The Dr. Hyman Show - Why Our Current Healthcare System Keeps Us Sick And How To Fix It

Episode Date: November 21, 2022

This episode is brought to you by Rupa Health, ButcherBox, and Essentia.   Heart disease, cancer, and stroke are the leading causes of death—and premature death at that—in the US. These diseases all have several risk factors in common, like smoking, physical inactivity, and poor diet, which policy often views simply as personal choices. We need to begin looking at disease prevention beyond individual decision-making.   In this podcast, I talk with Dr. Anand Parekh, Senator Bill Frist, and Dr. Dariush Mozaffarian on the need for government policymakers to address disease prevention.   Dr. Anand Parekh is the Bipartisan Policy Center’s chief medical advisor, providing clinical and public health expertise across the organization, particularly in the areas of aging, prevention, and global health. As a US Department of Health and Human Services deputy assistant secretary for health from 2008 to 2015, he developed and implemented national initiatives focused on prevention, wellness, and care management. He is the author of Prevention First: Policymaking for a Healthier America.   Senator Bill Frist is a heart and lung transplant surgeon and former US Senate majority leader. He led passage of the 2003 Medicare Modernization Act and the historic PEPFAR HIV/AIDS legislation that has saved millions of lives worldwide. As the founder and director of the Vanderbilt Multi-Organ Transplant Center, he has performed over 150 heart and lung transplants, authored over 100 peer-reviewed medical articles, and published seven books.   Dr. Dariush Mozaffarian is a cardiologist, Dean and Jean Mayer Professor at the Tufts Friedman School of Nutrition Science and Policy, and professor of medicine at Tufts Medical School. He has authored more than 400 scientific publications on dietary priorities for obesity, diabetes, and cardiovascular diseases and on evidence-based policy approaches to reduce these burdens in the US and globally. He has served in numerous advisory roles, including for the US and Canadian governments.⁣⁣ ⁣ This episode is brought to you by Rupa Health, ButcherBox, and Essentia.   Rupa Health is a place where Functional Medicine practitioners can access more than 2,000 specialty lab tests from over 20 labs. Check out a free, live demo with a Q&A or create an account at RupaHealth.com.   For a limited time, when you sign up for ButcherBox, they will send you 2 pounds of 100% grass-fed, grass-finished beef free in every box for the life of your subscription PLUS $10 off at ButcherBox.com/farmacy.   Get an extra $100 off your mattress purchase, on top of Essentia’s Black Friday sale, which will also take 25% OFF. Plus receive 2 FREE organic pillows (a $330 value) with your mattress purchase at myessentia.com/drmarkhyman.   Full-length episodes of these interviews can be found here: Dr. Anand Parekh Senator Bill Frist Dr. Dariush Mozaffarian

Coming up on this episode of The Doctor's Pharmacy. 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 are not as much there. Hey everyone, it's Dr. Mark. One of the most important tools I have for helping my patients optimize their health is testing. And that is why I love what Rupa Health is doing. Functional medicine testing can require placing orders with lots of different labs and it can kind of get really complicated for doctors and their patients to easily access results and keep track of everything. But Rupa Health has

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F-A-R-M-A-C-Y. That's butcherbox.com, four-slice pharmacy, to receive two pounds of ground beef, plus $10 off. Now let's get back to this week's episode of The Doctor's butcherbox.com forward slash pharmacy to receive two pounds of ground beef plus $10 off. Now let's get back to this week's episode of The Doctor's Pharmacy. Hi, this is Lauren Fee and one of the producers of The Doctor's Pharmacy podcast. The U.S. is home to the best hospitals, most highly trained doctors, and people come from all over the world to get medical treatment here. 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. In today's episode, we feature three conversations from the doctor's pharmacy on why public policy is a key component of disease prevention. Dr. Hyman speaks with Dr. Anad Parikh on the challenge to get policymakers to appreciate prevention, with former Senator Bill Frist on the importance of grassroots bipartisan efforts to generate change, and with Dr. Dariush Mazzafarian on the need for government policies and why we can't solely rely on big food to change. Let's jump in.

We all agree that prevention is 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. 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. You know, those dollars in prevention might be a slush fund. And, you know, 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, our 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's right. That looks over the costs of things for the government. That's right. 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, you know, 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 going to be a long haul.

Just to clarify for people, the way typically doctors get paid and hospitals get paid is like widgets. The more stuff you do, the more you get paid, the more angioplasties you do, the more surgeries you do, the more colonoscopies you do, 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, you know, paying for a car, but it didn't work. Like, 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 healthcare 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, you know, this hasn't really, you know,

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 As 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 that, you know, 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. You know, 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 for, you know, 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. 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 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 would think, I think that these are all sort of low. Well that's just to find 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. 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 out. Yeah. One of the things you mentioned 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. 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 and you know dynamics

yeah yeah it wasn't so much the food although it's healthier yeah it wasn't the healthiest and um 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 yeah where they literally take in poorly controlled like pretty overweight poorly controlled diabetics 60 percent yeah 60 reversal now in traditional medicine it's like zero it's amazing it's zero yeah right yeah 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. In weight loss studies, you get five. Everybody's dancing around, happy and 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 was 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're having earlier about prevention and treatment so prevention is important yeah it's a population-based intervention and you know you know not all the people you're going to do the intervention on are going to get the problem

otherwise not everybody who gets a colonoscopy was going to get colon cancer right yeah but everybody who's already sick yeah needs the intervention of lifestyle interventions because it's lifestyle is treatment, not only as prevention. Right. Right. Right. 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 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. 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 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.

