The Dr. Hyman Show - Why Healthcare Policy Needs To Focus On Prevention with Dr. Anand Parekh

Episode Date: January 8, 2020

We have the best hospitals, most highly trained doctors, and people come from all over the world to get medical treatments in the US. Yet, we’re lagging behind almost every other country in health metrics, including life expectancy and infant mortality. That’s because we’re not being set up for success: The policies and systems we rely on for healthcare aren’t supporting prevention, education, and accessibility for all our communities. We are spending a massive amount of money on healthcare (1 of every 5 federal dollars) but we’re not spending on the social services to invest in lifestyle wellness that prevents disease in the first place.  This week on The Doctor’s Farmacy, I sit down with Dr. Anand Parekh to talk about solutions to our country’s healthcare crisis and examine what’s already working. Dr. Parekh is the Bipartisan Policy Center’s (BPC) chief medical advisor, providing clinical and public health expertise across the organization, particularly in the areas of aging, prevention, and global health. Prior to joining BPC, he completed a decade of service at the U.S. Department of Health and Human Services (HHS). As a HHS deputy assistant secretary for health from 2008 to 2015, he developed and implemented national initiatives focused on prevention, wellness, and care management. He has spoken widely and written extensively on a variety of health topics and is the author of a new book entitled Prevention First – Policymaking for a Healthier America. This episode is brought to you by Thrive Market. Thrive Market has made it so easy for me to stay healthy, even with my intense travel schedule. Not only does Thrive offer 25 to 50% off all of my favorite brands, but they also give back. For every membership purchased, they give a membership to a family in need, and they make it easy to find the right membership for you and your family. You can choose from 1-month, 3-month, or 12-month plans. And right now, Thrive is offering all Doctor's Farmacy listeners a great deal, you’ll get up to $20 in shopping credit when you sign up, to spend on all your own favorite natural food, body, and household items. And any time you spend more than $49 you’ll get free carbon-neutral shipping. All you have to do is head over to thrivemarket.com/Hyman. Here are more of the details from our interview:  -Why life expectancy and other health metrics are so poor in the United States (5:09) -Why policymakers do not focus on prevention and proactive policies to improve health (13:21) -Personal responsibility in a toxic health environment (19:24) -Challenges with the Supplemental Nutrition Assistance Program (SNAP) or our food stamp system (21:06) -Social needs vs social determinants of health (28:12) -Obesity: the public health crisis of our century (31:46) -Dr. Parekh’s 5 key takeaways for policymakers (38:48) -Targeting and creating pathways for existing healthcare programs and interventions that have been shown effective (47:02) -Why the government is so important in scaling healthcare solutions (52:04) -The need for clinical-community linkages (52:31) Find Dr. Parekh’s book, Prevention First: Policymaking for a Healthier America here.   Check out the work being done by at the Bipartisan Policy Center here.

Coming up on this week's episode of The Doctor's Pharmacy. Policymakers need to help Americans make the healthy choice the easy choice. Hey everybody, it's Dr. Mark Hyman. So whenever I talk to my patients about going gluten-free, their first complaint is giving up pasta. Now, I love pasta, you love pasta, we all love pasta. But going gluten-free and even eating grain-free and low-carb doesn't have to mean missing pasta, thanks to something called Wonder Noodles from Thrive Market. Now, Wonder Noodles are also known as shirataki noodles and have been used for centuries in Asian cooking.

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Mark Hyman. That's pharmacy with an F, F-A-R-M-A-C-Y, a place for conversations that matter. And today's conversation I think will matter if you care about your health, the health of our country, and trying to find solutions to our chronic disease epidemic that's crippling everyone in this society in one way or another, whether it's someone you love or yourself or economy, or just all the crazy crises of health that we have in this world today that we really find are mostly unnecessary because we can prevent them. And that's why I've invited Dr. Anand Parekh, who's an extraordinary physician. He's the chief medical advisor for the Bipartisan Policy Center, which is a group of policymakers, physicians, scientists come together to solve difficult

problems around health in the country. It's pretty extraordinary and many other issues. He's provided incredible support to our nation through his work in the government. He's basically been focused on work that he did through his decade of service at the U.S. Department of Health and Human Services. He was the Deputy Assistant Secretary for Health from 2008 to 2015. He developed and implemented national initiatives on prevention, wellness, and care management. At the BPC now, he's focused on areas of aging, prevention, and global health. He's really an important figure in our country and trying to think differently about how we solve our big chronic health issues. He's a board-certified internal medicine doctor. He's a fellow of the American College of Physicians. He's an adjunct professor of health management and policy at the University of Michigan School of Public Health

and an assistant professor of medicine at Johns Hopkins. He's spoken widely and extensively and written a lot about topics on health, including his new book, Prevention First, Policymaking for a Healthy America, published by Johns Hopkins Press, which is an amazing book. I read it. It's a little dense,

but it is full of the solutions that we need to solve our chronic disease crisis. All right, welcome, doctor. Thank you, Dr. Hyman. Great to be on the podcast with you. So we met a number of years ago when I came to Washington. I was at Human Health and Human Services advocating for lifestyle interventions

for chronic disease as treatment. And I went around and met with many leaders in healthcare at the time, the head of the Senate Committee, Congress, Secretary Sebelius, Nancy Indepar head of the Senate Committee, Congress, Secretary Sibelius, Nancy DePaul in the White House, trying to advocate for a simple idea, which was we could take these patients with chronic disease and use aggressive lifestyle interventions in groups to help them transform their health and get better. And everybody was 100% on board and nobody wanted to vote against

it, but it ended up on the cutting room floor in the Affordable Care Act because there was all the backroom horse trading that I think that happened. But everybody was on board with the idea because they realized that we really have this global crisis, and in America, we're leading in that global crisis. We have the best trained doctors in the world. We have the best hospitals. We have the best technology. We have the most cutting-edge treatments and drugs for a whole multitude of problems. Patients come from all over the world to get healthcare here. But on the other hand, our own citizens are pretty unhealthy. In fact, we have pretty crappy life expectancy. I think we're 43rd in the world, yet we spend more than twice any other nation on healthcare. Services aren't guaranteed to everybody. We have uneven quality health care. We have services aren't guaranteed to everybody.

