Former CDC Director on Rebuilding Public Health and Trust in America | Dr. Tom Frieden

Summary

The Dr. Hyman Show

Former CDC Director on Rebuilding Public Health and Trust in America | Dr. Tom Frieden

Host: Dr. Mark Hyman
Guest: Dr. Tom Frieden (Former CDC Director, Commissioner of the NYC Health Department, President of Resolve to Save Lives)
Date: October 22, 2025

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Episode Overview

Dr. Mark Hyman sits down with Dr. Tom Frieden—former CDC Director, NYC Health Commissioner, and author of The Formula for Better Health—to delve into the chronic disease epidemic, loss of trust in public health, the nutritional landscape, the battle against big industry, and actionable policy and personal solutions. Dr. Frieden shares insights from his decades in public health, emphasizing the importance of integrated personal and societal action, scalable interventions, improved communication, and rebuilding trust in an era shaken by COVID-19.

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Key Discussion Points & Insights

Understanding Public Health & Loss of Trust

• Dr. Frieden highlights the "deep hole" public health is currently in due to waning public understanding and trust ([00:00], [04:26]).
  • “There isn't a good understanding of what public health is, why it's important, and how it could save a lot of lives, including yours.” — Dr. Tom Frieden [04:26]
• Trust in public institutions, especially after COVID-19, has eroded due to misinformation, echo chambers, changing guidance, and politicization ([05:12], [07:12]).
  • Dr. Hyman: “Trust is lost in buckets and it's gained in drips.” [08:35]

Restoring Public Trust: Dr. Frieden’s Three-Part Strategy ([07:12])

1. Listen first: Understand people’s fears and frustrations, and communicate as a two-way process.
2. Focus on visible small wins: Tangible, positive changes rekindle confidence.
3. Avoid unnecessary mandates: Require actions only when clearly essential.

“We have to listen better, communicate better. Communication starts with listening...The second thing is to make small wins...And the third thing is stay away from mandates unless absolutely necessary.” — Dr. Tom Frieden [07:12]

COVID Mandates, Masks, & Communication

• Discussion around COVID-19 mandates, drawing analogies from TB outbreaks:
  • Mask-wearing in immune-compromised settings is sensible, but blanket mandates fuel skepticism ([10:05]).
  • Closures helped early on but needed more nuanced, community-involved approaches ([12:43]).
  • Early messaging failures and political entanglement worsened public distrust ([13:45]).

    “CDC wasn't heard from again for all of 2020. And you didn't have the good public health messaging...At the start of every sentence: ‘Based on what we know now, this is what we're going to do. It's likely going to change.’” — Dr. Tom Frieden [14:16]

• Vaccine mandates: justified when preventing spread, but data shifted to suggest primarily self-benefit ([15:00]).

Seeing the Invisible: The Formula for Better Health

• See, Believe, Create:
  1. See the invisible: Identify underlying structural and epidemiological factors.
  2. Believe change is possible: Counter the “Cassandra curse” of public health warnings not being acted upon.
  3. Create a healthier future: Apply systematic approaches for both individuals and society ([22:30]).

“Public health is like Cassandra, the Greek mythological priestess who could see the future, but she was cursed. Nobody believed her predictions, so they didn't change their behavior. We can break that Cassandra curse.” — Dr. Tom Frieden [23:34]

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Case Studies & Policy Discussions

Tobacco: A Public Health Blueprint ([22:50])

• History of NYC’s efforts: absence of data, then rigorous surveys, then layered interventions.
• Tobacco industry tactics—modifying cigarettes for addictiveness and manipulating scientific machines.
  • “A single puff of a cigarette will deliver more free nicotine—‘crack nicotine’—to your brain than an intravenous injection.” — Dr. Tom Frieden [26:29]
• Effective measures:
  • Cigarette tax: Most effective lever—price sensitivity reduces use.
  • Public smoking bans: Social norms and policy reduced prevalence.
  • Hard-hitting ads: Showing disability/disfigurement motivates action.

  “Show disability and disfigurement. If you tell people they're going to die—everyone’s going to die. But show the harm, and it sticks.” — Dr. Tom Frieden [28:49]

Chronic Disease & Food Policy: The Current Battlefield

• Ultra-processed foods and refined sugars/starches as primary drivers of chronic disease ([20:36], [33:29]).
• Shift in public health challenges: now more people are biologically addicted to food (14% adults & children) than to alcohol ([32:49]).

  “People can stop smoking, but they can’t stop eating. And yet 60% of the food we’re eating is ultra processed food.” — Dr. Mark Hyman [32:49]

• Industry pushback parallels tobacco battles: food lobby astroturfing, co-opting advocacy groups, and using “freedom of choice” rhetoric.
• Successes in Latin America:
  • Warning labels (black stop signs) lead to rapid reformulation and reduced harmful food sales ([37:45]).
  • Taxation and restricting marketing to children/prohibiting sales in schools shown effective ([42:41]).

Salt vs. Sugar—Which Is Worse?

• Salt claimed to cause more deaths than sugar, with sodium-potassium imbalance at the root ([34:30]).
  • Policies needed: Potassium-enriched salts, regulatory limits, front-of-pack warning labels.
  • “Globally, half a century of urging people to eat less salt has done nothing. It’s in every processed food.” — Dr. Tom Frieden [35:14]

Policy Levers, Industry Barriers, and Advocacy

• Persuasion, litigation, and coalition-building crucial for policy change ([49:25], [97:38]).
• Prevention paradox (Geoffrey Rose): “A little bit of good for a lot of people does more than lots for a few.” ([52:00])

  “Losers [industries] organize, and the benefit for the public is diffuse and invisible. That's the paradox.” — Dr. Tom Frieden [52:00]

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Personal, Societal, and Clinical Interventions

Personal Action & Policy Synergy

• Individual action has limits—but individuals can drive policy by voting, advocacy, and organizing ([96:42]).
• “Less than 5% of Americans have the healthiest habits... It’s in your self-interest to get policies changed.” — Dr. Tom Frieden [96:42]

Primary Care System Failings

• 100 million Americans lack a primary care doctor, despite spending $4 trillion on healthcare ([04:26], [93:13]).
• Payment remodels (like Kaiser Permanente or value-based care) and team-based care essential for improvement.
• AI in healthcare holds promise for augmenting clinical decision-making, making care more accessible and efficient, but cannot fully replace human clinical judgment ([93:13], [94:58]).

The Healthcare Model: Prevention, Treatment, Empowerment

• Prevention and clinical care are complementary, not either/or.

  • Key actionable policies if ‘king’:
    • Tax sugar and soda; front-of-pack warning labels ([59:44], [61:19]).
    • Make primary care universally accessible.
    • Mandate effective reform in food supply (e.g., sodium cut, eliminate trans fats).
    • Strong kids’ advertising restrictions and school food reform.

