actually...

People's homes and their environments and actually got out of the clinic and the doctor's office. Well, homes and environments, but also, you know, into the stores and into the retail environment. And, you know, having an interest in nutrition, you know, one of the things that I wanted to focus on was, you know, food sources. And so we went into, you know, community grocery stores. And it was there that I took a picture that I still use in presentations to this day. It's this improvised wooden bin of kind of moldy onions and old potatoes. And that was the produce section of a supermarket.

It was called supermarket. Old, ugly, rotten produce, right. Terrible, right? And that was right next to shelf after shelf of highly processed, refined, sugar-added, salty, unhealthful snacks. And addictive and colorful and enticing. Addictive and colorful and enticing and all those things, right? Heavily marketed, yeah. Just kind of an overwhelming incentive or an overwhelming impetus to eat poorly or to not have the best diet. It was hard to make the right choice, easy to make the wrong choice. That's exactly right.

I mean, the default was to not do the healthy thing. So embedded a little bit in what you're talking about is the idea, I think that's pretty strongly held by most nutritionists, doctors, certainly policymakers, and certainly the food industry, which is that it's all about personal responsibility, that your choices are your own. And that if you make bad choices, it's because it's a moral failing or you're weak, or there's some issue with you that guides your choices. And you just were serious about your health you would just eat less and exercise more and everything would be fine what's wrong with that idea I think that's absolutely preposterous I mean I you know in my patients I'm struck by how

motivated people are how much they want to get better how much effort they put into doing the thing that, uh, will help them be healthier and yet, uh, being, uh, stifled in every, um, you know, at every turn, um, by an environment that's just not supportive of those efforts. Um, and so it's really, you know, it's, it's, it's, um, it's really not a matter of will or willpower or determination. I mean, my patients have, uh, you know, buckets of all, uh, and yet, um, are still, you know, find themselves in situations where, uh, it's just hard for them to succeed. And, um help them fail, really. Yeah. So the reason is because the environment that people are in is sort of a toxic nutritional landscape. It's a wasteland where you could say, get moldy onions and limp, rotten broccoli, as opposed to some other stuff, which is cheaper

and easier to get and more heavily promoted. And you write about something that's quite interesting in your research that I think people aren't aware of, which is not only the obvious stuff, which is heavy food marketing by food industry, not only having all the junk food in all the convenience stores and even grocery stores, and not only just the fast food stores, but something you call OSB. Now, that is sort of an interesting concept, which is something that actually drives a lot of behavior that people don't know about. And I really wasn't even aware of as a driver of a lot of the bad choices. Can you talk about what is OSB and why does it matter and how can we affect it? So OSB is an acronym that the journal came up with. So our first paper about this.

So it stands for Other Storefront Businesses. But it just gets to the point that there is a lot of unexpected food sources out there. So when people think about the food environment or food deserts or food swamps or these toxic landscapes of food, everyone's talking about either the paucity of grocery stores or full-service supermarkets or the overabundance of fast food outlets. But there are so many more sources of food out there than just food stores and restaurants. And to that point...

Like what? You mentioned barbershops, gyms hardware hardware stores available laundry mats i was in staples the other day right yeah food at home depot candy and staples everywhere candy cookies snacks um you know potato chips sugar sweetened beverages of you know every uh color and variety so it's like flashing neon lights buy this buy this and it's impulse buying and people don't actually think about it. It's all in places where they naturally are, but not normally a place where you would get food. Well, normally a place where you wouldn't think you would get food, but increasingly it's everywhere.

And so another study that we did, so not only just demonstrating the prevalence and how kind of ubiquitous it was, but the fact that it's becoming even more prevalent, even more ubiquitous. So what percent of overall food consumption are these OSBs for people who live in these urban or food desert environments? So we can't comment on consumption. We don't even know purchasing at this point, but we can tell you the proportion of food sources that they represent. So they're as numerous as restaurants at this point. So the volume of food available in

those is as much as restaurants more numerous than supermarkets uh more numerous than grocery stores more numerous than food stores and as numerous as restaurants currently and that's been increasing so we looked over a five-year period and there was a food of there was food available in 30 percent more businesses five years after an initial look than there was when we looked you know wow that's accelerating and they're not selling hummus and nuts at the checkout counter right generally not although i have to say so so um a third of all these kind of non-intuitive other storefront businesses offer food currently. That represents about a quarter of all the healthful options out there and about two-thirds of all the unhealthful options. Meaning what's available in those is mostly unhealthy.

Disproportionately unhealthy. Although, you know, occasionally you will find, you know, so people will sell nuts, they'll sell dried fruit, they'll sell, you know, whole grain crackers, they'll sell things that are, you know, less detrimental to good eating and the kind of things that we want patients to choose people to choose to be healthier. Yeah. But those are overwhelmed generally by the, you know, the sodas and the candy and the chips and the cookies and the, you know, the other things's a big issue. Uh, and it's one that hasn't gotten a lot of attention and that, uh, you know, people have kind of glossed over and that, you know, it gets lost in the whole discussion about, you know, food deserts and food swamps. And, you know, if a neighborhood has access to food or if they don't, like no one's really considering these things. And so how does that, how does that stuff get there? Well, how does it get there? Uh, I think it because it sells. So the food industry is deliberately creating another channel of distribution sort of under the radar that is hugely impactful and provides the volume far greater than we estimated.

We have every reason to believe that it is. And, you know, what my research has demonstrated and, you know, some of this is published already and some of it is in press or under production, but it's showing that the greatest, the food is more prominent, more prevalent, available in more places, in more challenged neighborhoods, in neighborhoods that are more disadvantaged, that suffer from diet and diet-related diseases. And so it's interesting that it's not, you know, uniformly available across the board. It tends to be more available in the communities that need it the least. So it's pretty amazing.

You're just sort of living your ivory tower, you know, writing about this stuff. You're literally working in the Bronx in underserved neighborhoods with the poor and minorities, seeing the stuff every single day, living and working in that environment. So you've written a lot about how do we start to change these toxic food environments? What are the levers that we can pull? What are the strategies that we can use to help shift that? Because at the end of the day, it's the food system and the food environment that is the bigger determinant by far of health, obesity, diabetes,

chronic disease than personal choice and responsibility. That's really clear. I think it's not certainly the consensus, but I think if you look at the data, there's no question about it. So what are the kinds of things that you've talked about? Because you're not just sort of criticizing this. You're talking about how do we change the food environment? What can we do creatively to actually make a difference?