We have uneven quality of care. We have health disparities. And we're lagging behind almost every other country in health metrics, including infant mortality, life expectancy. How come? It's a great question. A lot of, I think, important reasons for that. I think you're absolutely right. There are significant disparities in the United States, and I think that's one of

the reasons why we're different. Just take income. If you compare life expectancy of the top 1% wealthiest Americans, you compare it to the 1% poorest Americans, there's a 14-year life expectancy difference for men and a 10-year life expectancy difference for women. So income matters. Take race. Though infant mortality has gone down in this country, we are behind many of our peer nations. And one reason for that is disparities based on race and ethnicity. African-American populations, American Indian populations have significantly higher infant mortality rates than other subgroups. So race is also important. Our system also, Dr. Hyman, our health system is different in the sense that we only have about 90% of Americans with health insurance. Most of our peer countries have 99 to 100%.. So a lot of

differences that way. I think the final difference I would note is lately there's been a lot of research on how much we spend in this country on health care versus social services. And if you compare... We're paying for the wrong end of the equation. That's right. That's right. You know, we spend nearly 18 percent of our GDP, as you know, in the United States on healthcare compared to many other- That's almost $1.5 of our entire economy. That's exactly right. I mean, $3.6 trillion, and we are headed to $4, 5, $6 trillion in the near term. And if you compare that to our peer countries, many well-developed countries, that's almost twice as much on the social services side.

So what does that mean? That means investments in housing and nutrition and transportation and education and income supports. We spend probably a little bit less than our peer countries or about that much. But if you look at the ratio, so social services to health care, we're at about one to one, whereas most of the countries that we compare with are close to two to one. And that ratio matters because there's been research even domestically that looks at the 50 states in our country, and those states that have a higher social service to healthcare services ratio, they have better outcomes.

They have less chronic disease risk factors. They do better with chronic diseases, lower mortality rates. So it's really that ratio of social services to health care services as a country. We're out of whack. So they take care of people before they get sick, and we wait till they get sick. Absolutely. So whether it's children's and child care, whether it's seniors and in-home supports and home-delivered meals, whether it's paid family leave for working Americans. The social service reports, supports in those countries, we have them here, but the ratio of social services to health care service spending,

that is really what's different in this country. And I imagine what's not captured in that is, and we're spending twice as much on health care because we're not taking care of those people early, is also another invisible cost, which is productivity. Absolutely. Because if you have a population that's healthy, they're more productive, more engaged with their communities and families. When you have our population, which is super sick, you lose all this productivity value in the economy. So the costs are probably even more. Absolutely.

And that's not to take into account even from a national security perspective. Our military, this is the number one reason for new recruits who want to enter the military, the number one reason that they're not allowed to join is because of obesity and high body weight. So all of these issues, whether it's economic, military, national security, our standing, they will all connect back to the need to focus more upstream. Yeah. I mean, even, you know, I mean, General Jack Keane, I knew him. He was a big commander in Iraq war. And he said, you know, 70% of the recruits for the military are rejected because they're unfit to fight. Kids in school, their academic performance is terrible.

In America, we should have very high academic performance. We're, I think, 31st in math and reading in the world, and I think Vietnam is better than us. So if a very poor developing country does better than us, what's going on? It's really speaking to the food we're feeding our kids, to school lunches, to the amount of toxic food environment that we have that we're all exposed to that's driving these choices. And it's pretty much unregulated in this country. Absolutely. And I would say that this is the right time to be talking about this very subject, because this is the first time we're experiencing in 100 years in

our nation's history, since World War I, where in this country, we are now experiencing three consecutive years of life expectancy declines. And that's because of the opioid epidemic, the obesity crisis, as well as what's considered the plateauing and the decline of deaths from cardiovascular disease, as well as cancer. The CDC estimates that every year there are 250,000 potentially preventable deaths in the United States. So that's just taking the five leading causes of death, heart disease, stroke, cancer, chronic lower respiratory disease, and unintentional injury. If the states that had the highest mortality rates did as well as the states in this country that had the lowest mortality rates, we would save 250,000 Americans every single year. And so I think the timing of this conversation is really important. If you take a map, you can go in the CDC and see these maps of obesity, diabetes, and life

expectancy, they completely superimpose in terms of the states with the highest rates of these problems. That's right. And the worst are the Southeast. Yeah, yeah. Southern Crookland, I guess, where there's more obesity, there's more disease. And when I graduated medical school, probably you did too, there was not a single state that had an obesity rate over 20%.

That's right. school, probably you did too, there was not a single state that had an obesity rate over 20%. And now there's not a single state that has an obesity rate under 20% and many have 40 and many more are encroaching on 40. So when you think about 40% obesity rates, 75% overweight, I mean, the entire country is affected. Absolutely. And unfortunately, many of the states that you cited have that ratio of pretty low spending on social services to health care spending. And they also have high uninsured rates as well. So they're finding themselves spending a lot of money on the health care side of the equation for things that are preventable if we try to tackle them up.

And you were in key positions in government trying to think about these problems and create policies to help overcome some of these challenges. And, and that's not an easy job because there's so many competing forces that are at odds trying to solve the problem. Uh, we don't want to have a nanny state. You write about in your book, this nanny state idea that, you know, and I'm like, well, what's wrong with nannies? What do they do? Their job is to protect our children. Shouldn't we protect our children? I mean, think about it. If there was a foreign nation that was doing to our children what we're doing to them, we would go to war to protect our kids, right? Absolutely.

And yet we just kind of let it go. How do you break through that challenge of changing those policies? I thought a lot about this while writing the book. You know, we all agree that prevention's important, but why has it not been that policymakers sort of elevated, why haven't they elevated this issue to the top? And I came up with a couple of reasons that I'd be happy to share. You know, I think the first is, and you touched on this, a lot of policymakers are just reactive in general, and prevention requires a proactive approach. And the reason they're reactive is whether you're in the executive branch or you're a member of Congress, there are oftentimes so many emergencies, either real or imagined, or crises, or political controversies,

that oftentimes you spend a lot of time reacting. Putting out the fire. Absolutely. As opposed to thinking about proactive policies to improve health. And then, you know, prevention oftentimes takes time as well. So you have to have that patience. And oftentimes the results are, at least from a public health perspective, are often invisible when things are working and health is being protected.

And so I think the first reason is that the mindset of policymakers needs to shift from being reactive to proactive. I think the second reason is it could very well be that policymakers are just not as attuned to the evidence base, whether it's lifestyle medicine, whether it's prevention, whether it's a social determinants of health, understanding the evidence now that has been generated about the effects of all of these other modalities, I think is critical. And when you don't know the evidence, then you tend to think, well, that might be a slush fund. Those dollars in prevention might be a slush fund, and why should we support it? There are others then, as you said, who may

think of prevention as, you're right, part of the nanny state. Prevention is about individual responsibility, and the government shouldn't be involved. So I think those are a couple of reasons, but then I think it goes beyond that. You know, prevention and public health, they require resources. And right now in this country, if you look at our national health expenditure accounts, only about 3% of our dollars go to public health. Only about 5% go to primary and secondary prevention. And so even though we're in a tight fiscal climate, we're always going to be in a tight fiscal climate.