    “The only thing that actually substantially reduces consumption is this black stop sign... people spend at most six seconds making a decision of what to buy in the supermarket.” — Dr. Tom Frieden [61:19]

• Better blood pressure and lipid control—especially in diabetics—yields orders of magnitude more health gain than aggressively targeting blood sugar alone ([65:42]).

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Notable Quotes & Memorable Moments

• On Mandates & Trust:
  “Trust gets broken in an instant and it gets put back slowly.” — Dr. Tom Frieden [07:12]
• On Tactics:
  “Litigation revealed the industry’s sleazy tactics and opened the door for policy change.” — Dr. Tom Frieden [30:13]
• On Industry Influence:
  “Never try voluntary measures with the food industry. They don't work.” — Dr. Tom Frieden [90:18]
• On Positive Change:
  “We can break the Cassandra curse if we see the invisible, believe we can change, and create a healthier future.” — Dr. Tom Frieden [23:34]
• On Policy Limitation:
  “It's going to be tough… this idea that corporations are people and they have free speech rights…you can't make them say things that they don't want to say, even if it's the truth.” — Dr. Tom Frieden [62:54]

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Important Timestamps by Topic

• Public health and trust: [00:00] - [07:12]
• COVID-19 mandates and communication: [08:35] - [15:38]
• Formula for Better Health: [22:30]
• Tobacco Control Lessons: [22:52] - [29:41]
• Chronic Disease Origins & Ultra-Processed Food: [20:36], [32:49] - [33:30]
• Salt vs. Sugar: [34:30] - [42:08]
• Latin America’s policy innovations: [37:45] - [44:00]
• Industry manipulation and advocacy tactics: [46:31] - [52:00]
• Healthcare system reform and AI: [93:13] - [95:45]
• Actionable steps for policy and personal change: [59:44], [83:06], [96:42]

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Conclusion & Calls to Action

Dr. Frieden urges a blend of personal responsibility and systemic change:

• Individuals: Demand better policies, normalize healthy behaviors ("vote with your fork and your voice"), push for government accountability.
• Policy: Prioritize straightforward, high-impact interventions; make visible wins; follow tobacco control playbooks.
• Healthcare: Foster universal primary care, incentivize prevention, deploy technology wisely.

“If we improve health for everyone, we’ll have a more productive society... It’s not a Republican or Democrat issue. It’s about health or sickness. It’s about fact or fiction.” — Dr. Tom Frieden [80:37]

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Dr. Frieden’s Book:
The Formula for Better Health: How to Save Millions of Lives, Including Your Own
(All proceeds support public health initiatives.)

Final Thought:
“We really can make a lot of progress. Things that seem like they're inevitable, but they're not. We've made progress before... heart attacks and strokes can be gone as well.” — Dr. Tom Frieden [75:41]

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For more, listen to the full episode or visit Dr. Hyman’s website.

Transcript

[A]

We've got a deep hole to dig out of in public health. I realized about a decade ago is there isn't a good understanding of what public health is, why it's important, and how it could save a lot of lives, including yours.

[B]

How do we start to restore public trust in Public Health? Dr. Tom Frieden serves as the director of the center for Disease Control and Prevention of the CDC and the commissioner.

[C]

Of the New York City Health Department.

[B]

He's a physician whose advanced training in internal medicine, infectious disease, public health and epidemiology. And he currently runs Resolve to Save Lives, a nonprofit that addresses the world's deadliest health threats.

[A]

100 million Americans don't have a primary care doctor. That's ridiculous. $4 trillion in health care and we can't give this basic thing to a third of the people in this country. That's absurd.

[B]

The scary data is that 14% of adults and 14% of children are biologically addicted to food, which is actually more people than are addicted to alcohol. So this is a big problem because people can stop smoking, but they can't stop eating. Where are the big problems and what are the policies that need to happen and what do we do for ourselves.

[A]

When it comes to public health specifically? I think there three things we've got to do. One is.

[C]

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[B]

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[B]

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[B]

Mark well, Tom, it's an honor for me to have you on the podcast because I've been a huge fan for actually decades before you were CDC head in in 2009-2017 when you were the New York Health Commissioner and You were taking arrows in the back for trying to get trans fat out of food supply before the FDA said it was a non safe substance to eat or non grass. You were talking about ways of reducing hypertension through sodium restriction. You were working on trying to limit sizes of sodas and soda taxes. And we're really, you know, reaching really a lot of resistance. And the food industry is so powerful. And we were just chatting about our mutual friend Paul Farmer, who really addressed what he called structural violence. You know, we're trying to do public health, we're trying to do personal health. You're trying to be a doctor in a, in an office seeing patients, but you're up against this structural system, the social, economic and political conditions that drive disease. Big Food, Big Ag, Big Pharma, the medical industrial complex, whatever you want to call it, is a real thing. And you know, we were just chatting about how soda taxes, you know, are, can be very helpful. But I was saying how the hunger groups are all funded by big Food and of course they're gonna be against any restrictions on SNAP or soda or anything else or soda taxes. So we're in this situation where, you know, you were one of the first pioneers in public health to start talking about these issues and then doing something about it. And I read this, I don't know how this actually did the math works out. But you've helped reduce trans fat consumption for almost 4 billion people, which is about how many people were the earth when you and I were first born. So really planetary medicine. And I'm just so tickled and honored to have you on here to talk about your new book, the Formula for better Health, how to save millions of lives, including your own. I think the public health, personal health has not been properly integrated. I think this is really a huge problem in medicine where there's like public health and epidemiologists and people who are trying to do things on a public health level. And there's the doctors in their office doing on a personal health level. And there's not a lot of synergy or communication or thinking about how do we actually solve these problems holistically. And you do that. And it's a lot of what your book's about. It took 10 years to write, which is very impressive, I think, to have that much dedication, that much focus to getting it right. And telling a new narrative about how to think differently about public health is really ultimately what this is about. So I'm just thrilled to have you here.

[A]

Well, thank you so much, Mark. It's very nice of you to say. And the honest truth is I have been lucky. I've been lucky because I've had great mentors. I've been lucky because I happened to have opportunities to do jobs where I could make a big difference. And I've learned a lot. And what I realized about a decade ago is there isn't a good understanding of what public health is, why it's important, and how it could save a lot of lives, including yours. So I really struggled to get clear on both explaining what I knew and learning more, because when I got into some of this stuff, I realized, wait, I don't understand why that happens or what is the latest data show, or why don't we look at it this way? So I try to sort that out in the book.

[B]

I think it's important that we're having this conversation now, because in the earlier part of your career, when you were the Commissioner of Health for New York City, and then when you were the CDC director for eight years, we were in a period of time where there was still public trust in medicine and public health with the COVID pandemic, for a lot of reasons and various echo chambers and propaganda and, you know, the whole mismatch of kind of the culture around how to think about what was the truth or not the truth, and things we learned after we were told that weren't true. And there's so, like, there's a whole. There's a whole feeling now that there's sort of a mistrust in public health, and yet it's really important. And I don't.