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And it was a massive campaign against all odds and it succeeded and you were shepherding that through. And that was a huge achievement. We need a PEPFAR one campaign for the food system. We need a Manhattan Project for the food system. How would you go about, given all your experience and knowledge and your work at the Bipartisan Policy Center, laying that out in a way that was a doable strategy, a winnable way? Yeah. Well, I think, and remember, I did the sort of 20 years in medicine and 12 years

in politics and policy, but for the last 12 years, I used the private sector. And the example, the food that I gave, the example that I gave to you really comes out of the importance of the private sector and investments that are made, that are cutting edge, that ultimately define policy. I also work from the policy end. So even though I'm no longer Majority Leader of the Senate, you mentioned it. I'm on the board of the Robert Wood Johnson Foundation, where we talk about the health of the community. The non-medical determinants of health being much more important than the health care. That the food and our behavior and where we live and how we live is much more important than Bill Frist, the heart transplant surgeon, you know, doing dramatic things.

That's where the drama isn't very important. Don't want to diminish it. But the sort of 60% of the impact is in the dimensions that we were talking about. And that means we have to go to policy. People say, why did you leave medicine and go, you know, to the United States Senate? You know, what drove you to do it?

Did you lose your mind? Why did you do that? And I guess I did lose my mind. But one of the reasons is to be able to participate in the system that we're talking about, and that is ultimately public policy matters. Today, a lot of people dismiss government, dismiss institutions. But at the end of the day, the public policy matters. You've written about it.

We've talked about nutrition and agricultural policy. The Bipartisan Policy Center always, which is a center in Washington, D.C., bipartisan. Tom Dashiell and I run the health component. We stay on the issues of supplemental nutrition, on agricultural policy. We're on that because it does affect health care and the health, the burdens of disease, and the sort of quality of lives we're going to live. So it really starts from the private sector all the way up to the public sector. And you don't have to be a politician to participate in the public sector. Yeah, you don't. And so the key things that have to get changed

when you write about them, for example, in the bipartisan policy work, SNAP, food labels, reforms to Medicare, reimbursement around food as medicine, which you're talking about. How challenging do you think it is to get some of these things done? Because for example, with SNAP, the leveraging nutrition was a great report that was put up by the Bipartisan Policy Center, which outlined some of the things that need to be done, like sort of limiting access to, for example, sugar-sweetened beverages, which the dietary guidelines say we shouldn't eat.

But the SNAP benefits provide $7 billion a year for soda consumption. And so it's like schizophrenic. It's like the right hand doesn't know what the left hand of the government's doing. And there are people who are for it. There's people who are against it. For example, the hunger groups oppose any restrictions. And how do you thread that needle? Because I think it's such an important program, for example,

for feeding the hungry and food insecurity, but it also has secondary negative consequences of actually increasing poor health in that community and increasing the need for Medicaid and Medicare to pay for those patients who eat those foods who get sick, you know, so it's really a kind of a rabbit hole you don't want to go down. It is, it is, and again, you've written so much about it but you know the the food stamp program of the 1960s a program that you've written about is was mainly you know can people afford the food and let's just get them food let's just get them calories and some protein but let's get them calories and then in the 70s when when sort of i was coming

through in the medical in medical school we first began, well, that's not going to be enough. We really need to start looking to sort of better nutrition. But it took another 15 years to a healthier food and not just any food. But it took another 15 years, really, and the SNAP actually became SNAP, Supplemental Nutrition Program, after I left the Senate. But the fact that nutrition was put in the title, that was good. But then it took another five or six years before people say, what does nutrition really mean?

And I think the SNAP, the Bipartisan Policy Center report that you mentioned, basically said three things. Instead of taking the big policy issue and just arguing for it, it said, let's take three things. Number one, that food is medicine and healthy food has to be an objective of SNAP. That wasn't the objective back in the 60s. So do that, number one. Number two, sugary beverages.

We know from science, you've known for a long time, but for the last eight years, we know that it's probably the number one killer out there today in terms of when you look at metabolic disorder. That's just so prominent. I'm exaggerating a little bit and oversimplifying. But we made that number two. And then number three, in that just one report, and that one report goes to the 450 sort of policymakers out there,

the United States Congress. We made the healthier eating in terms of fruits and vegetables and to lower making them both affordable but also in the SNAP program itself. So we focused on all that. We took it now that's not because of that report, but obviously Obama administration came in, made huge progress. We have based on the science and that's been evaluated, you know, the health, the metabolic conditions were probably 40% healthier. Some reports say than we did with the old SNAP program.