Finding opportunities through our discretionary budgets or mandatory budgets, CBO doesn't always help with their 10-year budget window in terms of scoring. So just to clarify for people, the Congressional Budget Office is the watchdog that looks over the costs of things for the government and the policies and laws. And they score policies based on their impact over a 10-year period, but the benefits of prevention might be over a 20-year period. So it seems like a cost center instead of a cost savings. Absolutely, absolutely. And I think that's a very important point. And I think, so there needs to be more focus on finding the will, really, the political will, to expand resources using our discretionary budgets as well as our mandatory budgets through Medicare and Medicaid, because that's really how

we scale things. So I think that's also a critical point. I think, Dr. Hyman, another reason why policymakers haven't gravitated towards prevention is we have a $3.6 trillion healthcare system and frankly, you can't make as much money on prevention as you can on treatment. So the incentives there in the system are not as much there. Now, value-based healthcare- Not from the government, but from the people running healthcare. Absolutely. Now, value-based healthcare transformation with the focus on payment based on outcomes as opposed to volume should change that over time but that's that's that's gonna be a long haul so we were just to clarify for people you know the way typically doctors get paid in hospitals they paid is like widgets the more stuff you do the more you get paid

the more angioplasty as you do the more surgeries you do the more colonoscopies you the more visits you do the more money you make that's right and it doesn't care if the product is good or not. It's like, imagine paying for a car, but it didn't work. You're not paying for the outcome. And so value-based care is a new way of thinking that's incentivizing healthcare systems and doctors to be accountable for the outcomes of their patient's health. So keeping them healthy.

Now, if somebody bounces back to the hospital, the hospital makes money. In the future, the hospital won't make money. It'll be making money by keeping people out of the hospital. And that's a very different paradigm shift, but we're not quite there yet. Absolutely, absolutely. We're about a decade into this, but still the vast majority of health care payments are still currently paid based on the services provided and a fee per service. So we're not quite there. And I think the last reason why this hasn't really gotten the attention of policymakers

is really, I think if you look at the general public as well, we haven't galvanized the American public. And whether that's they don't realize the power of prevention or we haven't communicated to them the importance of sound policies to support the healthy choice. Policymakers need to help Americans make the healthy choice the easy choice. And so I think galvanizing the public, you know, there are not a lot of lobbying firms or interest groups going to members every single day in the halls of Congress preaching the power of prevention. But you do need a grassroots movement. You do need the American public to say, hey, I'm doing everything I can every day for my family to eat well, to exercise, to avoid substances, to stop smoking, to drink alcohol in moderation. I'm doing everything I can. But if there are not community supports, if there are

not policy supports, if there aren't policy systems and environmental change helping me and my family, it's going to be very, very difficult to do. And I think that's a critical message in this book. I think it's pretty important because if you don't actually provide an environment that allows people to make easy, healthy choices, you know, it's hard to do the right thing. And I think one of the biggest challenges in this conversation is the sort of dichotomy between the idea of personal responsibility and sort of the nanny state, you know, the environment we live in. How do we change the toxic environment? And I think, you know, most of the messaging from most of professional associations, much of our government policy, and certainly the food industry, is that it's your fault you're overweight. It's your fault you're sick. It's a personal choice,

just like smoking is a personal choice. And they talk about moderation. There's no good and bad calories. A thousand calories of broccoli is the same as a thousand calories of soda. There's focus on exercise as the solution. There's focus about moderation. It's really interesting, and it's a culture that's really focused on personal responsibility, but it ignores the fact that you actually can't be personally responsible in a toxic environment. If you can't go in your neighborhood and buy

a vegetable, and you have to take two hours of buses to buy a carrot, that's a problem, right? And if we don't address the environment we live in, we're not going to be able to get people to make healthy choices. I remember reading a study where they looked at people who were overweight and diabetic who lived in very low socioeconomic neighborhoods. They moved to a slightly better neighborhood and their blood sugar went down and their weight went down without any other intervention, just giving them a better zip code. So basically the zip code we have is a bigger determinant than our genetic code when it comes to our health. And we don't really seem to acknowledge that in our policies. We say it's all about choice. And I think one of the areas I wanted

to talk about in this is the whole SNAP debate. Now, the Bipartisan Policy Center, you write about in your book, Prevention First, did a very important report called Leading with Nutrition that outlined some of the challenges with our food stamp or SNAP program, Supplemental Nutritional Assistance, which is, I don't know what should we call that because it's Supplemental Food Assistance. It's not nutrition. I would call most of it because 75% of it is junk food. 10% of it is soda. And it's very clear that people who, you know, compared to an income eligible person who's not on SNAP is less healthy and they drink more soda and they have more health consequences. So, you know, people go, well, we can't really limit people's choice when it comes to soda. They have to be able to buy that. It's going to stigmatize them. And you're right,

the policymakers are influenced by big food. I mean, soda companies, Coca-Cola, I think 20% of their US income is from food stamps. Walmart, of the $750 billion in a farm bill for food stamps, about $138 billion goes to Walmart. So they don't want this to change. And it's a real challenge. And you're right. I mean, I remember walking into Senator Harkin's office. He's a really great senator. He's no longer a senator. But he said, well, what organization are you from? And I'm like, well, none. I'm just representing the science and the policy and my patients. And I want to get science into policy. He goes, well, that would make too much sense. And I think, so when you've got all this evidence that this is true, we know as doctors and scientists that this is really the problem. That's right.

But the policies really are being heavily influenced by lobby money. Yeah. How do you deal with that and sort of break this cycle of blaming the victim and not changing the environment and not helping people make better choices? Yeah, yeah.

Sorry, that was a little winded speech. No, terrific. And thank you for raising this topic. The SNAP program, previously the Food Stamp program, the purpose of the Bipartisan Policy Center Task Force was really put the N back in SNAP, which is exactly your point that nutrition and diet quality ought to be a key factor of that program. The program has been around for several decades now. 40 million Americans rely on the SNAP program every year.