[A]

I don't.

[B]

You probably, as an empty knowledge, know this guy. But when I went to the University of Audubon Medical School, one of my professors was John Last, who wrote the textbook on public health, Dictionary.

[A]

He's like, dictionary of Public Health.

[B]

He's the legend. And he was one of my early inspirations. And I did a public health expedition in Nepal when I was in medical school, looking at the public health of small rural communities up in the Himalayas. So, I mean, I went there because I wanted to go trekking, actually, but I got credits for it. But it was amazing. And how do we start to restore public trust in public health and address some of the big issues now? Because, yes, the pandemic was a big deal, but chronic illness kills far more people, and it's almost entirely preventable. And the things that we're facing now didn't exist 150 years ago. Diabetes, obesity, heart disease, they were like. It's like seeing someone with polio now, oh my God, there's this coming with polio. I was going to rush and see this case. I've never seen one. Or measles, you know, although that's increasing. But like, it's just, it's, it's. These are not necessarily inevitable conditions of being human beings and they're related to our public health. The reality is, is that we haven't really come to terms as a society with the massive impact of our epidemic of chronic disease. And whether you like it or not, or whether you believe it or not, like, at the very least, the whole MAHA movement has been like, hey, we have a problem, Houston. You know, like, what are we doing about it?

[A]

So I think, you know, to your question, what can we do to regain trust in public health? I think it's a specific question about a broader one, which is how can we get back to recognizing that even though we may disagree on a lot of things, there is something that's the common good. There are win wins in society, not just win loses. And there are things that we could do together that will help all of us. But when it comes to public health specifically, I think there are three things we've got to do. One is we have to listen better, we have to communicate better. But communication starts with listening. And listening means understanding. Yeah, people are really frustrated. They're scared. They don't know who to trust, what to trust. There's a lot of suspicion, there's a lot of lack of access to. 100 million Americans don't have a primary care doctor. That's ridiculous. $4 trillion in healthcare and we can't give this basic thing to a third of the people in this country. That's absurd. The second thing I think we have to do is to make small wins, things that make a difference that people can see in their own lives. And the third thing is stay away from mandates only require things when it's absolutely essential. Right. And I think with those three things we can step by, build back trust. But it's going to take a long time because trust gets broken in an instant and it gets put back slowly.

[B]

Yes. It's lost in buckets and it's gained in trips. Exactly. I just double click on something you said. You said one of the challenges of public health is these dictums and mandates which were a big part of COVID What's your view on what happened there in terms of the mandates around vaccines, around masks, around distancing, around lockdowns, around school closures and all the stuff that we now Recognize may have been really bad public health.

[A]

I discuss this in some detail in the book actually, though it's not mostly about COVID The fact is that take them one by one. Right. So before I was health commissioner, I worked on tuberculosis for more than a decade. First in New York City where we stopped a big outbreak, the biggest outbreak the US has ever had of multidrug resistant tuberculosis. Then in India where I supported the government to implement a program that saved millions of lives. And in tuberculosis in New York City we had a few patients, small number one, maybe 1 or 2% who just wouldn't take their medicines. And so we had to mandate them to take their medicines. And if that didn't work, we locked them up. Not in a jail, but in a hospital. We couldn't force them to take the medicines, but they had to stay until they were cured. So they eventually took their medicines and they got cured because they were a.

[B]

Harm to themselves or others.

[A]

And others. Right. So your right to swing your fist doesn't extend to my nose. And your right not to take your anti tuberculosis medications doesn't extend to coughing, untreatable, multi drug resistant into my lungs.

[B]

Right on a subway in New York City.

[A]

I think everyone can understand that. Get with the program. We did it with full concern for patient rights. We individualized the assessment. We only did it when nothing else would have worked. And it worked. We cured just about everybody who had been not cured, some of them for many years. So if that's not controversial, why is wearing a mask controversial? And let's just take them the three things that got mandated masks, closures and vaccines. Masks. You really have to look at the situation. Let's suppose you're walking into a ward of a hospital for kids with leukemia on cancer. You think it's a requirement, right to wear a mask? That's not an unreasonable thing because these.

[B]

Kids immune systems are suppressed and they're going to get sick.

[A]

If you look at East Asia, people wear masks all the time and their death rate.

[B]

No. I used to live in China. I'm like, why everyone? But it's because of the pollution.

[A]

Well, not just it even goes before that. It actually goes back to SARS 1 in the 90s and to flu where it's pretty clear that societies that use more masking have less flu. I said this in 2010 when I was CDC director. Nothing to do with COVID Covid hadn't come out yet. But you know, if we had a culture where if you're not feeling so good, you wear a mask, we'd all be healthier. When it comes to masks, at one extreme, you have the leukemia ward. Right. At the other extreme, you have outdoors, where it really doesn't make sense to mandate anyone wear a mask.

[B]

Jogger with a mask on.

[A]

Right, Right. Masks actually were a way at one point to open more of the economy faster, but they got so politicized that it was difficult. I was on a focus group where a guy said, I have cancer, I'm on treatment, but if anyone wears a mask, I don't trust anything they say. I happened to be on a flight the day the mask mandate was lifted, and the pilot got on the intercom and he said, please respect whatever mask decision the people around you have made. It was a beautiful comment. Right. Look, it's like wildfires or ozone. We like to know what our risk is. And if it's a high ozone place and you're got asthma or copd, you may want to not go out or you may want to wear a mask. Same thing for Covid. If it's raining Covid hard and you're immunosuppressed or you got a big talk next week, you want to give for a meeting or a wedding, you want to go to and you don't want to have Covid, maybe you want to wear a mask.

[B]

Sure. I mean, it's a nuance for sure decision that is based on your medical history, your conditions, who you are, what you're around. But as a mandate, you think it's a bad idea.

[A]

Closures are much more complicated. Closures? Look, when we didn't have a vaccine and hospitals were slammed and patients were dying, and we didn't have enough space in the morgue, actually, closures worked to tamp down, spread temporarily. They're not gonna. We can't hunker down forever. But that was done wrong in terms of when, where, for how long, what. And involvement of communities in that decision. And finally on vaccines, what really changed was what we understood. If you remember, when the first studies came out, it looked like they prevented spread that they were so good, you didn't get Covid, you didn't spread it to anyone. That's a vaccine where there's a case for a mandate. But then it became clear, no, actually, they mostly just protect you. So then it becomes more like a motorcycle helmet mandate. Maybe it makes sense, maybe it doesn't. Every community should decide. But clearly mandates are one of the things that, you know, both administrations got wrong. Communication is something that both administrations got wrong.

[B]

What's the communication? That was the Problem.

[A]

Well, if you go back to February 2020, Covid is just coming out. Nancy Messagne from the CDC says this could be really bad, but we need to be humble. We don't know. We may not have planned for everything, but disruption to everyday life may be severe. The Trump administration didn't like that. CDC wasn't heard from again for all of 2020. And you didn't have the, the good public health messaging, which was at the start of every sentence. We don't know everything based on what we know now. This is what we're going to do. It's likely going to change.