And how do we build on those things and scale them? So I think there are a lot of levers at a lot of different levels. Certainly for physicians, for health systems, I think there's a lot we can do, uh, or I think there's a lot more we can do. Uh, and there's been some, uh, glimmers of hope, uh, and things that people have done already. So for instance, in our clinic, we've experimented with a bunch of, um, initiatives to help address the issue of food access and communities and try to improve that. Uh, one thing is a fruit and vegetable prescription program. So not initiated by us, but something that we tried and glommed onto. Uh, and, um, you know, so this is a, um, strategy whereby, you know, patients come into the office,

they, uh, are suffering from obesity or diet related diseases, have a need for better food in their environment. And we write them a prescription just as we would for a medication or a device or any other. Like six nuts, three times a day. Well, we write them a prescription that says you should be eating more fruits and vegetables or generally, you know, um, you know, some, some amount of fruits and vegetables. Uh, and then that serves not only as written advice from a physician, a doctor from a trusted source to do the good thing but it also served as a coupon to then take to a local store to subsidize the purchase of those healthy foods so how's that how's the mechanism of payment there so the doctor writes a prescription doctor writes a prescription does insurance pay for the groceries the insurance does not pay for

the groceries so this was this is grant money? And so it's basically philanthropy money. Well, it is. And then but so the idea is to get it started. Yeah. And then it's working with the local stores, the corner stores, so that the grocery stores and you know, in some cases, we also used farmers markets to to make the supply of healthful food more available, right? So it works on kind of two levels. So it's not only increasing demand by, you know, giving direct advice for patients to eat more, but it's also working on the supply side by, you know, working with owners to say, you should stock this. We're going to be sending patients to you. This is going to create demand and opportunity.

And ultimately what it does is it gets both consumer and, uh, and, um, and the businesses into the habit of, um, uh, exchange of healthy food and it becomes more the norm, right? And it becomes, you know, something where, you know, well, this corner store is offering, you know, fruits and vegetables. We're sending patients there. Patients are shopping at that corner store now. The corner store that's not participating sees that they're losing business or that there's a competitive advantage to offering fruits and vegetables, and they come onto the scene, right? And so there could be this extension or this ripple effect out in the community that makes the food environment healthier overall. So it pushes people to buy

healthier food and businesses to stock healthier food. It does both of those things. Yeah. So it works on both. And I think any strategy is going to have to work on both the supply and the demand. Well, there's one other piece of that, which is I work in Cleveland and again with poor communities. And you say somebody eating avocado, they don't know what it is. Right. Then we bought one or have some kale. They don't know what it is, how to make it. How do you deal with the problem of the lack of awareness of even what to do with these foods excellent point excellent point um because one thing is they eat this and then they go well i didn't hear it some work um early during fellowship with the food trust in philadelphia which is a non-profit organization dedicated to the idea that everyone should have access to healthful food and there

they did some corner store work that worked both on the supply and demand side. So on the, on the supply side, they worked with corner store owners to stock, you know, fruits and vegetables and, you know, in forms that were appealing to kids. So I cut up fruit salads, you know, maybe with, you know, some shelf talkers or some advertising that made it look appealing. Tony the Tiger for fruits and vegetables. Yeah, or something. Well, exactly. You need some branding or some icon or logo. I had a friend who had a company called Super Sprouts,

which had Colby Carrot and Brian Broccoli, all the superhero vegetables. And I think one of the aspects of their marketing or advertising was actually coming up with a comic book to go along with it to kind of get kids. Get your superpowers. Yeah, make it cool. Make it something appealing to kids.

So that's on the supply side. On the demand side, they went into the schools and did tastings with kids, demonstrations with kids. So a lot of these kids are growing up in families that generationally have lost cooking skills, have, you know, moved to, you know, processed and convenience items that are, you know, opening dinner from a box as opposed to, you know, making it from scratch. And so a lot of these kids had never tasted a pepper. They'd never tasted a strawberry. They'd never tasted, you know, different kinds of fruits and vegetables.

And when they're given to them in fun shapes and novel ways and different mechanisms kids actually like they like them yeah and you know so you can um introduce the kids uh you know get their taste buds excited and then send them to the store where they see the item that they just had and you know and again it kind of sets up a loop and so you know this takes grant money or seed money or you know some type of initiative to get things running but once you know if you can if you can find that magic point where you get it started, it creates a positive cycle that reinforces, um, and it's good for communities. You know, the store owners have some reticence, right? I mean, they're, they're, you know, um, they don't necessarily all jump onto

the opportunity, but some realize a real business opportunity, a real opportunity to improve their communities. You know, many of the corner store owners or small store owners are from the communities that they're working in. And so they have a vested interest in, you know, making their communities healthier. And so, you know, those are, um, finding a little tweaks that can help people stimulate different behaviors, right? Absolutely little tweaks. And I think the more the better, right? So like the food industry spends, you know, impossible amounts of money promoting, marketing, making available stuff. Yeah, the stuff that we just do not want patients eating are the things that are making patients sick, quite frankly. I mean, they're selling sickness. And to counter that, we need as many strategies as possible.

I mean, think about it. I think the data changed by the end. We're $10 and $13 billion spent on just advertising and marketing poor quality food. And the worse the food is, the more marketing and advertising they devote to it. And it drives behavior. And the average kid sees 6,000 to 10,000 ads for processed junk food on TV and media. And probably now, it's hard to measure, but through social media and stealth advertising, it's probably even more.

It's more surreptitious. Even before, they used to say, here's a picture of a baby in the 50s drinking 7-Up and Coca-Cola and how good it is to get them to drink their formula. That's obvious and terrible. Nobody would go for that. Now it's all subliminal. It's celebrities. It's kind of, you know, friend marketing. And it seems like it's authentic and natural, but it's not. And it's deliberate. And it's one of the drivers of so much of the behavior. It's a problem. Yeah. And to your point about surreptitious advertising, and I should come back later to some other strategies

that we're using in the clinic to help counter that, but we did a study in the Bronx actually looking at subway advertising. So this is something that no one had really looked at before. I mean, people have done studies. And this is shocking. Everybody listen in because this is shocking. Well, I mean, people have done studies

looking at TV advertising and advertising on computer games and advert games and video, you know, and all kinds of screen media. But there hadn't been a lot looking at the environment where, you know, patients or particularly children are living, are playing, are going to school or commuting back and forth. So we decided, you know, wouldn't it be interesting to go and see what was being promoted in the subway system and the subway stations. And so we rode every subway line in the Bronx, got off at every station and looked at every ad. Wow. And characterized. And so, you know, it's like 68 stations on like seven lines and there

were like 1500 ads. And we, you know, did a content analysis and measured their sizes. And particularly we're looking for a promotion of unhealthy foods and beverages. What we found was that there was... We found there was ad for broccoli all over and grass-fed meats. So there was zero ads, not a single ad for a healthful food product. Nothing. Not a single one. Eat almonds, nothing.