It has substantially reduced food insecurity in this country, which is really important. And food insecurity does have indirect health benefits for children, for new mothers, for seniors as well. But with our obesogenic environment in the last several decades, the program has not evolved to ensure that diet quality and nutrition is paramount as well. And you're absolutely right. The number one consumption of SNAP enrollees are soda products. Now, that's not too different than the rest of the population where soda is number two. But it does sort of beg the question that are we doing the best job that

we can to incentivize the consumption of healthy food and disincentivize the consumption of unhealthy food? And what our task force did is, you know, there were Republicans on there, Democrats on there, and we asked ourselves some pretty tough, tough questions. SNAP is an important program. It reduces food insecurity. For sure. But how do you improve nutrition? When we look at sugar sweetened beverages, Dr. Harmon, as you know, there is no nutritional impact in soda and sugar sweetened beverages, and yet— Dr. Well, there is. It's harmful.

It's absolutely, yeah, in terms of good health. Dr. Not only a lack of benefit, but it's a tremendous harm as a leading cause of obesity and diabetes. And what we saw in the retailer community, in fact, during the period when Snap and Rollies were purchasing their food, sugar, sweetened beverage, and soda were really the ones that were being marketed to them. And I think we all found it. I want you to hit on that for a little

bit because people don't realize that when the first of the month comes people get their benefit cards that's when these stores that are in these poor neighborhoods highly advertise disproportionate marketing yeah and even yeah in in better neighborhoods that are more affluent they don't advertise absolutely so they're So literally, it's race targeting. It's poverty targeting. It's terrible. Yeah, yeah. And that adds to issues about health equity.

And it adds to health disparities as well. And so the task force recommended, it was a difficult recommendation, but that sugar-sweetened beverages ought to be excluded. And that doesn't mean that individuals can't purchase these things out of their own pocket. But from a health perspective and a taxpayer-funded program, we ought to be, again, incentivizing healthy food and disincentivizing unhealthy food. In fact, there was a follow-up study from Tufts University and Harvard School of Public Health that actually

looked at the mix of both incentives and disincentives over time, an excellent simulation, and found that you could prevent a substantial amount of heart disease and diabetes and save healthcare costs. Billions of dollars. Billions of dollars. And there is the Venn diagrams between SNAP and, for example, Medicaid overlap in such a way that this could have significant impacts on state Medicaid programs. So I think there's a lot there. We really wanted to elevate this issue that, yeah, the SNAP program is important, but if it can involve to elevate nutrition, then we can really do something for the public.

But you've got the hunger groups completely opposed to this, that are focused on food insecurity and hunger. And they're like, well, you can't restrict that. It's gonna stigmatize these people. You know, they should have the same opportunity to purchase it as everybody else. But you know, you can purchase a two liter bottle of soda, but you can't purchase a rotisserie chicken on Foodstamp.

So there are restrictions. You can't buy cigarettes, you can't buy alcohol, you can't buy cooked food. There's a lot of restrictions. Absolutely, absolutely. And the other programs we have in the government, like WIC, it's women, infants, and children, and school lunches.

They have nutrition guidelines that ensure quality nutrition, but we don't have that. And there's so many groups opposing any change. So how do you see that happening? It just seems like a hopeless cause. Yeah, yeah. Well, I think we talk about that a little bit in the book that we release the recommendations. And there weren't a lot of people who were cheering because on both sides, there were folks who said, oh, leave it alone. Don't touch it. We want to focus just on food insecurity. On the other side, there were folks saying, hey, well,

you know, we question the fiscal integrity of the program. And so we, again, had both sides involved. That's what we do at the Bipartisan Policy Center. And said, you know, for looking at from a health perspective, improving on the current program is the way to go. And that's been our message to lawmakers and policymakers as well. You know, the farm bill passed recently, but every several years, these issues get resurfaced. So I think we have to keep on, you know, ensuring that there's a drumbeat to ensure that the N in SNAP, the nutrition part, becomes a paramount principle. And, you know, and that's part of what you talk about is in terms of the social determinants of health. You know, we've talked about in the show before, but, you know, people understand that

the environment where you live is a bigger determinant of your health outcomes than anything else, right? Even than your diet or exercise or smoking. And those things are not addressed in healthcare. We sort of ignore them, you know? Yeah, yeah. And so you talk about, you know, healthcare without walls. What does that look like? And what do we have to think about differently in how to address these things?

Yeah. Healthcare is slowly moving in this direction, but they are, and probably they're in a better place to address social needs. And there is an important distinction, I think, between social needs and social determinants of health. Social determinants of health for housing, let's say, is building affordable housing. Addressing a social need is modifying the home to reduce falls, for example.

For nutrition, social determinants of health are ensuring that healthy food financing initiatives, you can increase the availability of healthier food, farmer's market. Social needs is ensuring there's a home-delivered meal. For transportation, social determinants of health is improving community infrastructure through land use or zoning policy.

For social needs, it's ensuring that there's ride-sharing available so people can make their appointments. So healthcare is getting into the business of social needs because they see it connected to the value proposition of improving outcomes and potentially reducing preventable health costs. And I think that's all fine, but healthcare is not going to take care of the broader social determinants of health. We still need focus and resources on education and income and housing and nutrition and transportation, because you're exactly right. Those have profound implications on the health of the population and are also connected to a lot of the behavioral risk factors that are driving chronic diseases. Yeah. So, you know, it seems

to me, and I'm obviously biased because I'm focused on food a lot, but it seems to me that, you know, the food and the food system, if we had to pick one thing to target, would be the biggest thing. And because that's affecting the chronic disease burden, the majority of, I think, chronic disease are caused in part by diet. That's 11 million people die every year around the world from diet-related disease. I think it's an underestimate because when you add in the additional causes such as diabetes and heart disease, it's like in the 40, 50 million range. Agreed. and heart disease and yeah it's sort of it's like in the 40 50 million range and and so um when you

when you when you have that level of of impact it seems like we can't address all these issues unless we fix the food system yeah and and that the forces that are opposing that are quite big you know just the farm bill alone is a half a billion dollars of lobbying on it just for that and majority of that is food stamp. So how do we, how do we, you've been in government, you've been in these conversations, you, you, you're not just sort of talking about it from a think tank. You've actually been there. What's your perspective on how you move the needle?