[B]

We treated Americans as if they were dumb and not able to understand nuance or anything like that.

[A]

And then in the Biden administration, frankly, I didn't agree with having the CDC speak from the White House because that means if you didn't vote for President Biden, you didn't believe what the CDC was saying. So you really need to separate the technical from the political. They need to be aligned, but they need to be separated. So you don't feel that that person with the white coat is doing something that a politician told them to say. So I think we've got a deep hole to dig out of in public.

[B]

Health in the vaccine. You want to touch on that? Cause I think, you know, people. That was the biggest thing for people was like, you know, my body. I'm, you know, medical free. The medical freedom movement. I'm a sovereign. How do you dare you tell me what to stick in my body here?

[A]

I say give people information, encourage them to talk to their doctor or clinician. The data is very clear that the vaccine reduces severe il boosters reduce severe illness. But it's like the flu vaccine. There were some in public health who were like, oh, my goodness, we don't have enough people vaccinated. Like, I go back long enough so that almost nobody was getting the flu vaccine. Every year, little by little, people got more confidence in it, more faith in it. They saw that it reduced. Is it perfect? No, it's, you know, compared to other vaccines, the flu vaccine is a lousy vaccine. It's safe, but it's only 30 to 60% effective. So it's not great, but it's the best protection we have against flu.

[B]

So you don't have vitamin D reduces your flu by 75%. We should have a vitamin D mandate. And same thing with COVID We didn't have. The data was there from Israel and other countries where if your level was over 50, there were no deaths.

[A]

Tricky, tricky, tricky Tricky topic, tricky topic.

[B]

Okay, well, let's go.

[A]

Well, I want to step back a little bit because what I do in the book is I talk about a formula, see, believe, create a way of systematically working to protect our own health and the health of our family and our community and in the sea. I talk about in one of the aspects of seeing the invisible, because that's the superpower of public health, seeing the invisible, seeing the pathway to progress. And part of that is really good technical rigor. And I distinguish between things that are essentially certain, things that are probable, things that are possible, and things that are theories. Now, the theories may be right, but we may not have the evidence or they may have been disproven. But I think when we give people personal health advice, we should stick with the things that have definite proof and that are a big deal for their own health. And I think there are a limited number of those things.

[B]

And low risk.

[A]

That's right. Most of them are pretty easy to do.

[B]

Vitamin D is like, is almost as low risk as you can get.

[A]

Well, it's fat soluble, so you can have too much for sure, but not.

[B]

Be careful overdosing it the right way. And yeah, you can overdose, but like, you have to take a lot.

[A]

I did actually some of the initial studies on vitamin A because there was a measles outbreak in New York City when I was an Epidemic Intelligence Service officer. And we had acute and convalescent sera and so I could get the vitamin A levels of all of the patients with measles. And I showed that when they were acutely ill, they all came down. Vitamin A is acute phase reactant that lowers, goes way down when you're sick and have fever, and then it comes back up a couple of weeks later. The studies show that, you know, some moderate benefit of treatment in kids under the age of two in the US Globally, where stewards are much more tenuous. There's a mortality benefit for treating kids with measles with vitamin A, but obviously vaccine is the most effective.

[C]

Our immune system is supposed to protect.

[B]

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[C]

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[A]

Do way to prevent it. Vitamin D is tricky because our measurement is complicated. There's certain things, Mark, I think we're gonna learn so much more in the future about lipids, about vitamin D, the way we measure it now, what we measure, what the different types show, they're really different. I mean, take lipids where I went into it in some detail when I was at cdc. We say LDL bad, HDL good.

[B]

Not so simple.

[A]

Not so simple, right. LDL is like hundreds or thousands of different typ of molecules. Same with HDL. And some HDLs are unhealthy and some LDLs are healthy. So we'll learn more, but we know enough to take certain actions.

[B]

Now, moving on from the swamp of vaccines, I kind of want to, I want to zoom out and talk about what's happening in America right now because and increasing globally, which is that we have this chronic disease epidemic that you spent a lot of time thinking about, that you wrote this book about. And this is a global book. It's not just about America. The formula for better health, how to save millions, I would say billions of lives, including your own. We haven't really taken a serious look at those interventions that are going to make the biggest difference. And there's now a movement and David Kessler is going to come on podcast this afternoon after you. Who's really taking a stand for making ultra processed food an issue that we have to face, and particularly the refined starches and sugars as the biggest driver of the chronic disease epidemic. But there's other things like obviously the sodium potassium ratios and hypertension, which is also related to some degree to insulin resistance. And small fact that for those of you who are listening, when you eat sugar, your insulin level goes up. When your insulin goes up, you retain salt or sodium, so you retain fluid, so you get high blood pressure. This is just a known medical fact. I'm not sure if you're aware of that, but it's pretty straightforward. So one of the best ways to lower blood pressure is to not only limit salt, but to limit sugar as a way to actually reduce your retention of sodium. And I've seen this over and over and over again, and it's probably the quickest, fast way to lower blood pressure. And in America is really suffering from this epidemic of metabolic disease, pre diabetes, diabetes, obesity, and that leads to heart disease, cancer, dementia, and obviously diabetes. So this is a big problem. And I'd love you to sort of summarize the things that you talk about in the book that I think we should all be aware of as Americans and as a global population of where are the big problems, where should we be pushing, and what are the policies that need to happen? Can they happen? And what do we do for ourselves?

[A]

Well, let's focus on chronic disease. And the formula for better health is See, believe, create. Three steps. See the invisible. Believe that what seems like it's going to be there forever can actually be changed and then work systematically to create a healthier future.

[B]

I love that. See, believe, create.

[A]

And for each of these, there's a personal toilet. Take it anytime there's a personal part of it and there's a societal part of it. Can I take two examples and take you through those four things? Let's take. This is your show, tobacco. And let's take sugar. All right. And we think about the societal and the personal. See the invisible. So when I became health commissioner In New York City, we had no data on how many people smoked in New York City didn't exist. So we had to start survey, rigorous, systematic, standardized survey. And came back. 22% of adults smoked.

[C]

Wow.

[A]

And it hadn't changed in a decade. So we.

[B]

This was in the 80s.

[A]

This was in. No, not 90s, actually. 2000, 2002. I became city. I became a New York City health commissioner. We didn't know. Right. And public health really is like Cassandra. Cassandra was this Greek mythological priestess who could see the future, but she was cursed. Nobody believed her predictions, so they didn't change their behavior. We can break that Cassandra curse if we see the invisible, believe we can change it and create a healthier future. So we knew that 22% of New Yorkers smoked. That was 1.2 million people at that point. That meant we Knew at least 400,000 New Yorkers were gonna die from smoking related causes. About a third of them from cancer, about a third from heart disease, and about a third from lung disease and other things. So these were 400,000 people about to go over the cliff. And the other thing we could see is what works. What works to stop smoking. Now, when I got to cdc, I found out some of the things the tobacco industry does to keep people smoking. It is amazing. And I describe it in the book.