Nothing. However, ads for unhealthful food products. So alcohol, sugar-sweetened beverages, sugary cereals, processed foods, fast foods, were disproportionately found in stations that were in neighborhoods, home to communities that were challenged by various demographic and diet-related issues. More diabetes, more obesity. More diabetes, more hypertension, more hypercholesterolemia, high cholesterol.

These are poor minorities. And then also more poverty, lower education, more children in the neighborhoods, more foreign born, more immigrants, right? So adds disproportionately to that. So we looked and we said, well, maybe it's just a function of the fact that these are just the bigger, biggest stations, right? So like Yankee Stadium is a big outlier. You know, it's a huge number of ads in Yankee Stadium.

So maybe it's just a function of foot traffic, right? So, you know, advertisers are just, you know, selling to the biggest, biggest possible audiences. Eyeballs, right? Yeah, many eyeballs as possible, right? So they're just putting their money where they can reach the most eyeballs. And it just so happens that those are in these neighborhoods. Well, it turns out exactly the opposite.

So it turns out that those unhelpful ads were not related proportionately to the amount of foot traffic or the number of eyeballs. The inverse was true. So it wasn't that they were trying to reach the biggest audiences. They were trying to reach select audiences. And the select audiences that they seem to be trying to reach were those who are most challenged. Right. So poor minority foreign born children living in poverty.

So this is important for people to just pause and understand what this is about. So basically, these are areas where the worst affected by obesity, disease, poverty, where the minorities live, people who have lack of education and are the most burdened. Yet, by volume of people, the number of eyeballs, it wasn't the greatest. It was just the ones that were at most risk. Now, why is that happening? Because it's much easier for the food industry to sell people who are already eating poorly more bad food than have you or I start to eating Coca-Cola, drinking Coca-Cola, or eating processed food, or having junk. So they target existing communities to create what they call heavy users.

Michael Moss talked about it in his book, Salter and Fact. This is a deliberate strategy by the food industry. Now, when you say, well, they're not bad actors or just have legacy products, they have unintended consequences, they're trying to shift their product formulation, okay, they are, maybe they are.

But they're also employing these nefarious tactics which are targeting the most at risk and the ones who have the least amount of ability to stand up and have a voice for what's going on, the least ability to understand it, and also the most affected. I mean, this is, in my view, criminal. I agree 100%. And I think it's awful. think, you know, the silver lining that came out of that research was that, um, uh, it happened to be published at a time when there was a huge campaign and, uh, uh, a lot of effort and interest in getting alcohol ads out of the subway system, out of the, out of mass transit. Um, and what we

were able to document was that among the unhealthy food products or food and beverage products that we looked at, we were able to subtract out alcohol and saw that the same relationships held, right? So the same disproportionate advertising, the same targeted marketing. And so that was compelling evidence to then bring to the MTA, you know, who runs the subway to say, you know, this, this is just unspeakable, right? And it moved, it moved people. I mean, mean, you know, it was one rare case where evidence can influence policy. And that's unusual. Yeah. And rare in this day and age. But it wound up, you know, a unanimous vote to take alcohol ads out of mass transit vehicles and properties. So across the whole system. So that was a win. However, as with any, you know, public health win or, or

initiative, you know, you have to worry about unintended consequences. So I was really happy about that, that, you know, children are no longer going to be, you know, children, minorities, the poor uneducated, uh, or lesser educated rather, uh, are not going to be exposed to alcohol ads on their daily commutes or as they go around the city, um, you know, go to and from their homes uh what you have to worry about is what fills that space right do you think we should be banning unhelpful advertising and marketing well my concern is that now that the alcohol advertising is gone what's going to come in are ads for coca-cola and m m's and yeah you know um you

know other unhelpful products that appeal to children more directly and that they're direct consumers of. Do I think we should ban it? So I'm always cautious about bans. So I think, you know, bans are well intended, but, you know, as I said, you know, as with any public health campaign, but particularly with bans, there are unintended consequences. So you have to really think like what, you know, if you ban the unhealthy, you know, food products, for instance, you know, what comes in to fill that space? Yeah, it's interesting. You know, there's an initiative in Chile, which you probably heard around, which is a sweeping set of reforms we've chatted about on the podcast before. And I talked to Barry Popkin, who was one of the architects of the

reforms in Mexico and Chile around food policy because they're so disproportionately affected by the obesity and diabetes epidemic. And what he said was they got a fair bit of funding to look at the impact of the change of these policies. And one of the policies was eliminating any character cartoons from kids' marketing or any products, right? So cereal boxes can't have superheroes or anybody else on there. They eliminate any advertising in movies, rent, radio, TV, I think even online for kids between

6 a.m. and 10 p.m. And that they even put in an 80% soda tax, but what was more impactful than all the other policies was eliminating the marketing, like fourfold bigger impact, which was shocking to me and spoke to the fact that we have to find a way to deal with this. We are one of the only westernized or civilized countries or developed countries that allow unrestricted food marketing to kids. Now, it was the First Amendment, right? We have right to free speech. Corporations are people. According to Citizens United, they should be able to sort of say whatever they want to say. And yet, we do regulate things around children differently. And I think when it comes to children, and particularly given that 40% of kids are overweight now, that if a kid's a teenager who's obese or overweight, their life

expectancy is 13 years less than someone who's not at that age. These are really serious issues. And so I think, you know, we have to figure out how do we get the political will to do this? How do we get the data to show this impact? And Some of the other countries are innovating around this. So if you were, you know, in charge. Well, I was just going to say, I think that's absolutely true. And it's exciting work that's, you know, come out of those other countries. You know, in this country, I think we've focused on tobacco and alcohol, which I think everyone can agree are kind of unambiguously, you know, not good for kids to be exposed to or, you know, early introduction to or initiation with. It gets a little tricky in the food landscape because, you know, it becomes a

question of, well, what is healthy, what is unhealthy, and how do you define that? And I actually think, you know, marketing for healthy foods could be a beneficial thing. I mean, you know, as you mentioned earlier, you know, put a cartoon character on some broccoli. They don't eliminate marketing for food, just the unhealthy stuff. And then how do you define unhealthy? Yeah, how do you define unhealthy? I don't know. I think you and I could probably agree on how to define unhealthy.