I mean, do we have to wait for an administration? Do we have to wait till the community of activists rises up and like abolition and changes our government? I mean, what do we have to do to see change? Because it's discouraging for people to sort of feel like they can do anything about this. Yeah. Yeah. Given the political winds in this country change, you know, pretty regularly, I think

it's important, Dr. Hyman, that we take incremental progress whenever we can. But you're absolutely right. Your premise that I... So take a base hit? I think you have to educate policymakers. That's what part of this book is. It shouldn't be that we're just going for base hits. We should go for the home run. But it's also important when there are incremental opportunities to take them. I agree 100% with your premise. I call obesity

the public health challenge of our century. I mean, that is the critical challenge. Cancer will soon in this country be the leading cause of death for Americans, and it'll surpass heart disease. And the reason for that is really obesity and poor diet. So people don't understand this, but obesity is linked to cancer. It's not just heart disease and diabetes. Yeah, at least a dozen cancers are now very well, the establishment, the link between obesity and cancer is now pretty well developed. And the most common cancers, breast, colon, prostate, all the big ones. Yeah, yeah. So I think that we need to, you know, so when I talk about sort of incremental progress,

so for example, right now, you know, I try to look at things as sort of glass half full from a policy perspective. You look at the Food and Drug Administration. I think there's an important, in the next several months, a new change to the nutrition facts label in that all foods will need to have information about added sugars. And that's pretty important. In fact, there was a recent study done that if, in fact, this is done over the next two decades, there would be substantial reductions in both diabetes and cardiovascular deaths and significant healthcare cost savings. Now, if the industry

actually then reformulated their foods, given that now this is transparent on the label, there would be even more, a doubling of an impact over 20 years, I think. It would go from $30 billion in healthcare cost savings to $60 billion, and from 1 million cases of heart disease and diabetes averted to 2 million. So these are substantial pieces. Salt, voluntary sodium reduction. So it's voluntary. This was started in the Obama administration in 2016, but this current administration is moving forward with voluntary sodium targets in 150 different food groups. And if indeed manufacturers are able to meet these targets,

within two years, we can reduce the average consumption of sodium in this country, which is about 3,400 milligrams to 3,000. Within 10 years, we can get to 2,300 milligrams. And that could save substantial lives down the road in terms of heart disease and reduce healthcare costs. So I think there are some things that don't get a lot of attention, I think, that are important. There are then more challenging things. Sugar, sweetened beverages, and the taxation of that, and the politics of that. Portion size, which I think is a really important issue also over the last several decades. The portions of food that we get are so large. So Deborah Cohen, who's a researcher at RAND, has done some important work on portion

sizes and has shown that as portions have increased, our consumption has increased, of course, as well. And she's actually advocated for standardizing portion size, just like we do with alcohol. So if you have a certain amount of alcohol, there's a standard size. If there's a standard size of portions, you could reduce consumption there, particularly for unhealthy food. This takes away the whole idea of personal choice. It's sort of like mandating different portion sizes. I remember Dan Buettner, who wrote the book Blue Zones, created an initiative, and I think it was in some Midwest state, and essentially got community interventions that were invisible so

everybody switched out their place to 10-inch plates yeah what was it the checkout counters the grocery stores changed to healthy options that a candy yes they built walking paths they basically created initiatives that were just sort of frictionless yeah a lot of people to make better choices yeah and that made a huge difference in healthcare costs and health outcomes. I mean, it's stuff that we think of as sort of the nanny state, but it's actually stuff that's proven to be effective. And I would say that it doesn't just, I would probably say that it doesn't actually

take away individual choice. So people are certainly- Go back for seconds. Yeah, absolutely. But I think it's shown that when the healthy choice is the easy choice, that people change their practices. And I think that information, take menu labeling now, which is common. And that policy change, so giving people the information, I think the behavioral economics

piece that you're talking about, those things, I think incremental ways forward in those areas, I think are important as well. My favorite studies were they took people and gave them a bowl of cereal. One bowl constantly refilled from the bottom and the other one just was a fixed amount of cereal. And the ones that had the constant refilling, so they just kept eating it. It was like a trick bowl. That might be me because I actually love cereal. I got to admit on your podcast that cereal is one of my weaknesses. That's okay. We all have our weaknesses.

Although I think I'm a cereal killer. I hate cereal. I think it's one of the worst inventions of our society. It's 75% sugar. Talk about added sugar right there. Oh my God. Yeah, that's huge. Absolutely.

Okay. So as a policymaker, I mean I was a policy think tank advocate, you sort of mentioned a lot of these initiatives you think can make a difference. But I just keep pushing back against the idea of, you know, how does the individual citizen sort of get their congressman to go? Because they don't have, you know,

millions of dollars to go lobby, right? When I went to Washington, I paid my own ticket, I paid my own hotel. And Washington's not cheap. I paid my own ticket i paid my hotel and washington's not cheap i paid my own food and they're like who are you where are you from and what are you doing like because they've never seen an individual be an advocate uh and so but there are ways right there are ways to get involved and i think uh there's a i think the food policy action network is i think a group that scores your congressmen and senators on their voting on food and ag policies. So there are ways to sort of affect it. But it's tough because, you know,

you've got, for example, on the SNAP subject, you're probably aware of this, but when there's a hearing about SNAP to try to improve the nutrition quality in SNAP and talk about the soda reduction, maybe you were at the hearing. There were many of the committee members in the Ed Committee who basically said, it's all about personal responsibility, it's about more exercise, that's the real problem, it's not about the food. And when you look at who was funding their campaigns,

it was soda companies, to the tune of literally collectively millions of dollars. How do you fight that? Yeah. Yeah. Well, I think it's, you know, first and foremost, helping Americans understand that there are things that government and policymakers can do to support them in these areas, that it's not just about personal responsibility.

And so some of it is sort of education and empowerment there. Some of it is also the doctor-patient relationship. As you know, Dr. Hyman is a trusted one. I think ensuring that healthcare professionals can be that voice as well to support patients. Some of this is educating policymakers as well, and policymakers, you know, on their own, understanding the importance of prevention. So in my book, for example, there are five sort of key takeaways for policymakers at the end in terms of what they can do to support Americans. You know, the first, for example, to make prevention the number one priority for this or any administration coming in. The Health and Human Services Secretary saying, you know, there's a lot of mission essential

functions, but prevention will be the number one priority. All of our agencies, whether it's the Centers for Disease Control and Prevention or the FDA or the National Institutes of Health, you know, figure out how prevention elevates to the top. Number two, healthcare professionals, in value-based healthcare transformation, we're now going to measure you and hold you accountable, not just for how well you manage diabetes or heart disease, but how well you prevent them in the first place. We're going to hold you accountable, not for how much you screen, just screen for obesity or tobacco. Just do the test for blood sugar, but actually get them better. We're going to hold you accountable, not for how much you screen, just screen for obesity or tobacco.

Just do the test for blood sugar, but actually get them better. But actually reduce it. And what that'll do is force sort of the healthcare community to build the clinical community linkages to help support individuals. So that's sort of a second takeaway. A third takeaway is- These are all in the book. These are all in the book, right? Prevention first.