And now you have president Trump coming in trying to roll that back. were probably 40% healthier, some reports say, than we did with the old SNAP program. And now you have President Trump coming in trying to roll that back. And that rollback, now the only thing that's going to stop that, again, as you said, all the lobbying is out there against it, is going to be the science. If we're 40% healthier, we're 40% more productive at work, there's 40% less absenteeism, the GDP, the economy is growing, the jobs are being created. And it's that sort of reasoning that ultimately we need to push through, continue to push through.

When you, again, you've written this whole story, but things like the Bipartisan Policy Center and other foundations need to echo that directly into the policy centers. Yeah, I think that's right. I mean, I think, you know, I'm always curious about, you know, policy ideas becoming then policy and then becoming implemented. And it seems like there do a lot through regulations then we have our legislative branch where all the money is and people forget that and the house of representatives is where all the sort of money starts and therefore ultimately has to be translated but then even after the law is passed it goes back to the execution and those are different people the only thing i can say is it comes back, and this reason I'm talking to you now and you're talking to me

and we've got hundreds of thousands of listeners, it comes back to the American people and how educated, how knowledgeable they are that they can translate that up through their mayors, through their school boards, through their city boards, through the state, and ultimately it gets through the system itself. And that's why democracy is a tough, tough system of government

to implement and execute because it takes so long to get through it. But again, the HIV age is a great example for our listeners to listen to because it was killing 3 million people a year, not 60,000 a year, 3 million people a year globally. Huge stigma around it, impossible to do. And by coming together, Democrats and Republicans in a global, an appreciation of the global environment, just like nutrition is and metabolic disorder, it's a global issue. By coming together over a period of two years,

we were totally able to reverse what up until that time, the previous 20 years since the early 1980s, had been set over in the corner and stigmatized. And now there are 20 million people alive because of that legislation. So policy can work, so we've got to stick with it. It reminds me of what Winston Churchill said, which was democracy is the worst form of government, except for all the others. And I think, you know, you're kind of a unicorn because you thread the needle between a heart surgeon, which is the sort of

epitome of acute care rescue medicine, and public health, which has been a large focus of your work, and particularly with the Robert Wood Johnson Foundation. Like you said, you were there operating on the downstream consequences of all this stuff, and you're like, wait a minute, maybe we better figure out a way to not get these people on my operating table. And a lot of the work you're doing now in Nashville with Nashville Health and the Robert Wood Johnson Foundation is focused on population health and how the social determinants, which are food and your housing and your economic opportunities and all the things that we don't think are that important,

which may make up to 80% of the difference in your health, in your actual health quality of life and productivity. What do you see is required for the government to sort of really shift to say, wait a minute, we're focusing on the wrong end of the stick here. Yes, we need to, you know, maintain our best healthcare and in a few years, 83 million will have three or more chronic diseases, and this metabolic health only being 12% of the population, 88% are not healthy. How do we start to shift our focus and share some of the work you're doing there? Because it's so important, and it's such a different framework for how we solve these problems than just more access to care and better financing and better efficiencies. It's flipping the whole problem on its head. point and again it's nice to put politics aside but politics are important in our democracy and where we are today but the language that we use is is critical and the study of language and the storytelling if we want to move and establish movements and for the HIV AIDS end of things, one of the things that we did was focus on young

people and people like Jesse Helms, sort of an arch conservative who had written an article in the New York Times about how evil and immoral HIV AIDS is, and therefore we should not support any sort of helping people. That changed over about two or three months as we focused on things like a drug called niverapine, which you know, and that for just 50 cents, you can give that to somebody and that would reverse 10 million orphans out there to growing over time. And when Jesse Helms heard that there's a really sort of cost-effective way to protect babies and future babies and orphans and people, all of a sudden he said he became our biggest advocate. And he pulled in a huge constituency, and evangelicals came to abortion issues and try to politicize it in all ways. But if you say family planning, you say the healthy timing and spacing of babies.

I don't even mention it, but you just say that. All of a sudden, people come to the room, and I think we can do a better job. Instead of saying eat healthy or eat your vegetables at all, really do frame it. And I'll just close with saying what does speak. And the Affordable Care Act became so unpopular because it focused just on access, which is important. It didn't focus on cost. It didn't focus on money. To the individual person, their prices were going up

and they weren't getting any more benefits. So I think the more we can translate things into cost, to effectiveness, to well-being, and we know that a healthier, we know from my heart transplant, my heart transplants, they would do well long-term if nutritionally and metabolically they were strong. So yeah, I did a heart transplant, my heart transplants, they would do well long term if nutritionally and metabolically they were strong. So, yeah, I did a heart transplant. I wanted to live 50 years and it came back to nutrition and a healthier lifestyle coming in. So I think if we do translate nutrition policy, not just good, bad, eat healthier, but translate it into a healthier person is a more productive person and greater well-being and it means more