Well, we probably could come up with some definitions. And this is the pushback from the sugar-sweetened beverage injury. And one of the tricky nuances and caveats has been tried in different municipalities, right? So certainly sugared sodas, right? But do diet sodas fall under that, you know, umbrella? Philadelphia thinks so. Do juices, do juice drinks, do, you know, do flavored waters? Yes. That, you know, right? So, right. So, you know, it becomes a sticky issue. I just got back from Abu Dhabi and it's an interesting, it's a

benevolent leadership there, which is fairly autocratic. They can make very easy, quick decisions and they're not beholden to the food industry because there's no taxation in the country. They get no revenue from the food industry. They really don't have investments in the food industry. There's no way for them to influence policy. And they had this massive obesity and diabetes epidemic. And they put in a 100% tax on energy drinks and a 50% tax on soda.

And one of the products was Red Bull that was impacted. And I think the finance minister from Austria, he said, where I think Red Bull's from or something, called the guy who was sort of in the government and said, hey, what's going on? We're seeing a 70% reduction in consumption of this. And we're going to have to lay off all these people.

He's like, well, we made the policy. We're sorry. That's how it's going. And the pushback from the food industry is quite strong. Well, and no doubt it would be. I mean, it cuts directly into their profits. And this is, by the way, this is a government official calling another government official saying your policies are hurting our companies, which is not in the public health's interest.

Right. Well, so even with the success that's been seen with some of these measures, a lot of that success has been narrowly conceptualized or focused just on food. And I think, you know, particularly with advertising, as I mentioned before, you know, if advertising for food is eliminated, something else comes in to fill that space. And if that something else is not good for health either, you know, I mean I mean, let's just say, um, you know, in this country, we don't have tobacco advertising. Well, let's just say, you know, you eliminate food advertising and not tobacco advertising comes in or e-cigarette advertising comes in or advertising for, you know, um, misogynistic movies or, you know, or, you know, or things that, right. Like that,

that impact people's health in other realms other than, you know, food or, uh, what they consume, you know, that's not necessarily a net benefit for public health. Um, and so I think that all has to be considered. And likewise with the sugar, you know, if you're, you know, Red Bull sales go down or sugar, sweetened beverage sales go down, maybe that's a good thing, but does that train? So maybe people aren't spending their money on their sugar stream beverages anymore. Now they're buying cookies and cakes and sweets instead and drinking, you know, is that necessarily the win? Is that a better, um, I think they're looking at overall health. You're looking at obesity. I think you have to look at overall health. And I think that's one of the problems with past research. And one of the, um,

you know, one of the things that where I think, uh, research and policy and awareness needs to move into the future is that you can't narrowly look at single ingredients or single foods or even diet in isolation from broader lifestyle and broader health. I think you have to look at the whole picture and see what the ultimate impact is on people, on communities, on quality of life. Totally. So you talk a lot about food as medicine and when food isn't medicine. And you really highlight the lack of nutrition education in medical school that's been talked about. And you're a doctor in a health care system.

And yet it's clear that the solutions aren't necessarily in the doctor's office. And you've really done a lot of work on looking at what are the approaches that a health system can take to own the health of their populations and communities through better health and nutrition practices. So what are the kinds of initiatives that you've explored that could be fixes to the food disaster that's in the communities that you see? Yeah. So, I mean, as you said and as I mentioned, you know, it's frustrating in clinic to engage with patients one on one and face all these obstacles. from getting outside of the literal boxes of doctors' offices and clinics and hospitals and out into the community and making it so that the environment better supports people's

motivations to be healthy, right? And their intent to do the right thing and to help them. And so, as I said, you know, we've done some work in our clinic. You know, I mentioned the fruit and vegetable prescription program. I mentioned some of the work that the Food Trust has done. We've also done things like directly try to impact food access. So we've partnered with a farmer's market that comes to our clinic during the farmer's market season. So you go to the doctor's office, you can go to the farmer's market at the same time. And you can get a voucher, right? You get written advice from the doctor, a little financial subsidy and the,

you know, fresh fruits and vegetables in appealing form, you know, are, you know, freshly picked and right available to you. And we've also done, you know, things like cooking demonstrations and tastings to help patients understand what to do with these products. You know, a lot of them are foreign. A lot of the products are foreign to patients, right? They haven't seen them before. They haven't tasted them before.

They don't know what to do with them, how to prepare them, if they'll even like them. And to shell out money for that is a big gamble and risk. And not necessarily someone's going to take unless you can demonstrate to them, oh, this is what you do, and this is how easy it is, and this is what it tastes like. And they want to know. And they want to know. they want to know we did a cooking class at cleveland clinic one of the hospitals 300 people showed up yeah and we demonstrated how to make smoothies and different healthy foods and and they were just so engaged and these were not you know sophisticated yeah

you know people who were shopping at whole foods They were people who just wanted to get better health who were often disadvantaged. Yeah. And I think, I think that's crucially important. I mean, other things that we've done are things like bodega, helping bodegas redesign. So like, you know, going out into the community, into the stores around our clinic and, you know, speaking with owners, you know know trying to incentivize them to stock healthy foods i mean the fruit and vegetable prescription so you walk into the bodega with your white coat and you say hey you might even go in as a group of white coats and say yeah hey i'm a doctor in the community i care about the community you're working in the community you come from the community you know is there something we can do to help incentivize you to

store healthier products or where can we make some what do they say nobody's going to buy it they're not going to sometimes they do and so but so so you see what you can negotiate and see what you can experiment with and sometimes it happens just by patient demand like you know if i tell patients that you know if you're going to be choosing bread you want to choose like a whole grain bread or a sprouted bread and they go to their store and they tell me all they have is white bread well then that starts a conversation with the owner and the patient says you know my doctor tells me i should have is white bread. Well, then that starts a conversation with the owner and the patient says, you know, my doctor tells me I should have whole wheat bread. Would you carry whole wheat bread? Yeah. It just sounds to me that, you know, white bread, chicken bread is just as bad as sugar, if not worse. Yeah. And they still put high fructose corn syrup in the bread.