These are sort of the five overarching takeaways for policymakers, which I think then can be helpful to Americans out there. The third is, in this country, if you're a drug, a pill or a device, there's a pathway in this country for that intervention to be scaled. There is a Food and Drug Administration that assesses safety and efficacy. And once FDA approves that intervention, CMS, Medicare, and Medicaid decides whether it's reasonable and necessary for payment or for coverage. And then a lot of private payers follow what Medicare does. But if you're- Just to interrupt you there for a minute. The recent study that was published showing that stents and bypass and angioplasties don't work for the majority of

patients that get them is not a new story. I read this article in different iterations in the past, and it keeps getting repeated as the research gets more robust. And yet, Medicare and Medicaid pay for these services because they're a device and they're sort of in, but they won't pay for stuff that works like that lifestyle program that can reverse diabetes. Right, right, right, right. On the treatment side. So, but if you're an evidence based program and either prevention or treatment lifestyle focused to your point, there is no pathway in this country. Like there is if you're a drug or, or a device. Yeah. And, and yet there are so many evidence-based programs like the one you just mentioned, the lifestyle treatment or prevention programs, whether it's falls prevention or chronic disease self-management programs.

There are so many programs out there where thousands are benefiting but millions need to be benefited. So in my book, I actually call for a parallel pathway. Yeah. Just like you have FDA looking at the safety and efficacy of drugs or devices, whether it's CDC or the Administration on Aging, Congress ought to give them a regulatory authority to review a lot of these evidence-based community treatment or prevention programs. And if they meet the bar, then CMS would have to consider them as being reasonable and necessary

for payment, just like they do for a drug. So in other words, at Cleveland Clinic, we've got our program called Fun program called functioning for life where we take people in with chronic disease we change their lifestyle we change their diet we actually through social support help support help them change their behavior we're seeing extraordinary results i mean reversing diabetes heart failure all kinds of stuff weight loss obviously and yet you know it's not really reimbursed that's right and we're saving we're saving so much money. Right. And we're not getting paid for what we do.

We get paid, you know, 30 cents on the dollar. And we're lucky if we make 100 bucks on a patient and we see them or less, you know. And it doesn't even cover our cost of running our center. Yeah. But we're providing so much value in the system. Yeah. Which is benefiting Medicare, Medicaid, and also private insurers. And so the whole system is sort of rigged to not incentivize to do the right thing.

Yeah, absolutely. And there's no money to study it. I was like, I'd love to get, you know, I mean, there's literally billions of dollars spent on research in this country and almost nothing spent on nutrition or lifestyle research. That's right. And therefore, a parallel pathway could help infuse resources to research as well as ensure that there's not a double standard for a lot of these interventions that are focused on lifestyle or occur outside

the clinical arena. Amen to that. Now there's two other points. Two others. The fourth is, look, we have about a $4 trillion budget in the federal government. This is prevention, public health, it's too important to underfund this. And there needs to be bipartisan support to finance evidence-based prevention and public health interventions. So it could be community-based

prevention programs. I talk about several things that we did at Health and Human Services from the Recovery Act back in 2009. There are opportunities to finance the public health infrastructure, which is significantly underfunded in this country. A public health emergency fund, so the next Ebola or the Zika we face, we're not waiting on Congress to fight for months at a time before their resources. But targeted investments to lift up prevention and public health, that has to be a national priority. And I think in terms of bipartisanship, how do you crack that nut? There was an important commission on evidence-based policymaking that Senator Patty Murray and former Speaker Paul Ryan actually led a couple of years ago and talked about sort of the importance of evidence-based policymaking.

In that same vein, there ought to be bipartisanship around what are those priorities in the prevention and public health space that we actually need to invest more in. Right. Because the truth is, you know, food industry and pharma are not investing in research around this. That's right. That's right. And that leads me to sort of the fifth point, which is we need, Dr. Hyman, more research. I mean, we have evidence-based right now, but we need more research into prevention. Now, the National Institutes on Health estimates that 19% of their budget every year goes to prevention. Now, one could ask, is that the right number or not?

I don't know. Is that really true? 19% of the NIH budget goes to prevention? 19%. Now, there was another study that I recently saw that if you look at the National Cancer Institute, only 5% of their budget goes to prevention. So whatever the number is, I think that these are all sort of low. Well, let's just define prevention.

Because is a mammogram prevention? Is a colonoscopy prevention? No. It's early detection. Yeah. Yeah. Right? True prevention is really dealing with the causes, the upstream causes that you talk about in your book. detection. Yeah. Yeah. Right?

True prevention is really dealing with the causes, the upstream causes that you talk about in your book. Right. Right. Right. And so I would argue, and I argue in the book, that there ought to be a much more focused research emphasis on prevention that looks at not just sort of the biology of illnesses, but also the importance of behavioral change as

well as policy as well as other areas. And that will also actually help the Congressional Budget Office, irrespective of what happens with the 10-year budget window, the more research, the more evidence there will help policymakers. So I think in all five of these areas, number one, leadership prioritizing prevention. Number two, healthcare professionals focusing on prevention, not just management. Number three, a parallel pathway for lifestyle interventions and evidence-based community prevention interventions. Number four, public health resources. And number five, prevention research.

All of these, they're all heavy lifts, Dr. Hyman, but I think that I wouldn't be writing a book if these weren't heavy lifts, but these are absolutely important for policymakers on both sides of the aisle to understand the importance of these. And I think if there's movement on the policy side, the American public will see this also as a way to support themselves as they try to make sort of the healthy choice. But the American public is clamoring for assistance. Behavioral change is difficult given the environment which you have so beautifully described. And I think the best way to counter that environment is through policy change and empowered Americans

speaking up. Yeah, one of the things you mention in your book, in addition to sort of these points, is sort of targeting things that work but aren't paid for. So digital health, for example. You mentioned Omada Health, which I helped advise when they were starting out. Right, right. And I said to them, look, the diabetes prevention was a good start, but it's based on a little bit antiquated nutritional data about low-fat diets and high-carb diets for diabetics.

But it worked because, and I met people who were in the program, and they said, well, it worked because we came to groups because we had to write down everything we ate because we exercised together. Yeah, the group dynamics, yeah. Yeah, and it wasn't so much the food, although it was healthier. Yeah, yeah. It wasn't the healthiest. And there's been more sort of advanced versions of that that have developed that are digital.

For example, Virta Health, you probably heard about, where they literally take in poorly controlled, like pretty overweight, poorly controlled diabetics, 60%, 60% reversal. Now, in traditional medicine, it's like zero. It's zero, right? Unless you get a gastric bypass. And they had 60% reversal. They had 90% or more off of insulin or very low insulin doses. They had 12% weight loss, which is a massive amount. Weight loss studies, you get five, everybody's dancing around, happy, excited for 5% weight loss. And they did it through a digital platform where there were coaches and support. There was remote monitoring for ketones, for weight, for blood sugar. And they published the data.