productivity at work does mean a growing of economy means fewer absentee days the economy growing individual well-being increased which translates into national effects in their economy and the affordable care act not you know missed it this time around, I think, if we get the right language. And we do end up couching it into growth, personal than anything else. And you see that with the homeless population, providing them housing, literally paying for their apartments, reduces healthcare costs dramatically, and it's actually an economic benefit. Or I was speaking to the former head of population health at Cleveland Clinic where I work, and he said, you know, if we provided housing and food for young mothers, we would dramatically reduce preterm births and neonatal costs, which are literally in the billions and billions of dollars. And yet our healthcare system isn't set up to provide food or housing

or any of the things that actually make the most difference. That's what's so striking to me. Yeah. And I think, you know, the things that people listen to us, they say, well, again, you're talking about Washington DC and policy and all that stuff, and it's so far away, but it really isn't. When I left the Senate, the first thing I did is come back to Nashville, Tennessee, where I grew up, Vanderbilt and family and all, and Nashville, ironically, it's sort of a Silicon Valley of health services. All the hospital chains, disease management chains, psychiatric hospital chains are based there on a per capita basis, much bigger than New York or Boston or Washington in terms of the reach.

But ironically, in the Davidson County, where all these home offices are, the population health measures, and it could be metabolic disorders, diabetes, obesity, how long somebody lives, infant mortality, are higher there than other sort of brother-sister cities around the country of comparable size. And so we started a local initiative called Nashville Health, not appointed by the mayor or the governor. Those are good, but they tend to go away when they go away.

But a collaborative of 120 nonprofits, the academic institution partnering with government, addressing these local issues. And because it's not health care, it's health. And as you said, 80% of that are things like food and housing and access to the internet. That's where our focus is. And we're making measurable change in the local community. And I throw that out there because whoever's listening to us, they'll look around. Do you have a collaborative like that addressing these issues at that ground level?

And that's where this great movement can be of educating mayors and educating governors and educating Congress people starting in one's own community. Yeah, that's true. We were at, we were at a friend's house, Jimmy Haslam, and his brother was the governor of Tennessee, and we were chatting, and he said, a third of our Tennessee budget is Medicaid, which is predominantly because of populations who are affected by these social determinants

and desperate to find solutions. But I don't think they're hearing the right ideas. I don't think they're hearing the right information. And I think, you know, the fact that, you know, you're out there talking about this and that there's these models like national health, I think hopefully will spur governors and mayors and others to actually start to act on this because this is where we have to move. I think, you know, in healthcare right now, there's this movement towards population health. Cleveland Clinic just stood up a new program called 4C, Cleveland Clinic Community Care, to try to actually act in this space. And they started a food is medicine program. So you see these global leaders like Cleveland Clinic leaning into this space,

but I still find it's so incremental. And I am like, wait, you know, this is like, I feel like I've got a big, you know, a truck full of water and I'm, you know, in the desert and there's on the other side of this glass wall and everybody's dying of thirst. And it's like, it's so not that hard. And yet, and we're just, it's so frustrating. So I think you're right. I think it's like it's so not that hard and yet and we're just it's so frustrating

so i think you're right i think it's a grassroots efforts and and on the local local levels being being focused on this and it's also educating policymakers and that's really why you know i i wrote my book food fix is why i started the the food fix campaign to try to create a coordinated effort like you're talking about for the 2000 people in Washington that actually need to be educated to understand these things. Because, you know, I don't believe there's anybody that wakes up in the morning and says, you know, you know, I just want to keep people sick in America. And I, you know, I want to maintain the status quo. I mean, people,

whether you're a big CEO of a food company or you're a politician, everybody wants better for themselves, for their families, for their country. It's just that we don't have the roadmap to get there. And I think this is the kind of stuff that actually has to be at the forefront of whoever is in the next administration in the aftermath of COVID-19, because in just in terms of pandemic preparedness, how do we deal even the next pandemic that's going to come unless we make a more resilient healthcare system, a more resilient population? And I think, you know, I think you've worked so hard to do that.

So how would you, if you were president today, what would you be like leading the charge on to get us going in the right direction around this incredible burden of health disparities and chronic disease and social determinants? Yeah, it's a great question. First of all, I'd go back and- I would vote for you, actually. I'm a Democrat, but I would vote for you. Thank you, but you're not going to have the chance to. Come on. Why aren't the good people running?