I don't understand. And like five other kinds of sweeteners. Well, I mean, so, you know, talking about solutions outside of cake bread. Yeah, no, it's, it's, it is dessert bread. Um, and I think, um, you know, that gets to a bigger issue. So I, before I mentioned, there are many levers on many levels and that gets to a bigger level of, you know, our food production system and our subsidies and, you know, how we do, um, crop management in this country and what we focus our interest on. I mean, you know, the amount of interest, effort and resources that go into producing corn and soybeans and, you know,

other commodity crops that get then highly processed and injected into virtually everything is astronomical. If we better, you know, aligned our systems with healthy food production, I think it'd be better overall. So farm bill revisions. Well, farm bill revisions. But, you know, so it'd be better for us as consumers. And then, you know, there's also arguments better for us as a planet, right? So, you know, our health is also related to the health of the planet.

And when we don't, you know, respect the earth, I mean, you know, this just happens to be where we live and we don't have a lot of options uh to go elsewhere so yeah i mean people don't realize that you know eating processed food made from corn wheat and soy yeah is actually a huge contributor to climate change people think oh if you eat meat it's going to be the problem no the way we grow these commodity crops destroys the, depletes the water supplies, the carbon can't be held in the soil. Produces the forests. Yeah, clear-cutting to raise more of these crops.

And so we're destroying the rainforest of the prairies, which is the soil, which actually probably has a bigger capacity to hold carbon. And people don't realize that. So you're thinking, oh, I'm eating soy, corn, and wheat. I'm a plant plant-based diet and yet you might be just as big a contributor to climate change if you're not aware of how the food is grown yeah although i

will say that you know those those uh corn and soy products i mean a lot of those are used to feed our animals yeah well that's the other problem so the animal it's like double animal agriculture doesn't get a pass here no it's double whammy yeah it's a total double whammy. Animal agriculture doesn't get a pass here. No, it's double whammy. It's a total double whammy. But I mean, that's part of the animal production system and part of our factory farming, highly commercial industrial processing, right? So we've kind of gotten away from... Everything has become big ag, big production.

So what about small ag? You talk about some of the initiatives you're doing with community gardens. Community gardens, yeah. So we had a community garden. How does the health system intersect with, like, how does that happen? I mean, these are all, you know, little small projects that I think can grow and blossom, right? But I think there's real interest in that. And, you know, I did a study in Philadelphia during fellowship where I talked to, um, uh, patients, well, community residents really, um, about their, um, incentives, uh, about the things that promote, uh, healthy food production and the things that, um, you know, get them to eat otherwise. Yeah. And one of the things I heard, you know, we did a whole wide swath of patients. In the older patients, predominantly they were from the South.

They were from farming traditions. They had grown crops as kids. They still engaged in gardening and they were, you know, involved in food production. Whereas as you go through the generations, there's a loss of that food production knowledge. There's a loss of that food preparation knowledge. There's increased reliance on convenience and processed and packaged items. And so bringing that back, you know, there, there is, there is a, um, there is a knowledge base there, right?

I mean, so the, the old heads in these communities were very much in favor of, you know, producing food and growing food and community gardening. And I think get really excited when there are initiatives like that where, you know, they don't have to rely on the food industry to you know supply you know these almost unrecognizable probably you know things that they would never have eaten as kids but now have become part of their you know regular dietary pattern you know in old age because you know our food system has changed so dramatically so i think um you know there there is opportunity there it's huge and you get kids

involved and they love it they love gardening they love they're astounded but they can't believe that food grows on a plant yeah my daughter thought we grew eggplants she was like where's the egg she was like yeah i'm gonna pick this maybe it's the egg no but when you see when you see a piece of fruit on a plant and like you know like the earth the soil the plant produced that that you eat you know cuz right otherwise their their whole conception is divorce it comes in a shrink-react package that they open up in the store and they think you know fruit comes from a can or fruit comes from a jar no fruit comes from the plant it comes from the earth and you can grow it and you can be

self-sufficient and you don't have to rely on industry to provide you with inferior product you can you know be a part of that you know and so in urban landscapes that's more of a challenge i mean you know there's space issues and stuff but but there are definitely there are definitely lots that have been converted sure you know how to bring in salt from the outside you know it's amazing making um this point sort of stimulates me to think about the victory gardens in World War II. So many people aren't aware that 40% of our food during World War II was produced from people's own home gardens. And, you know, we were at war.

And in a sense, we're at war now. that was causing 70% of our population to be obese, one in two people have chronic disease that was costing literally 84% of our 20% GDP that's used for chronic disease, we'd be at war. If another country was doing to our kids what we're doing and the food industry is doing, we'd be at war. So maybe we need to think about the victory victory gardens a little bit differently here and say, well, let's reengage people in the growing and production of food. You know, we used to have 50%

of people on farms. Now we have less than two. And I think it's not that hard to grow stuff. You know, obviously you can't grow all your own food. Well, yeah, I mean, I don't think we have to initially transition back to an agrarian society. However, there are opportunities. I mean, so even when there aren't, you know, lots or soil available on land, I mean, there are all kinds of rooftop gardening, which have, you know, benefits not only for food production, but also like community beautification and socialization and heat retention. Have you been to the Grange in Brooklyn and the big rooftop garden there? I haven't, but I've seen it and I know, yeah, I've been to a similar setup in Chicago and it's unbelievable.