It's a ketogenic intervention, which is the opposite of the DPP, which is basically high fat. And yet this is not reimbursed. And it's the amount of savings in these patients is astronomical. So how do we sort of get, because this sort of goes back to the conversation we were having earlier

about prevention and treatment. So prevention is important. It's a population-based intervention. And, you know, not all the people you're going to do the intervention on are going to get the problem. In other words, not everybody who gets a colonoscopy was going to get colon cancer, right? But everybody who's already sick needs the intervention of lifestyle interventions. Because it's lifestyle as treatment, not only as prevention. But that's not reimbursed. And yet it's probably the biggest bang for the buck in terms of our health care system and how do we how do we get our government

to start to understand that and maybe it's what you talked about is yeah funding more research that proves the model right right well i think it's all the above also having pathways again as you said there's no real pathway uh medicare and Medicaid don't really know what to do with a lot of these interventions that are not sort of the traditional sort of medical model. As you know, in 1965 when Medicare was first created, it was essentially paid for the treatment of disease using, you know, routine medical services. So it hasn't really caught up with today's day and age and what we know about the importance of lifestyle medicine, either with prevention or treatment. So I think some of this is research. Some of this are new pathways in the government, regulatory pathways.

Some of this is educating the public. It's really going to take, I think, all of the above to sort of change the status quo, because there are a lot of opportunities out there that are not being realized right now. So you were in the middle of it all. Did you feel like there was movement when you were there? That people were trying to actually shift the policies in ways that actually were effective? Or was it sort of spinning wheels? Yeah, yeah. No, I think, you know, certainly... Because people go, government's broken, it's not going to do anything, what's the point? But you have a different view.

Yeah, there are lots of things that I saw, I mean, with the Affordable Care Act, just take clinical preventive services. One part of that was now high-value clinical preventive services. There ought to be no cost sharing for them, and that makes sense from a value-based insurance design perspective.

And that should increase the likelihood that Americans receive high-value, evidence-based clinical preventive services. So meaning if people need to get screened for disease or a pap test or a mammogram, they shouldn't have to pay for it. And the private insurance shouldn't give them a co-pay. And Medicare shouldn't give them a co-pay. That's absolutely right. Cancer screenings or counseling interventions for tobacco, alcohol, immunizations, these

things can improve health. We can't get a nutrition appointment reimbursed. Well, alcohol, immunizations, these things can improve health. We can't get a nutrition appointment reimbursed. Well, right, right. I think we saw ways to go in some areas, but that's just one example where we're trying to make it easier for people to access important clinical preventive services. In terms of community preventive services, I know that the diabetes prevention program maybe has antiquated sort of nutrition aspect of the intensive lifestyle piece there. But there, the team at Medicare and Medicaid, just getting the diabetes prevention program through

took a lot of work. It required the authorities of a newly created center at Medicare and Medicaid called CMMI, which is a Center for Medicare and Medicaid Innovation. There was a test essentially of the diabetes prevention program. It was found to save money and reduce costs. That's the only way it got expanded. But that's why I call for a parallel pathway. Otherwise, you're reliant on- But the government has to fund this. This is not coming from industry, right? Yeah, exactly. Exactly. So I think the government, and the reason why the government's so important is the private sector is critical, but there's only so much from a scale perspective that philanthropy

or nonprofit organizations can do. The needs here are for millions, and we're only reaching thousands. And the only way to scale from thousands to millions, there could be other ways, but there is a role for government, and I think that's part of the premise of the book as well. And the sort of community-based stuff is important because when you think about where disease happens or where health happens, it doesn't happen in the hospital or the clinic. You know, 80% of our health is determined by where we live and by our diet and lifestyle and our genes, things that have nothing to do with what you get when you go to the hospital

or see the doctor. And yet 80% of our funding is for what happens with the doctor and hospital. So it's completely backwards. Yeah, it is. Absolutely. I mean, we talk about the importance, for example, you know, nutrition counseling. But if you get the best nutrition counseling, but then somebody walks out of that clinical setting, they see fast food establishments, they see no farmers markets,

there are no Meals on Wheels programs, how do you expect them to... So the whole idea of clinical community linkage is to reinforce what happens, all the important efforts on the clinical side to reinforce them on the community side, otherwise they're not gonna stick. So one example, a couple years ago I was out in the south side of Chicago, and I visited a program called Community Rx. And essentially, in this program, Community Rx. Community is medicine. Exactly.

The Community Rx, the program mapped out social service providers and community-based organizations around the city, and then they took that information, linked it to the electronic health record, and linked it to particular conditions and diagnoses. So at the same time, whenever a patient came to a community health center, they always got a healthy Rx script based on their diagnosis, matching them up with appropriate community services in the community. So what they learned in the clinical setting was then they received essentially referrals to get supports in the community to reinforce what they learned in the

clinic. And that's just sort of one example of how we need to build these clinical community. Yeah, you know, clinic we started a program with program with because I'm very strong advocate of getting out of the hospital yeah and it's there when you need it I mean I had heart rhythm problem this year and I had to have an ablation I'm like thank God but you know most of the problems in these communities are not what's going on in the hospital and can't be solved there so you went to you know very underserved African American community in Cleveland, near Cleveland Clinic, and we started a community program in a community center.

It wasn't in a hospital, it was in their community health center. And no, it wasn't even a hospital, just a community center. And we developed a group program. I arranged for them to get meals, sort of fresh, whole food meals. Got them the right nutrients,

just as a sort of temporary solution. See what would happen if people had the support. Because in their neighborhood, there was nowhere to get good food. And within like six weeks, it's a 10-week program. We're going to have a follow-on for a year. There were dramatic changes. I mean, people lost 20 pounds in five weeks. They had dramatic drops in their blood sugar, their blood pressure.

This woman who had a stroke, couldn't really talk or lift anything, now was talking and actually was able to carry things with her arm. I mean, I was shocked. And it was so simple. And we taught them to cook. We did cooking classes together.

They went shopping. They learned about food. We had talks with the nutritionists and the health coaches. And it's really powerful because they wanted to change. They just didn't know what or how. And nobody showed them or nobody told them.

And I think those kinds of things are what we need to be thinking about. Because this is not going to be solved in the hospital. We still need acute care medicine, for sure. But the problems we have aren't solved in the hospitals. Yeah, absolutely agree. I'll give you another example. Geisinger Health System in Central Pennsylvania.