I just don't understand. You know, it is interesting that people say, how are you spending your time? And first of all, as you know, I do a podcast. And that podcast is really interesting. It's called A Second Opinion. But I'm talking to people just like you are. And it's really interesting. My particular podcast looks at this intersection of health and healing, the life that you and I live as physicians,

intersected with policy, the sort of things we talk about today. And the third big bubble is innovation, you know, the creativity innovation. So we bring people on and not to be advertising it too much, but the interesting thing is that when we gravitate back to that intersection of policy, number one, number two, health and healing, number three, innovation innovation just at that intersection there it comes back to exactly what we're talking about these non-medical determinants

overall that will lower cost improve outcomes have greater well-being productivity for the nation coming back and then you end up starting with shelter and you start with housing and you start with access to access and consumption of healthy foods and nutrition. And then you gravitate back out to do that. You're one of the few scientists, physicians who've come to the insight that we can't just treat patients in the office and tell them what to eat, that we have to fix the food environment, that healthcare fix is not just about better care coordination or better efficiencies or improving payment systems or prevention in some vague way but it has to do with changing the context in which we eat the foods that we have access to

and the policies that promote the consumption of more and more of the bad stuff and we're sort of incentivizing the wrong things so um one how did you kind of have the aha and two let's talk about this because it seems like you know one one in five dollars is for health care and about 80 of that is for chronic disease and most of that is from diet that if we go upstream unless you go upstream we're not going to fix the problem. Yeah, I just want to highlight and repeat what you said. You know, one in five dollars in the entire U.S. economy is spent on health care. One in four dollars in the entire federal budget is spent on Medicare and Medicaid.

And that's projected to go up exponentially. This is swallowing the economics of our country. It's swallowing our government budgets. It's swallowing the economics of our country. It's swallowing our government budgets. It's swallowing competitiveness of business. It's pretty shocking if you think about food, how big of a part of our lives it is, how big of a part of the economy it is. I can't think of any other part of our economy, any other products that we interact with every day where safety is left up to the consumer. You know, imagine if you went to toy stores and... I love this analogy. You know, just imagine you went to toy stores and everybody knew there was lots of toys that

were unsafe for the kids. There were lots of toys that were okay, not, I mean, a little bit unsafe, but not fully safe. And there were some toys that were really safe. Or you walked into a building or you went to buy a house and some houses met earthquake standards and fire standards and electrical standards and plumbing standards others didn't at all not even close um and some houses were kind of in between some things were met or other things were not met or teachers in school some teachers you know were were safe you know and were good for the teachers and others were known. Everyone knew the teachers were dangerous for the children in different ways. We would never leave it up to the individual family

or the individual person to deal with that mess, right? We would say, this is outrageous, right? We want safe toys, safe cars, safe homes, some minimum standards, right? And yet in food, it's the only system where we sort of say, well, it's up to the individual person. We need education. We need labeling. We need dietary guidelines. You know, we just need to leave it up to the person and just not do anything else. And I think, you know, again, that's to me kind of the, you know, kind of the craziest thing about our policy approach

so far is that it's all up to the individual consumer. And so, of course, we need to keep choice and there's a range of foods that people should be able to choose from, but all of them should be reasonably safe. Yeah. All of them. Well, the challenge with that is that the food industry has polluted the science with studies that confound the truth, that challenge notions that they're unsafe. You know, American Beverage Association fund studies that soda doesn't cause obesity and kind of muddies the waters. And so the argument is, well, who's going to be the judge and determine whether or not this is safe or not safe, right?

Some people think, well, Twinkie's fine if you eat it once a week, but maybe not. Well, yeah, I get asked about, you know, what my thoughts on the role of the food industry a lot. And it's like everything else, it's complicated. It's not straightforward. So first, I have to say that the food industry has followed and continues to follow a lot of the really harmful and, you know, unwelcome playbook of tobacco, where it's about deception, denial, attacking the scientists, you know, hardball lobbying, softball, buying of influence, a lot of the same tactics. But I think at the end of the day, you know, the analogy to tobacco only goes so far. And many of those

examples are actually around soda and big soda. There are still present for other foods, but it's really about big soda. But I think the analogy with tobacco only goes so far for a few reasons. First, the food company is incredibly diverse and heterogeneous. There's thousands of companies with thousands of products compared to tobacco. Second, I think that with tobacco, it's a fight to the death. Whereas with food, we need the food industry. We need their scale. We with food, we need the food industry. We need their scale. We need their expertise.

We need their technology. We need their distribution systems. And when I say big food, I mean from agribusiness to large supermarket, international supermarkets, to restaurants, to manufacturers. People think of the manufacturers, but there's four pieces to big food. And I think third, and I think maybe most importantly we shouldn't forget, is the food industry mostly for the last 50 years did what we as public health experts and scientists told them to do. And now in the last 20 years, it hasn't been that long, as we've really gotten to new science, we're saying, wait a minute, while you did what we asked you to do, slow down and change and refresh. And this is where the problem is that some food companies are asked you to do, slow down and change and refresh. And this is where

the problem is that some food companies are slowly trying to do the right thing and trying to pick that up, mostly because they're being pushed by their losses in sales. Some because they believe in doing the right thing. Others are fighting and digging in every step of the way. So there's a lot of heterogeneity. But I think what's interesting is that you know it's interesting there was a guy who was was at the milking conference who was the head of a big food company he's like i feel like a frightened dinosaur yeah yeah i i all all the people i speak to and i've heard from they see that the food revolution is coming there's absolutely the food in 10 years is not going to look like the food it does now. And so I think what keeps me up at night is not that there's not going to be change, there's going to be change, but that the change isn't going to be informed by evidence. And so,