There are also indoor growing options, growing walls and things. There's a Bronx teacher, Steve Ritz, who's become very famous and he does a lot of work with food production and getting kids engaged in taking ownership of their food. And, you know, he does a lot with like green walls and, you know, indoor growing options, which are, you know, perfectly viable and something you can do even in the city and, you know, require a lot less resources than people think and, you know, can be beneficial on multiple fronts. So you're not just sort of conceiving of these things you're actually implementing these things in the bronx and poor communities what changes have you seen as a result of that um well you know locally so you know in the so with our um

you know programs around our clinic with like the uh bodega or small store redesign with the fruit and vegetable prescription program with the farmer's market with community gardens we've also done things like bodega walks or grocery walks where you know you go out with a nutritionist or a doctor into the store you do kind of a guided tour of the shelves how to read a label how Hopefully it's a doctor who knows something about nutrition. Yeah, exactly. It's you and one other guy in Bronx. Right, right, right. People motivated and educated and informed to do this kind of work. But, you know, through that, you know, patients become more engaged, more involved, more aware,

more motivated, and better prepared, better able to navigate these challenging environments. So, you know, in many cases... And you see the change in your clinic and patient outcomes and their health? So I mean, I can point to select examples, right? I can't say that that's across the board, but there's no question that a better prepared patient is better able to make changes, implement them. And I've had many patients who uh, who have been able to get off medication, improve their health, improve their, you know, their numbers, so to speak,

you know, the ways that we, um, kind of track their progress from a chronic disease standpoint, um, just by virtue of making these lifestyle changes, just by virtue of changing what they're eating, uh, or, you know, making tweaks to their food shopping and preparation and consumption patterns. That's interesting. You know, the issue is, you know, how do we shift health practice and health policy to motivate these changes? And right now, I would say we really don't have evidence-based medicine in America.

We have reimbursement-based medicine. So there's an interesting pilot you probably heard about for a food pharmacy by Geisinger Health Systems in Pennsylvania where they took food-insecure diabetics. These were people who were just worried about whether they're going to get food. They don't have a lot of money. They're poorly controlled. They're just struggling. They identified poorly controlled. They're just struggling. They identified these

patients. They gave them $2,400 a year for food, for food pantries and groceries. Then they provided the support for them to actually know what to do with it. They provided health coaches, nutritionists, education, support groups. And they followed these patients for a year. And the average patient, because they were having amputations and hospitalizations and complications their costs were astronomical 240 000 per patient yeah and in one year just by giving 2400 food and a little social support they were able to save 192 000 per That's 80% savings while dramatically improving their health and lowering the hemoglobin A1C, their average blood sugar, and getting them off medications. And yet, this is not something that's paid for. Well, and I think that's the critical point. I mean,

I think you alluded to that before. It's about political will and who bears the cost. So there can be tremendous cost savings, but who reaps those benefits and, you know, who, you know, pays to get these initiatives started. And I think that misalignment is one of the big barriers or issues right now. But I mean, there are a lot of strategies that you can experiment with. You know, there have also been, you know, health systems that have experimented with food pantries actually in the health system themselves or in the hospitals that have done CSAs, so community supported agriculture, where local farms will come and deliver a box of goods that patients can pick up at a clinic site or at a hospital site or things like that. So there are ways to engage. And actually, one of the things that I've been interested in that my research has kind of got me thinking about is how do we change the landscape that is changing? So this landscape is becoming more unhealthful. So there's more food available and more of it is less healthful.

Some of that work is published already. Some of it is under production and should be coming out soon. But we've documented that over time, there's more food available in more places and more of it is just not good for good health. Right. And so much of that is driven by the storefront landscape. Right. So the food stores, the restaurants, but then these OSB or other storefront businesses. And so what do you do to combat that? Or what do you do to, you know, work against those forces? So I think mobile options hold a lot of promise because they aren't restricted or constrained by, you know, the storefront model. So you don't need the capital. It's like a food truck or a food bus.

Yeah, or a green cart. In New York City, we have these green carts, which are fresh fruit and vegetable vendors, which can move from place to place even within a given day. And they can come into a neighborhood and make available healthful products to patients, communities, you know, healthful products to, uh, patients, communities, uh, residents in need, uh, and, you know, be in multiple places, you know,

throughout a day. And what do these look like? Are these refrigerated buses or are they like push carts like my grandmother used to use in the Lower East Side? So, so generally they're push carts. Um, so we did a, we did a, uh, a a couple studies of the mobile vendors across the Bronx. And what we found was that a small percentage of them are these Department of Health condone endorsed green carts. So this is a city program, which is unprocessed fresh fruits and vegetables, which are available on a push cart and can go into neighborhoods that are, you know, the city has designated as challenged, which is most of the Bronx. Yeah. It's almost the entire surface area of the Bronx.

That said though, we found that the vast majority, so over two thirds or about, sorry, about two thirds of all the vendors out there were unlicensed, unpermitted and people just selling, you know, impromptu from, you know, improvised setups out of the back of a car, out of the side of a van, you know, out of a blanket on the street. I think that's great when they're selling healthful foods. Majority of the time, they're not. So majority of the time they're selling junk, you know, chips and candy and cookies and homemade pastries and, you know, other stuff. However, this is sort of a, uh, a natural sort of industry that's in those

communities. It's a natural industry in the communities. However, there are vendors that are selling, you know, fresh fruits and vegetables and healthier products. And I think if we can incentivize those, if we can, you know, make it so that there are policies that, you know, um, support and promote the placement of those types of vendors and communities in need, uh, and getting them to the people that, uh, would really benefit from having access to them. And I think that could be a real positive thing and, you know, could reap, uh, So how do you support these mobile vendors? Well, there are a number of ways.

So, I mean, one thing you may. So they are selling perishable products. And so, you know, and fruits and vegetables aren't necessarily cheap. Right. So if you can come up with like some bulk purchasing arrangements so that they can negotiate for like lower prices and, you know, have them kind of buy on mass to help keep prices down. That's one thing. Uh, another thing might be, um, you know, supporting the purchase of the vehicle themselves. Right. So, I mean, that's out of pocket money for the vendor, but if they could,

could be some subsidy just in terms of, um, you know, loans for the cart or for the van or for the truck or whatever vehicle they're vending from uh or some prioritized uh or or um some special treatment in terms of the permitting or licensing or where they can uh sell or things like that so these are organically developed businesses these are not something that some company designs that we're going to pay mobile food carts they're just like there already well the green carts are a city program the the official green carts but other vendors are largely you know a gumption of some entrepreneur and you're thinking of how do we partner with them to how do we partner with them to like you know to incentivize the sale of healthy product and then the placement of vendors selling helpful products in the communities most in need and then also restricting you know of vendors selling helpful products into the communities most in need

and then also restricting you know those selling less helpful products or selling that you know the people selling the cotton candy and the hot dogs and the um you know the donut trucks and you know those kind of things like we don't necessarily need more of the ice cream van coming around it was an article in new york times in this whole series called plant fat about brazil and how in these poor communities way up in the mountains York Times in this whole series called Planet Fat about Brazil and how in these poor communities way up in the mountains they had these little push carts but they were not filled with healthy food.