Your podcast is called The Doctor's Pharmacy. They opened up their first food pharmacy a couple years ago, and they did a really good job matching the acuity of the individual with the intensity of the intervention. So they took poorly controlled diabetic patients who screened positive for food insecurity, and the intervention there was not just sort of diabetes self-management training and counseling. They actually provided two meals a day for, you know, 10 meals a week. For the whole family. For the whole family.

Right. And what they found just in their pilot was that the average hemoglobin A1c, which is an indicator of severity of diabetes, fell from 9.6% to 7.5%. And why that matters is every 1% drop reduces mortality from diabetes and complications by 20% and saves $8,000 in healthcare costs. And what's also important to realize is that two-point drop may not seem like a lot, but if a drug gets a half a point drop, it's a raging success, right? There you go. So it's four times as good as drug effects.

That's right. That's right. Absolutely. So there's evidence-based. So why doesn't Medicare now pay for food pharmacies and pay for food for everybody? Yeah. Well, I think we need to move in that direction. Again, it's the medical model that has been the focus of policymakers for so long.

And as we build this evidence base, and in some areas it's substantial now, that different, quote-unquote, types of interventions can actually do more than the traditional interventions. More than medical interventions. More than medical interventions. More than medical interventions. That's where we need to focus because that's where we'll deliver not just the best improvements in health, but also the most significant health care cost savings. So if you were an autocrat and you were in charge of America and policy and you were the Putin of health care, you could too, I mean, that's not a good analogy, but you could actually just take a wand and make the changes that you see

are going to make the most difference. What would they be? You mentioned the five things already. Because those things are realistic. But if you really had things that were going to have the biggest impact, what would you do? Not just in terms of healthcare,

but across our whole society in terms of making the changes that need to happen. So I'd be laser focused on the risk factors driving chronic diseases in this country, as well as the social determinants of health. And there are organizations out there like Trust for America's Health who've issued recommendations in this area. But I think it's really a package, Dr. Hyman, of policy changes. So on the chronic disease risk factor side of the equation, whether it's tobacco or, you know, poor diet, lack of physical activity, alcohol, there are a series of policy interventions there, smoke-free laws are raising pricing on tobacco, reducing alcohol sort of outlet density, increasing nutrition, physical activity access in schools, reducing the availability of unhealthy foods in different ways. There are a package of housing, housing first, whether

it's education, universal pre-kindergarten, whether it's income, paid family leave, earned income tax credit. There are a series of interventions that go beyond the four walls of the clinical setting, but tackle both the social determinants of health as well as the lifestyles, the risk factors driving chronic disease. And in this country, as you know, half of adults have chronic diseases. 60% now. Yeah, 60% now. Half of that half have multiple chronic conditions, which was really my focus at Health and Human Services.

And virtually all the $3.6 trillion that we spend in this country go there. So I would be laser-like focused on the risk factors driving chronic disease and the interplay that the social determinants have and policies there. So a lot of this, again, is outside the four walls of the clinical setting. I agree. I would add in there, and I think, you know, as you're going in the upstream conversation is, you know, what is driving the social determinants? What is driving the disease? For the most part, I would say it's our food system. And, you know, you have to change the way we grow food, what food we grow, how it's supported,

all those upstream things. It's like, we're just still down in the weeds if we don't actually change the food environment. Yeah, if you look at the subsidies going to that, our agriculture sector, the marketing by the food industry, there are a lot of forces that, whether they admit it or not, make it harder. Make it harder for Americans out there to make the healthy choice the easy choice. And, you know, I don't think we want to demonize parts of our society, but we want to work with all sectors of our society to see how we can all push health forward. And I think that's in the best interest of everyone.

Well, look, we came down hard on tobacco because we were clear about its danger. But now obesity and food has overtaken tobacco as the leading cause of death. So I think we have to start to really think about that honestly. And I think the industry does as well. I mean, for the sake of their own future and their bottom line, they need to understand which products of theirs are leading to ill health and change their practice and culture as well. So, you know, and I think there are some, you know, in the industry who have taken positive steps. And I think when that happens, we need to applaud them. But I think you're absolutely right.

As a whole, I think it's important where it's not possible to see that voluntary steps. I think government's got a role. It's got a really important role because, you know, ultimately that's why we have governments. Yeah. You know, I always say sort of health and education. Those are the two most important things. You know, health provides the foundation. Education provides the acceleration.

You know, as we pursue our goals in life. And if anywhere where a government needs to lean forward, it's got to be in those types of areas. I agree. I think that's great. Well, thank you for your work. Well, thank you. Thank you for working for us in the government for so long, trying to do the right thing. And now with the Bipartisan Policy Commission, which is, I think, one of the most important organizations out there, bringing parties from all sides together to solve difficult problems across government. And I think, you know, what I think

is you need a big lobby arm. Yeah, yeah. You need like a hundred million dollar lobbying fund to be out there telling these stories in ways that get lawmakers to pay attention. So thank you so much for your work and for your book, Prevention First, Policymaking for a Healthier America. It's a real contribution to our thinking about how do we do the right thing?

Because if we keep going the way we're going, we're screwed. So thank you. And check out the book on Amazon where we get books and your bookstore, Barnes and Nobles. And check out the work at the Bipartisan Policy Center. I love their stuff. It's a little nerdy. I'm a little geeky, but I love that stuff. You might too. And if you love this podcast, please share with your friends and family on social media. Leave a comment. We'd love to hear from you. Subscribe wherever you get your podcasts. And we'll see you next time on The Doctor's Pharmacy. Thank you. Thank you for your leadership, Dr. Hyman. Thank you. Thank you. Hi, everyone. It's Dr. Mark Hyman. So two quick

things. Number one, thanks so much for listening to this week's podcast. It really means a lot to me. If you love the podcast, I'd really appreciate you sharing with your friends and family. Second, I want to tell you about a brand new newsletter I started called Mark's Picks. Every week, I'm going to send out a list of a few things that I've been using to take my own health to the next level. This could be books, podcasts, research that I found, supplement recommendations, recipes, or even gadgets. I use a few of those. And if you'd like to get access to this free weekly list, all you have to do is visit drhyman.com forward slash pics.

That's drhyman.com forward slash pics. I'll only email you once a week, I promise, and I'll never send you anything else besides my own recommendations. So just go to drhyman.com forward slash PICS, that's P-I-C-K-S, to sign up free today. Hi, everyone. I hope you enjoyed this week's episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their find a practitioner database. It's important that

you have someone in your corner who's trained, who's a licensed healthcare practitioner, and can help you make changes, especially when it comes to your health.