you know, we need innovation in the food system. We need investment in the food system, but going from Doritos to Cool Ranch Doritos is not innovation. Going from gummy bears to non-GMO gummy bears is not innovation, right? We need real innovation. Making an Oreo of 90 calories instead of 100 calories. Exactly. Cut six trillion calories out of the food supply. There's a major food company who wanted to reduce

the calories in their ice cream, so they added air. Yeah. Right? So that per cup, there'd be fewer calories, right? But adding air to food is not going to improve its health, right? So I think that, you'd be fewer calories, right? But adding air to food is not going to improve its health, right? So I think that, you know, that's the kind of thing that I worry about. All calories are the same, sure. Yeah. Yeah. So we need to, but the public, I think the biggest thing the public is demanding

from their food right now is trust. And big food is not trusted. And that's a wake-up call. And that's good that that's a wake-up call. And so I think that we don't want to demonize the entire food industry. There's a lot of folks trying to do the right thing. A lot of graduates from our school at Tufts in the industry trying to help them do the right thing. But we also want to work with industry and also work against industry when we need to. Give them carrots, give them sticks, help them and sell healthier, more equitable, more sustainable food. And I think that's happening. I think I see these big companies like Nestle and Pepsi just struggling to reinvent themselves.

But it's tough because they've got... I talked to the head of Nestle and he's like because they've got you know i mean i talked to the head of nestle and he's like yeah we have lean cuisine which is mostly carbs because it's low fat and because we call it lean the fda says we can't change the composition of it so we can't make it healthier even though we want to and i'm like it's an 800 million dollar business i get it these are like big issues for them but and this is where, Mark, government has a key role, right? Because if you leave it up to every individual food company to try to fight the system, they're going to go under. If they innovate and the other companies don't, they'll go under. So this is where government

has really a role to play to even out the playing field and help these food companies do the right thing. So let's talk about what those policies are, because there's a lot of things you've written about. And I want to get into some of them. You talk about your best buy policy changes that are going to be not one thing but a series of things that attack multiple sectors where there's issues whether it's policy schools, whether it's quality issues, whether it's you know labeling, whether it's research, all these things are needed in concert to actually shift the whole dynamic from what we have now. But one of the articles wrote was called The Real Cost of Food. Can taxes and subsidies improve public health in JAMA a few years ago? And one of the challenges

that, you know, we sort of don't want a nanny state, but in essence, we are creating a nanny state in reverse because we're being a nanny to but in in essence we are creating a nanny state in reverse because we're being a nanny to the big food companies by subsidizing commodities that are wheat corn and soy that are almost 60 percent of our calories and the people who consume the most of them are the sickest and of course we then fund food stamps uh which is predominantly I think it's 70 plus percent of it goes to junk food and 7 billion, almost 10 percent goes just to soda. So we've created a system where we're having price supports for the bad food, but not for the good food. You talk about flipping that upside down. Well, so you said a lot. There's a lot of points there. So, and, you know, just what's really interesting and, again, sort of wonderful from a point of view of wanting to study this is that just like there's no single magic bullet to eating and nutrition science shows us that you can't just pick one piece of the diet and fix it and everything's fine, the same is true for policy.

There's going to be no magic bullet. There's a range of solutions that are needed. I think that taxes and subsidies are pretty crucial, and I'll talk about that in a minute. But I would go back to your comment about subsidies. There's been this sort of popular myth that's kind of urban legend that's spread through the media that somehow there's subsidies to commodities that's making the prices cheaper. And I just want to really say clearly that's totally false, that all U.S. policy for commodities keeps the prices high. The reason, you know, what farmer in the U.S. wants their prices low, right?

They all want their prices high. And so sugar is a great example. People say, well, there's subsidies, you know. And first, most of the subsidies have turned to crop insurance crop insurance gives farmers insurance so that they have a really bad season because of you know drought or something they don't go under and so most subsidies now are actually crop insurance for those commodities not direct cash you know uh subsidies um that's still a form of a subsidy but it's not direct yeah but but corn is a great example we actually keep the price of sugar high in this country because natural Brazilian sugar is much cheaper than corn syrup.

Much, much cheaper sugar from Brazilian farms than U.S. corn farmers. I talked to the vice chair of Pepsi. He's like, Mark, I said, why do you use high fructose corn syrup in your drinks? He says, because the government makes it too cheap for us not to. Well, they make it cheaper than natural sugar by putting tariffs on the Brazilian cane sugar to protect corn farmers. Right, right. So if we took away all the price supports, which actually keep the price high, corn farmers would go out of business, but the market would be flooded with cheap sugar from other countries. So that's just one example of this kind of conventional notion somehow. I don't know, Michael Pollan, someone wrote about this and it's just entered the commercialism.