[B]

Oh, tell us the Secrets.

[A]

It's amazing. You know, it started with the CDC tobacco lab ordered what's called a smoking machine, which actually exists, which the tobacco industry used to say how much healthier their cigarettes were. And so the first clue that there was some bad stuff happening was that the tobacco industry tried to block the sale of the tobacco smoking machine to the cdc. But the company said, hey, we want to sell it. So they sold it. First thing they found is that each cigarette had holes in the filter. Now, when you smoke a cigarette, you cover those holes. And so when you cover the holes, all the smoke comes right into your lungs. But the smoking machine didn't cover those holes. So they got all this, what's called side stream air coming in, diluting the cigarette smoke and reducing how much, they said.

[B]

But that was just kind of a rigged machine.

[A]

Rigged machine. But they figured out how to fix that. But that was just the beginning. Then they found that if you look at the amount of nicotine, there's the most nicotine at the tip of the cigarette. Why? Because after, you know how chain smokers stub out the cigarette when it's halfway smoked, that's because they need to get another hit of nicotine. But that was just the beginning. Then they realized that they were alkalinizing the tobacco because if you alkalinize with.

[B]

Urea or other things, painful to smoke.

[A]

Actually an increase, it potentiates absorption, so you absorb it faster. Then they found that they're adding sugars because that increases binding to the lung receptors. And things like menthol not only make it smoother, but they may increase actually the number of nicotine receptors in the brain.

[B]

And they were studying this. So they studied this. This isn't like, oh, oops, we. We sit in the brain.

[A]

No, no, this is all in there.

[B]

It's all by design.

[A]

All by design. So with this design, a single puff of a cigarette will deliver more free nicotine or crack nicotine to your brain than an injection, an intravenous injection of nicotine. So, you know, these are invisible things that are changing how people behave. And the more you see them, the more you can do something about them. The path to progress is another thing we can see and what the path to progress was. Tax cigarettes. It's the single most effective thing you can do to help people quit smoking. Most people want to quit it. And price is really important. And there's a actually.

[B]

But a pack used to be like a dollar. Now it's $10, right? So like, that's. It's not like a little tax. It's a big tax.

[A]

And the bigger the tax, the bigger the impact. And the impact we saw because we had this survey now we taxed cigarettes another buck 42 a pack in the next year. Big reduction in smoking after 10 years of no reduction, a significant reduction. What's the next effective thing you can do? Next most effective thing you can do is go smoke free in all your restaurants and bars. We did that. It was a massive political fight. Y in the next year, came way down again.

[B]

And just to give you some kudos, just so you understand, now, you can't smoke on a plane, you can't smoke in a restaurant, you can't smoke in a hotel. That was you?

[A]

Well, some of that was me. It was really advocates doing this all over the country, all over the world.

[B]

But take a little credit.

[A]

Wouldn't have happened without Mike Bloomberg, to be frank. He went to the mat on this. The next year, I thought, you know, okay, we started that downward trend. It'll continue. But because we could see the invisible, because we had a tracking system in place, we found out that actually the decrease had stalled. And it was scary. Here it was, you know, I'd come back from India to take this job, I'd taken on tobacco. It was the highest priority and we were failing. So I looked at the data and the next most effective thing you can do is run hard hitting ads. So. All right, I'm not sure that'll work. It's expensive. $10 million to do that. You could run a bunch of clinics for that, hire a bunch of staff. We did it. We had the data. Big further reduction, especially in the groups we targeted most with the ad.

[B]

Yeah, I mean, the limp cigarette in the Marlboro Man's mouth, that really worked, you know?

[A]

You know, it's interesting what works. It's very interesting because we studied it. We studied it. What works is showing disability and disfigurement. If you tell people you're gonna die, like everyone's gonna die.

[B]

Show your black lungs. Yul Brenner and his black lungs.

[A]

And if you can. If, but, but. And when I was at cdc, we did the tips from former smokers campaign. And I got to know Terry, a wonderful woman from North Carolina. She had been a cheerleader in high school. She had worked on a tobacco farm. She had started smoking two packs of cigarettes a day. She was funny, she was vivacious. And she got cancer at a young age in her 40s. She ended up getting surgery, chemotherapy, tracheotomy. And we had these tips from former smokers. And, you know, she was so effective. She helped more smokers quit, saved more lives than most doctors ever will. But on the tobacco side, yeah, individuals may blame themselves, oh, why can't I quit? But that's happening.

[B]

Because advertising, marketing, not easy, right? So you did the, the restricting where you can smoke and you did taxes and you did hard hitting ads. Hard hitting ads.

[A]

And we did cessation where we helped people quit with nicotine patches.

[B]

But was that, was that what created the most Delta? Or was it the fact that it wasn't regulation, it wasn't legislation, it was litigation that finally brought tobacco to its knees and to a class action shoot. And this was, I think, under David Kessler actually got the litigation did a lot.

[A]

So litigation revealed the discovery, the discovery, these sleazy tactics of the industry, the lies. And that opened the door and made it easier to do things like tax cigarettes and go smoke free. So there is an interplay between.

[B]

But you know, and most people listening know that in the 70s, a lot of these big tobacco companies saw the decline of smoking and they started buying the food companies. Rgr, Nabisco, you know, you know, what was it? Crafts, Reynolds, Kraft or something? It was Like Philip Morris, Kraft. It was like there were these big tobacco companies started buying these companies. And I don't know whether it's intentionally or not. And Michael Moss talks about his book Salt Sugar Burn Fat, how the food industry scientists created, you know, tasting labs where they hired craving experts to find the bliss point of food to create literally heavy users, quote, unquote, all their own language, internal language in the industry. And so it almost seems the same way that they were deliberately designing food to keep us biologically addicted. And the scary data is that 14% of adults and 14% of children are biologically addicted to food, which is actually more with people than are addicted to alcohol. Alcohol is 14% of adults, but not kids. So this is a big problem. And then many other people fall in the kind of semi addicted, craving, can't stop eating sugar carb kind of category because of how it affects the brain. So the question I have for you is you were about to sort of talk about sugar. This is even a bigger problem because people can stop smoking, but they can't stop eating. And yet 60% of the food we're eating is ultra processed food. Probably 75% of that is sugar and starch and other weird derivatives of sugar and starch that David Kessler points out in his petition to the FDA on defining ultra processed food. And how do we navigate that? Because, you know, you've got, you know, the hunger group saying, oh, it's regressive and dangerous to restrict access to this to the poor. We're just providing convenience, safe food. We're going to damage the food supply. You're going to make people be unable to afford good food. This is, this is a huge service to America, blah, blah, blah, and there and that. It's, you know, you basically your fault if you're overweight. Everything in moderation. It's all about calories in, calories out. And not all calories are created equal. They have different effects on your hormones, your brain chemistry, your metabolism. And so how do we navigate this? Because to me, this is their biggest global crisis right now. And the Global Burden of Disease study showed clearly that 195 countries, food was the biggest killer. More than smoking, more than more than anything else. So, you know, you've tackled these big problems. You've been inside government, you've won some big wins. We now have an administration that seems alert to this, and people in the administration seem talking about it. Are they going about it the right way? What do we need to be doing? Because I don't think this is an individual problem. You know, yes, as a one on one doctor, I can coach my patients and I can help them understand what's going on and I can put them in a group and have group support and I can move the needle in a couple of people. But on a public health level, this is just getting worse and worse.