They were filled with processed food and sugar. It was thought to be healthy and promoted as better than in poor communities that didn't know better. And so they're thinking, well, we're just going to have this powdered shake or we're going to have this processed this or that and it's healthy.

And it's shifting to a model where you actually i mean i you know my my family moved here from uh russia and poland at the turn of the century 19th century and my grand great grandparents all i push cards you know selling pickles or you know some some like sewing stuff and thimbles you know it's like that's a whole different way of actually creating a more distributive, egalitarian and better quality access to food than is in these communities. Right. Yeah. But it's challenging. You know, and it's not it's not I shouldn't represent it as a single solution or even the solution.

But I think it's one strategy that could be helpful. I mean, one of the challenges and one of the things that our research, um, made clear was that, um, you know, not being protected in these, you know, enclosed boxes. These are vendors who are vulnerable to the weather, right? And so when the weather's not nice, they're not out. I mean, and it's hot out, you know, your lettuce is going to be kind of gross and wilted. Well, that's a, that's another issue. So like the perishability and how quickly you have to move product yeah is another issue um but so yeah weather plays a key role um and um um you know and then also the the distribution of unhelpful to helpful currently is not ideal so do you find

yourself like a unicorn in the health system in the Bronx? I mean, is there interest in this? I mean, are you just out there in the wilderness crying and nobody's paying attention or like what? Cause it seems like, Oh no, people are definitely, it seems like such a different model of like how you're thinking about treating disease. So, and I think our health system is interested in, and I think increasingly, you know, as accountable care organizations and as there's, you know, as reimbursement is linked to or payment is linked to how communities do and how, um, uh, how much you engage in health promotion and disease prevention, as opposed to just, you know, treating disease when it comes to your door. Um, I think those things all, uh, lead to having interest in these types of initiatives. So just to be clear for people who are listening,

value-based care means that you're going to get paid for doing the right thing and getting people healthy and better outcomes at lower costs rather than just doing more stuff. Like right now, everybody wins the more surgeries you do, the more procedures you do, the more visits you have, the more medications. That's how the system is rigged now. And there's a movement afoot to change the reimbursement to pay for actually people getting better and doing better at lower costs, which then motivates initiatives. But the

problem with healthcare systems is they don't know how to do this. This isn't their bailiwick. This isn't their bodega, so to speak. And they don't actually understand how to actually be in the community, drive these changes where the problem is. No, absolutely. And I think, you know, the bigger healthcare systems recognize that and are experimenting with it. And, you know, I mentioned some of the initiatives, you know, in our health system and around the country. And what's the health system you work in? Montefiore, Montefiore, which is in the Bronx. It's the predominant provider of care in the Bronx. I mean, it's huge. It's a behemoth and, um, and it engages

in a lot of good work. I mean, I think our, you know, office of community health, uh, and the community health folks, uh, in the health system are, you know, doing a lot of this work, um, including like some mapping stuff, you know, to see where kind of the hotspots are for obesity and diet related diseases, and then linking that up to, you know, retail outlets and what the food sources are. And, you know, are these areas that we want to target and, you know, what are they, where, where do we want to focus our attention and that kind of thing. Um, so I mean, there's a lot of interesting work and yes, I don't think anybody knows how to do this, but we're all experimenting and we're all trying things. And I think, like I said, and the leadership in the

Montreux health system is engaged and interested in doing this kind of fully supportive. Yeah. Yeah. I think so. From the top down. Um, because there's, there's benefit to it. I mean, it's a financial win too, right?

It's not, you know, as long as you're getting paid, it's altruistic, but I mean, like there's, you know, like if you keep patients healthy, you're rewarded for that. If you keep them from getting readmitted, you know, you're rewarded for that. If you keep them from getting readmitted, you know, you're rewarded for that. We're kind of though in that no man's land where all the payments aren't value-based and they're still, like we're experiencing that at Cleveland Clinic where we're trying to create a whole new initiative called Cleveland Clinic Community Care. And that is a wonderful population of initiative to try to do these things. But we're all at the same time feeling the pressure of, you know, how do we, you know, pay the overhead when we have, uh, you know, all these pressures around volume and it's, it's a tough no man's land. Yeah. Well, and, and I think to your point earlier, I mean, maybe,

uh, it's not doctors who should be doing this. I mean, doctors can be engaged in this work and probably should be, and should pay attention to it, but we're not experts in this realm. And you use community health workers, use health coaches workers use uh you know um use a diabetic diabetic educators you use nutritionists you use uh social workers you know it's a whole team um and you know through that collaboration and through that kind of team-based model where everyone has a role, you know, something good comes. And are you guys measuring how these initiatives and things are working? So, you know, the, the research aspect has been, or the assessment evaluation has been less rigorous.

And that's one place where we need to grow. But. What's beautiful. I think Bloomberg gave $30 dollars to assess the impact of some of these policy changes in places like Mexico and Chile and the impact they have on the health of the population consumption patterns yeah sure well I think the Department of Health in New York DOHMH Department of Health and Mental Hygiene you know has a lot of initiatives in this space and has done some evaluation I mean one of the excitingiene, you know, has a lot of initiatives in this space and has done some evaluation. And one of the exciting things, so, you know, I mentioned the green

carts or the, you know, fruit and vegetable vendors. So one piece that I saw them publish, and I never saw the follow-up, this was just kind of a one, a one pager or a brief, but what it suggested was that in the communities where these vendors are placed or locate or where they find themselves, that there is a broader fruit and vegetable provision across the board. So not just from the mobile vendors themselves, but from the surrounding storefront businesses, because they see, well, these vendors come in and now they're, you know, getting a market share and maybe taking customers away or whatever. And so they compete on that. And now they start providing fruits and vegetables themselves. And so the overall provision for the community improves and there's those ripple effects like I talked about before. And you're saying your patients want this stuff. It's

not like you're providing these access, but then they know how do we know when to buy that? Well, they do and they don't. So again, to my point earlier about, you know, the generational differences and the increased reliance on, you know, processed food. And to your point about, you know, the marketing, you know, these, the food industry knows that if you get kids early and you set up their tastes, habits, patterns, behaviors in childhood, you've got a customer for life. Right. And so like, you know, you get kids hooked on like sugary, salty, fatty,