But it doesn't allow for the production of more and more of the food. In other words, they pay for them to produce food, even if they, for example, in bad soils or in ditches, and then they fail and they pay for this money. I mean, I've heard all these stories. The great majority of commodity crops in our country aren't eaten by humans so the great majority of commodity crops in our country go to livestock or go to energy um you know so so i thought that's i thought that's what what nixon's policies on earl butts were designed to do which is to drive the prices of milk and meat down because they were consuming these commodity crops. And he was worried about

the prices going too high and not getting elected. And he got Earl Butts to change the policies. I thought that's what the whole thing was about. I would have to go and look at that history. I don't know that history. I know about Earl Butts and his kind of green revolution. But the farm bill and kind of the subsidy approach has been oversimplified. There's actually a lot of things in the newer farm bills to promote specialty crops that are called specialty crops like fruits and vegetables to start to promote them. A better approach would be to go to the retail level, right? A better approach would be to go directly to the consumer. And I think we should do that because right now the price we pay for foods doesn't reflect the true societal cost of the food and health care

and lost productivity and suffering. All the externalities. All the externalities. Even how we grow the food, how it affects soils and water and climate. Absolutely. And so it's really not a punitive approach or a favoritism approach. It's just bringing true market prices to food. Food should reflect the true market cost and benefit to people. And so if we taxed most

foods, most packaged and processed foods with a flat tax, 10%, 20%, 30%, whatever we could do, and then we used all of that money, crucially, we used all of that money to heavily subsidize at the retail level, at the consumer purchase level, or at the farm cost level if you invest in farmer training, new equipment, other things, then you would use all that money to invest in and reduce the price of minimally processed healthy foods like fruits and vegetables and nuts and seeds and plant oils and fish and yogurt and things like that, you would turn the prices upside down or at least more normal, right? Where you couldn't buy a soda, you know, a 36-ounce soda for 99 cents anymore. And you wouldn't have to pay 50 cents or 70 cents for an apple.

You'd pay 25 cents, 20 cents for an apple. You'd pay a dollar for a serving of salmon right you'd pay a dollar 30 for soda instead yeah that would change all the incentives for farmers for retailers for restaurants for manufacturers and for the consumer and so you know what's happened over the last 40 years is the price of soda and has gone down 40 percent the price of fruits and vegetables have gone up 40%. Well, fruits and vegetables in season are still quite affordable. The USDA did a nice analysis of that. So fruits and vegetables in season are quite affordable, but

there's a lot of fruits and vegetables out of season now, and those, of course, are really expensive because they're getting shipped around the world. So that's another challenge. But I think that price is clearly one tool that the government needs to use to help address healthier food. And it sounds sort of pie in the sky, like this will never happen, but there's now at least a dozen countries

around the world that have passed soda taxes. Mexico has passed a junk food tax. Yeah. Unfortunately, none of that money is being used, to my knowledge, for subsidizing healthy foods. And so that makes the taxes only regressive in terms of finances for the poor. Although it's progressive for health for the poor, it's regressive for finances. We should use the revenue from those taxes to create incentives and systems for making healthy food less expensive

while helping farmers right we don't want to just make the food less expensive by by putting farmers out of business so i think that's you know price is just an absolutely crucial tool and we've learned from tobacco for example how important price is so what are your best buy policies if you were willing to sort of be in charge for a little bit and could just do what you wanted and yes i think you're in north korea just make a decision and whatever you want to do yeah well i i yeah there's a lot of challenges in north korea for sure um that maybe food wouldn't be the first thing i'd address but it would be up there um so i think that uh you know there's probably six or seven categories of policies that I think are really crucial.

One is fiscal economic incentives. Like we talked about, direct-to-consumer incentives or taxes. Industry incentives, fiscal incentives. Give them incentives for marketing and advertising and developing of healthy foods and give them disincentives for the opposite. No, but you shouldn't give them a tax break for spending billions of dollars

advertising junk food to kids. Yeah, that's actually been proposed in Congress. It hasn't gained steam or gotten out of committee, but it's been proposed to take away the tax breaks that companies now get for marketing junk food. Fiscal incentives through SNAP, the food stamps program. Fiscal incentives is one category. You know, two other categories are crucial is to change the environments in schools and work

sites. Their kids spend much of their day in schools. Adults spend much of their day at work sites. There's a lot of ways, wellness programming, environmental standards, procurement policies to make schools and work sites, places where you, and hospitals, you know, places where you can only really get healthy food, food that tastes good and is healthy and is good. Well, our school lunch policy now doesn't exactly do that, right? Pizzas are vegetable and French fries are vegetable. Well, the 2010 Healthy Hunger-Free Kids Act was actually a pretty enormous advance. And so school lunch is much, much better than it was before that um there are still holes but but it's actually probably one of the best policies food policies we have nationally

is the lunch 50 percent of schools you know you go in and get brand name food on different days monday it's mcdonald's a tuesday it's burger king wednesday it's dominoes it's like that's 50 percent of schools and 80 percent have contracts with soda companies well soda is not allowed in public schools but all the sports drinks which are extremely high in sugar no no soda is not allowed in schools including sports drinks uh competitive foods they're smart snack standards and they're not they're pretty much there's no sugar sweetened beverages in schools yeah that's pretty much 100 juice is okay but but sugar sweetened beverages are out of schools with healthy Hunger-Free Kids Act. Pretty landmark, actually.