[A]

So I think you're absolutely right.

[B]

When you and I graduated medical school, there was not a single state with an obesity rate over 20%. Now there's not one under 30 and most are 40 something.

[A]

Well, my father was a cardiologist and I shadowed him in his practice for a month. And he was a wonderful physician. And you know, there was essentially no obesity. It's very rare. And I'll talk about that a little bit. But I want to. Just as we transition from tobacco to nutrition, not only has industry that's gotten rich off of making people sick learned from tobacco and applied it to food, but we in society, in public health and medicine, as individuals, we need to learn those lessons also. What worked to reduce tobacco, now we have to say the tobacco epidemic is not over. It still kills more Americans than any other preventable cause. Half a million a year. There's still a lot of people smoking. It's come way down. But the war isn't over on tobacco. But we've learned a lot.

[B]

But food kills more. Right?

[A]

Well, let's go into nutrition. I got asked, actually it was by one of my kids, I got asked when he was about four or five years old, he said, daddy, which is worser, sugar or salt? And you know, it's a hard question, but after a couple of decades of thinking about it, it's salt. Salt is worse. Salt kills more people than sugar. Now they're both bad. There's no reason to fight, you know, this, that. But let's start with salt because this is an area where we can make a really big difference. But half a century of urging people to eat less salt has done nothing. Nothing, in fact globally, because it's in every processed food.

[B]

You can't eat anything without it. When you go to a restaurant, you buy something in the grocery store.

[A]

Astonishingly high. Astonishingly high.

[B]

It's not the salt you add at your dinner table.

[A]

That's right. That's right.

[B]

It's the salt added by corporations.

[A]

And it's almost impossible. It's not impossible. It's very, very difficult for an individual.

[B]

To reduce their salt level unless they stop eating ultra processed food. That will help or don't eat out at fast food restaurants.

[A]

But you know, how practical are some of the things that we're recommending for people? Like Jim Salas said to me when I was health commissioner, he said something maybe big impact. I was trying to increase physical activity and I didn't know how in the population. And he said, you'll never get more than 5% of people going to a gym regularly. I thought, oh, that's a really good point. Right. So if we want to affect society as a whole, we have to think about scalable intervention. And I talk about how to, how to get scale in the book. But when we look globally at policies that have worked to reduce sodium, they're really only two. One of them is to promote potassium enriched low sodium salts. And this is a great life hack. This is probably, you know, one of the best life hacks you can have. You can just change the brand of salt you use at home and you can reduce your risk of a heart attack, stroke or early diabetes. But that's only home cooked food.

[B]

That's only eating everything that Americans is like a factory.

[A]

Hey, you know, we don't have to solve all problems to solve some problem. So it's something, right? It's something you can do. In terms of public policy, the policies that we saw coming out of Latin America, Chile, Argentina, Mexico, Colombia, where they put a black stop sign that says too much salt, too much sugar, too much fat, you can debate the fat or too many calories, these make dramatic changes because they improve both the options and the choices. The companies don't want a black mark on their food, so they reformulate really quick. Like 30, 40, 50% of foods after saying we couldn't possibly reformulate the day after it becomes required. Oh, we reformulated. And the second thing is it changes the choices that people make. And you can tie that policy to things like, hey, if it's got a mark, you can't advertise it on tv, you can't sell it in public places. We're going to tax it. So the public policy approach, like with tobacco taxation, smoke free places the equivalent in food restricting advertising.

[B]

Like there's no tobacco ads in magazines or television, right.

[A]

Or you know, you can't have tobacco on public property. Why can you have junk food on public property? So I think on sodium it's really difficult as individuals. But for those who are really health conscious, you could do things like just for once count the sodium and potassium that you consume in a 24 hour period. Because the strongest predictor of heart health is consuming more potassium than sodium. We mostly consume about three times More sodium than potassium. But if we cut way back on sodium and you get used to it, you know, I've cut sodium out of my diet. I eat hardly any salt and food that comes in the restaurant. Salty. I can't eat it. It tastes like brine. You know, I mean, who wants to eat that?

[B]

Yeah, like, yeah, you know, it's interesting you say this, but, you know, cause I looked at some of the Leo Cordain and other works on the Paleolithic diets and Melva Kanner and you know, they published in New England Journal. It was really fascinating to read that work. And one of the key highlights of was that the sodium potassium ratio has flipped since our hunter gatherer days. 10 to 1 potassium to sodium. And it's now almost the opposite in terms of 10 to 1 sodium to potassium. And potassium comes from eating vegetables and fruit. And so you can make a potassium soup. I have a whole recipe in my book called the Ultra Broth which essentially is you throw in a lot of root vegetables, show a lot of onion, you throw just a bunch of veggies in there and you cook it down and drink the broth and it's just, just full of potassium. And I think, you know that that's really the other benefit. It's not just absolutely eating low sodium, it's actually increasing your potassium intake, you know, and that's why fruits and vegetables are part of the DASH diet and all this, because they have more potassium and they work.

[A]

So the, the inter salt study that was done by Jerry Stamler and his colleagues and, and Jerry and my father did research together on sodium in the 1950s.

[B]

Oh wow.

[A]

So he just passed away at 103. He was very active, still writing articles at 103.

[B]

I'm counting on that. I'm counting on that. You and me, Tom.

[A]

Let's hope. Now what they studied in Intersalt was 32 communities in 28 countries. And they identified four communities that were basically pre industrial communities and they had no age related increase in blood pressure. They were 90 over 60 at age 16 and 90 over 60 at age 60. And yeah, there were other things, but the amount of sodium they consumed was about a tenth what we consume. And they didn't have any symptoms of low sodium. We really have so much sodium in our diets and it's so unhealthy. The more we can replace it. And again, it's going to be the public policies that make a difference telling people to eat healthier. You know, we have 50 years of failure doing that. Now there Are things that are important. One of the things I go into.

[B]

The public health thing with the salt, though, like what, what are we talking about?

[A]

Those labels promote low sodium potassium enriched salt, not just at home, but in industrial food and restaurant food as well.

[B]

What we hear limited. Can you regulate to limit it on ultra processed food or in restaurants, say you can't have more than 2,500 grams of sodium in like 1 tablespoon.