you know, unhealthful processed stuff. They're less amenable to trying like the healthier things. That said, parents, patients, those who are suffering know that they need to change, want to change and want these options. And when they come, I think are appreciative. Right. They're appreciative of any assistance you can give to help navigate. change and want these options. Uh, and when they come, I think are appreciative, right? They're appreciative of any assistance you can give to help navigate. You know, I think you use the word toxic and I don't think that's misplaced the toxic environment, right? This, this environment that's just overwhelming, this overwhelming ubiquitous abundance of unhealthful, less

healthy stuff. That's right there for impulse purchases in the communities that need them the least with just these small pockets of good things to find in the way. And so helping them find those small pockets of good things and how to maximize them and optimize them and make them more available and more available to them. Okay. Final question. You are given complete authority to make sweeping changes in healthcare and our food system and health policies, food policies. What are the top things that you would focus on to have the biggest impact to transform our disease creating economy and our bad health, chronic disease epidemic and our toxic food system? Given what you know, because you've been studying this your whole life

and you know more than everybody how to do this. I know more than everybody. You're pretty. But I have done a lot of work in this area and I've thought about it a bit. I mean, I think as a guiding principle, we want to encourage less food from factories and more food from farms.

So less food from industrial processing plants and more food from living botanical plants. Yeah, that's a micropon. Yeah, so- If it was grown in a plant, eat it. If it was made in a plant, don't eat it. Yeah, that's a rough paraphrasing, but yeah, that sounds pollen-esque.

So I think, so marketing is key. I mean, I think we've talked about that a few times during this segment. And I think, uh, that's a huge lever and one that, um, um, I think could, um, could produce a lot of benefit if we could restrict the marketing of less healthful things and promote the marketing of more healthful things. I think that would be, um, uh, hugely impactful On the supply side, I think we have to, you know, subsidize the production of healthful foods and not, you know, reward, you know, these commodity

crops that are, you know, overproduced and toxic, not only to us, but to our planet and to like, uh, broader health more generally. Um, so I think, you know, working on the food production, the, the supply side, working on, um, uh, advertising, marketing, education, and desire to eat healthy on the, on the demand side. Um, you know, those are, those are kind of the two things that I would try to address simultaneously and there may be multiple mechanisms to do that i don't know that anyone's found the one right solution i don't know there is one right solution i think this is a complex multifactorial process uh problem that requires a multifaceted approach yeah it's interesting in europe they

don't use high fructose corn syrup because it's more expensive and i talked to the vice chair pepsi once and he's like mark the reason it's more expensive. And I talked to the vice chair of Pepsi once and he's like, Mark, the reason we use more expensive than sugar. Yeah. I said, the reason because of tariffs are more expensive than sugar. Not here.

That's what I mean. Oh yeah. Yeah. Okay. And so, but he said, Mark, in this country,

like it's so cheap. The government makes it so cheap that I can't afford not to use it as a businessman. That's exactly right. You can't afford not to. And so that's the problem. Yeah. So when you live in a world where that's the reality,

where you can't afford not to do the unhealthy thing, then you've got a problem. It's true. So dealing with the marketing and the education, all the pieces around what drives behavior, which we know very well from advertising marketing, and two, providing supports and incentives for growing the right kind of food and removing the supports and incentives for doing the wrong kind of

food production. But I think, so this has been a generational decline, right? So this process has not happened overnight. I mean, it's been insidious in lots of respects and it's been, it process that, um, has taken time to get to where it is. And I think coming, you know, climbing out of that hole is likewise going to take generations, right? You don't, you don't just flip a switch and change things overnight.

I mean, as I mentioned earlier, you know, tastes, habits, behaviors, preferences developed, you know, in infancy or maybe even before birth, uh, you know, with, with, um, um, you know, exposures during, um, you know, prenatal, uh, during the prenatal period. Yeah. I would love to see one more thing. I would love to see our government and our states and cities, um, incentivize, pay for our train and deploy a million or more community health workers and health coaches, because you and I as doctors, we're not going to be able to solve this problem. We need people in the communities, in people's homes, like you said, taking them to grocery shopping, showing them how to make something

with an avocado, how to actually find the right kinds of foods, what to do with it. People want to know. And that was the most striking thing that you said today for me was you were dealing with some of the most sick and disadvantaged people in this country, and they want to get better. They want to do the right thing. They want to make healthy choices. They don't know how. They can't get access,

and they aren't aware of what to do, and it's just too difficult an environment. So changing that is huge, and I think that's really the message here is that we have to stop blaming the individual and start changing the environment that they live in in a real way with real incentives that I think are happening. There are pockets of innovation and creativity happening.

You mentioned a lot of them during this show. And I think that's really what people need to focus on. It's not necessarily waiting for the government to fix it. But people can actually start doing things like the community gardens like the communities where agriculture like yes The the things that cities are doing like these green cards I mean these are like little little solutions that aren't gonna solve the whole problem But if enough of this starts happening starts to shift the culture and shift the yeah, absolutely And I don't think you're gonna legislate your way out of this

Problem and I do think you know in terms of cultural shift and of the, one of the other things I didn't mention that we do in our clinic is group visits. And the nice thing about a group visit is you don't need community health workers. You create a community of patients and patients learn from each other and everyone knows something and everyone contributes to the group. And so you get that group think that group knowledge, very powerful. And then you can have group successes and you know you build those groups and then they you know translate to broader changes broader cultural you know community cultural societal changes families yeah yeah so and that's another part of the solution i think yeah we do that at cleveland clinic and what we're finding is that people

who are in the groups yeah have far better outcomes and medical outcomes than the ones doing one-on-one visits with the doctor. Absolutely. Well, because there's social support. There's value in social support. There's value in recognizing you're not the only one. There's value in learning from your peers. There's value in having that support network.

I always say community is the cure and group is the medicine. I did a TED talk called, if we. That's nice. Yeah, a TED Med talk called If We Can't Cure the Patient, Can the Community? And I believe strongly that that's really where the focus of healthcare has to be. Well, thank you

for joining us, Sean. Thanks for having me. This was fun. You're an amazing physician, researcher, thinker in this space. Very brave to take on these issues.

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Always work with your doctor. And if you can, find a functional medicine doctor. My staff, including physicians and nutritionists at the Ultra Wellness Center in Massachusetts, is trained in functional medicine to find the root cause of disease and create health for you every step of the way. For more information about the Ultra Wellness Center, visit ultrawellnesscenter.com.