There are, again, some holes, but it's pretty landmark. But more can be done, I agree. So I think schools, work sites, fiscal incentives, those are three categories. Healthcare reform, there's a lot to do in healthcare, and that's a whole other podcast, but getting food in the electronic health record, the number one cause of health isn't tracked in the electronic health record. That tells you everything, right? Right. Right. Our health, you got to train the doctors and yeah, fruit and vegetable prescriptions, medical education, um, medically tailored meals, changing quality guidelines, changing reimbursement guidelines. There's a lot to do in healthcare reform. Uh,

research and innovation is crucial. Before you jump on there, just to show you how powerful that is, what you just said, that if you get food prescriptions, the impact can be powerful. Why would the government want to pay for food? It seems like a waste of money. People have to eat anyway. But Geisinger did a study where they actually took very treatment-resistant type 2 diabetics who were poorly controlled, the most food food insecure they were costing an average of 248 000 a year and they gave them 2400 of food and some support social support and help to use the food and learn what they're doing and they reduce their cost to 48 080 cost reduction while improving dramatically the health of the people and so it's's a no-brainer, but you can't get Medicare to cover a fruit and vegetable prescription.

Well, so yeah, you're describing medically tailored meals, and what you say is really crucial. About 5% of the population costs about 50% of health care costs. All the patients with really complex chronic diseases, kidney disease, cancer, heart failure, AIDS, a range of really severe conditions. And several interventional studies now have shown that if you actually give those people food, give them three meals a day, which costs about $20 a day, it's much, much cheaper.

You save money because they don't go to the hospital, they don't get admitted, they don't go to the emergency room. And because of that, right, things are changing so quickly, you know, Mark, because of that, California has just launched a $6 million pilot to do medically tailored meals in eight counties in California this year. And if it works and they see the same results, they're going to extend it to all of California. So change is coming. Change is a coming. Change is a coming. Yeah. And so, you know health care is a fourth bucket another a fifth bucket which i think is crucial for policy is research and innovation there's a lot we know

but there's so much left to learn there's so much left to learn about how foods affect our brains our microbiomes the differences between different processing methods that we've talked about i mean we could go on and on and we don't focus on we and you you wrote that we spend about a billion and a half on nutrition research and about 60 billion on all the drug and other research so it's like yeah there's the the numbers are really you know telling that the federal government itself estimated that all of its nutrition research is about one and a half billion dollars a year and that sounds like a lot but again all of the country's drug industry research pharmaceutical research is about 60 billion a year advertising on candy in the u.s is about

5 billion a year compared to 1.5 billion on nutrition research advertising on candy is 5 billion a year and just purchasing of candy is 50 billion a year in the u.s and so you know that 1.5 billion is just nothing compared to you know, what the true issue is going on. I heard some scary thing. We spend more on animal pet care and food than we do on education for our kids. I have not seen that, but that really would be sad if that were true.

I am amazing. So we really need research and innovation. I think we need a new National Institute of Nutrition at the NIH. The NIH has a National Cancer Institute, a National Heart, Lung, and Blood Institute. All these institutes focus on diseases. We need a National Institute of Nutrition. It's the National Institute of Health. Food is the biggest challenge to health. Let's create a new National Institute of Nutrition. And again, that sounds impossible, but the National Cancer Institute was added to NIH not that long ago because of just the concerted acts of a few people going to Congress and saying, hey, we need a war on cancer. We need a war on bad food and a

victory for healthy food. We need a National Institute of Nutrition. We need public-private partnerships and guardrails so industry can fund nutrition research. I think industry has a role to fund nutrition research, but we really have to figure out how to do that transparently and carefully and independently. I mean, it's tough. You've got 40% of the Academy of Nutrition Dietetics, which is our dietetic group in America, being funded by the food industry. It's a challenge.

It's a heart- healthy cereal with seven teaspoons of sugar you know that you want to quit the american heart association it's challenging it's challenging i mean i mean the food industry has expertise that we need and they also have negative influence that we don't need and so how can we use the expertise and and minimize the the negative so and then i think the last area you know transparency around and have transparency around food in general and i think the last policy area we talked about economic incentives schools work sites research and innovation the health care system the last area is sort of quality standards there are some basic things the same way we have quality standards for

toys or for cars or for houses we need need some minimum quality standards. And the easiest places to start are additives. So we need some quality standards. Basically, the government's saying you shouldn't have too much of these things in food. It's just a minimum standard. We already have done that for trans fat. That's a huge win for the U.S. It took 50 years. Yeah, it took a long time, but we've done it.

We need to do that for salt and for added sugar additives. And then we need marketing restrictions on marketing of unhealthy foods to young kids. I hope you enjoyed today's episode. One of the best ways you can support this podcast is by leaving us a rating and review below. Until next time, thanks for tuning in. Hey everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you all the experts that I know and I love and that I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter and in it I share my favorite stuff from foods to supplements to gadgets to tools to enhance your

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