[A]

What the Latin America model is that works very well is if it's above this level, it gets a warning label and then that encourages reformulation. You can also set maximums, you can track things, but it's hard to reduce sodium as individuals and as a society. And it means taking on industry. Like they make money. Look, salt is really cheap. And salt in cardboard taste good. Yes, exactly. And if you put it in your chicken, you know, a lot of the chicken you buy in the store.

[B]

Oh my God.

[A]

Is in brine. And guess what? That is that salt and water. And you're selling it by waste weight.

[B]

Yeah.

[A]

So what am I selling? I'm buying salt water for, you know, a couple bucks a pound.

[B]

Yeah, well, that's my point about the sugar, because when you increase insulin, you increase sodium retention and that causes fluid retention and that increases your blood pressure. Like, I'm 65, my blood pressure is 105 or 110 over 70, and I eat tons of salt. Like, I don't eat processed food. I don't. I go out to restaurants sometimes, but like, I'm very careful. But, you know, I don't worry about how much salt I add in the food I'm cooking at home. Right. It's just, it's not an issue because the rest of my salt intake is so low.

[A]

Well, I think for what I find with people that I counsel on nutrition is rather than deny yourself stuff you love, find stuff that's healthy and eat more of it. Right. So like high potassium food. Sweet potatoes, salmon, tomatoes, mushrooms. I mean, this is stuff that tastes good. Avocados, bananas, yogurt, pistachios, like my diet.

[B]

Right.

[A]

So like, instead of deny yourself stuff, then find stuff that's healthy that you like to do. Same for physical activity. Now you want to talk sugar before.

[B]

We do that salt thing is important. And I think it's going to relate to the sugar conversation too. Because what, you know, people may not really hear that you said is that in South America, across the board, in most countries there, they've had had radical, sweeping policy changes that have been studied that have profound impact and you worked with Bloomberg and Johns Hopkins and helping with some of their public health stuff. And they've been very involved in these policies in South America. And there were a number of things that were collectively done that are incredibly hard to do here. And I'd love to hear your opinion about how that would get done. Soda tax of 18%, restricting food marketing to kids between 6 and 10pm Getting all the crap out of schools, having no infant formula advertising, having these warning labels on the front of the packages that have the stop signs with black. This is going to kill you. Basically, these are all policies that work and they've been demonstrated work. And in this country, trying to change food labeling, trying to restrict food advertising, trying to do any of these things is almost impossible because you've got the First Amendment, you've got the industry lobby that's bigger than almost any other lobby in the food and ag industry lobby. How do you think about this here? Because globally, it seems like people are catching on, especially because those countries are putting the bill a lot for the healthcare.

[A]

Well, my organization resolved to Save Lives works on nutrition issues around the world. We have supported more than 50 countries to ban artificial trans fat that will, as you said, protect 4 billion people, prevent 9 million deaths from heart attacks. And the other nutritional measures that will reduce heart attacks are reducing sodium and improving the healthfulness of foods. It always involves taking on industry because there are very powerful economic interests. And I talk about in the book how, how you do that, right? You can't just wring your hands and say, oh, we don't have the political will. That's sloppy thinking. Who are the winners? Who are the losers? Who are the deciders? Who are the influencers? Who are the advocates and champions? What are the partnerships that's gonna work? Look, Coke and Pepsi hate each other, right? But they work together to block tobacco taxes and reform in health policy. So we can work with groups that we may not agree with on everything, but we agree with on some things.

[B]

The American Beverage association, they both belong to, that used to be called the American Soda Pop Association.

[A]

It's terrible thinking about, you know, what can be done when at the local level, at the state level, at the national level, where there's a window of opportunity. Soda taxes are a really important example. Like soda taxes work. And I use it as a case study in the book because we tried them in New York City and New York State and we got shot down. I had written an article in 2009, Ounces of Prevention, proposing a penny an ounce tax. And for A while President Obama thought about it and his budget director thought about it and then the industry came down like a ton of bricks and you never heard about it again. But since that time, the Bloomberg foundation has supported cities all over the US and countries all over the world to implement soda taxes. We found a beverage association publication that said soda taxes were the biggest threat to their industry that ever occurred. And they are because they really reduce consumption. And one of the aspects of the formula for better health is believing we can make progress. And part of that believing is showing that what, what is existing now is not normal. Like the amount of soda people consume now is nothing like what people consumed when we grew up. It's become as cheap or cheaper than water and consumed in huge quantities. When I was at cdc we used the best study there is, NHANES to see.

[B]

That's the National Health and Nutrition Examination Survey. It's done by the government regularly on tens of thousands of people. Look at all their health issues and biomarkers and it's really rigorous.

[A]

It's really rigorous. And what that shows was that we actually hadn't reduced our physical activity that much in the US in the last couple decades. But we've increased our calorie consumption by about 300 calories per person per day. And about half of that is from.

[B]

Soda and the other probably have is ultra processed food. You know, we have 500 more calories of food on the market than we did in the 70s because of the increase in corn production and the way in crops subsidies and supports change from the FDR policies under Earl Butts to the, the policies under Nixon that made it, you know, incentivized to grow as much food as you can and get paid for it even if it goes to waste or it's, you know, used to make us eat more. So I think, you know, the, the, the, the thing you mentioned for example about the soda tax in New York and I'm sure you're aware of this, but the NAACP and the Hispanic Federation were funded by Coca Cola and Pepsi to actually, I know, oppose those taxes. So you've got people who are the most effective. These populations that are underserved, that are genetically susceptible, that are suffering disproportionate rates of diabetes and obesity and kidney failure and the list goes on. They're the ones who are the victims of this and they're co opted this is the dirty tactics that they use. You mentioned astroturfing. There's co opting of professional societies. I mean the American Heart association got mad at me because I said they get $192 million from industry, which they do, and a big portion of that is from the food industry. And they're like, oh, well. And they like defend them, like, look, you're taking money from these guys. And so you've got, you know, front groups like the American Council on Science and Health that confuse everybody was saying pesticides, trans fats and, you know, sugar and high fructose corn syrup are all healthy for you. You know, tobacco's great. Right? And you've got, and you've got science being funded by industry 12 times the rate as regulars, nutrition science by the government. And so you've got all these areas that are, that are almost circling the wagons and it's not like subtle. You mentioned soda taxes. Yeah, they work. And you're right, they're a threat. And that's why in California, when the soda tax craze was going on in Berkeley started and then every little town started doing soda taxes, the industry got together and they, they basically put a ballot petition which had nothing to do with anything, saying if, if you want to pass any state or local law, you need a 2/3 majority, which is insane. And so that would have frozen the entire government of California. And they went to Governor Gerry Brown, otherwise known as Governor Moonbeam, the most left probably governor in history, and said if you don't put a semi permanent lockdown on any further soda taxes, we're going to pass this ballot and you're screwed. Like that's what they're doing. And how do you fight that?

[A]

I think we learn from the past. And this is the essence of the formula. See the invisible, including the reasons we don't change. Why does the Cassandra curse exist? See the path.

[B]

The curse is what?

[A]

The Cassandra curse. Cassandra could see the future, but she was cursed. No one believed the tragedies that would happen. And so they didn't change their behavior and they didn't prevent those tragedies. So the Cassandra curse is something that we may know that our smoking is going to kill us, but we don't stop. We may know that eating something unhealthy is going to kill us, but we're going to eat it anyway. Why does that occur? And it has to do with our perceptions, our perceptions of ourselves, our world, our future. And there are ways to counteract them that. But then see what really works. Like there's a lot of stuff that's performative, like high, I'm sorry, but high fructose corn syrup versus regular sugar. Right. It's almost a wash. Calories, right? I can't tell you whether one tastes better or not. That's not my area of expertise. But nutritionally this is performative nonsense.

[B]

I mean there, there are subtle differences in terms of free fructose and its.

[A]

Effect on it and liver disease potential. There are some things that are maybes, but like compare that with soda tax or front to pack warnings to empower consumers to know what's healthy and what's not at the glance. There's no comparison.

[B]

That's what I said. I got interviewed on a show, I think News Nation about the Coke switch to sugar, making it more available here. And I'm like, well to quote Sarah Palin, you put lipstick on a pig, it's still a pig. So you put sugar in a Coke, it's still well placed. It.

[C]

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[A]

To make progress. This is, you know, public health is never easy. One of the I'll get a little technical here. One of the drivers of the Cassandra crash, one of the reasons we don't take action on things that might kill us is a public health concept from Jeffrey Rose called the Prevention Paradox. And what the prevention Paradox says is basically harm or benefit that's a little bit for a lot of people will cause more good or more harm than harm or benefit to a small number. That's a very technical way of saying basically things that do a little bit of good for a lot of people will do much more good than things that do a lot of good for a few People. And yet when we pass regulations, laws, due policies or programs, the losers in that, the tobacco industry, the food industry, that's a very concentrated loss. That's a few groups. They're organized, they're powerful. The people who benefit don't know they're going to benefit. That's a very diffuse benefit. And so the prevention principle, the prevention paradox, tells us that the biggest changes come from the smallest changes. And there's a political corollary of that, which is that there's going to be a systematic opposition that's very powerful to public health action. So how do you get around it? You first analyze who are the winners, who are the losers, and you figure out, okay, who's going to win from them. Well, insurers would win if we have less obesity. Employers would win if we have less obesity and map it out and who's going to win?

[B]

Would insurers win because they make more money by increasing their premiums? They just keep going up and up and up and they don't really care because the more sick you are, the more they can raise the premiums, the more money they make and they get a percent that's fixed. It seems like a rigged game.

[A]

Well, life insurers do better.

[B]

Yeah, life insurers for sure. And that's why John Hancock, by the way, has got their Vitality program, why they're actually giving function. My company's a preventive health data platform, services of lab testing for proactive preventive care to their members.

[A]

It's interesting, there was a long term partnership between MetLife and the new York City Health Department to promote health. But, but you also think about who are the deciders, who are the influencers. And sometimes someone comes in with a commitment to do something and it becomes possible. You think about pragmatism and timing, like what can be gotten through when at what level. Maybe we can't get soda taxes through at the state level, but we can get them through in some cities. Maybe Philadelphia did it, but the first.

[B]

Time they tried coke, gave $10 million, $10 to the children's hospital and they buckled and they backed down.

[A]

And you know, one of the reasons, another driver of the Cassandra curve, I get all like, no, no, I'm gonna. It's fun. It allows me to get a little wonky here. But another, another driver of the Cassandra curse is something called hyperbolic discounting, which means we shortchange the future. And we will. If something's gonna happen to me tomorrow, I'll take action to avoid it. If it's Gonna happen in a year or 10 years. I'm not gonna avoid it. I use this for my scheduling mark. I decide when I get an invitation, and it's six months. I used to go to these things. Why did I agree to do this? And then I learned I'm not the.

[B]

Only one who feels that way.

[A]

So here's. Here's the hack. Here's the hack.

[B]

I have nothing on my calendar in six months. Sure, why not?

[A]

Here's the hack. When I learned about hyperbolic discounting, I said, all right, I'm going to pretend it's tomorrow. Would I want to do it tomorrow? If I say no, I don't accept the invitation.

[B]

That might be the biggest benefit I've ever gotten from having someone on my podcast. Because my wife always talks about future forecasting. I'm like, what's my future self going to want on that day? And I'm like, eh? And she's like, no, you're not going to want to do that. I promise you.

[A]

So the same is true for health, if we can imagine the future. And the reason I bring it up with Philadelphia is the way to counteract hyperbolic discounting that short changing the future is to give yourself short term benefits. And what Philadelphia said is, hey, we're going to use this soda tax to fund pre K. Yeah. Childcare. And then you have an immediate benefit as well as long term benefits. So there are ways to counteract the Cassandra cares. And you have to look for those moments of opportunity where you can make progress. Advocates can make a huge difference in these things. You know, never doubt that advocates can make a huge difference in whether it's tobacco or food policy.

[B]

Well, that's Margaret Mead. Right? Never doubt that a small group of committed people can change the world. In fact, fact, it's the only thing that ever has.

[A]

So.

[B]

And you're one of those.

[A]

It's nice of you to say, but, you know, I've learned from great advocates. And I tell a story in the book about Matt Myers. He's a very effective tobacco control advocate. At one point, the state of Vermont was debating whether or not to go smoke free. And there was one vote in the assembly that would determine whether they succeeded. And so Matt went to the assemblyman, they said, assemblyman, here are two ads. The first one thanks you for protecting Vermont's children. The second holds you responsible for the cancer and heart disease and suffering and death of Vermont's children. One of these is definitely running tomorrow. You get to choose which one by how you vote today.

[B]

That sounds like the Godfather, I made him an offer he can't refuse. Right. I mean, those tactics can work. But you know, what's interesting to me is I've been and like as you have been pounding this drum for decades and first went to the White House in 2005 and started to try to advocate in these ways and in 2009 was very involved in trying to change policies around the Affordable Care act for prevention and health and food is medicine. And you know, it's been such a slow process. And for us, you know, we've been doing this a long time, but there seems like to be this interesting moment now where it's not like invisible anymore. And you talk about making the invisible visible, the cultural movement around. I think what happened with COVID medical freedom and that translating to make America healthy again, right or wrong, is a moment of awakening. And so the question I want to point to you and you pointed a lot of things that need to be done, like sodium potassium ratios, reducing ultra processed food, smoking, you know, other simple public health measures. If you were king right now, President Trump, the Supreme Court and Congress said you have a magic wand. What could be realistically done over the next eight years to dramatically impact this chronic disease epidemic that's killing most of Americans, that 6 out of 10 people have a chronic illness, that 93% are metabolically unhealthy on their way to diabetes, that, you know, cancer rates are going up, autoimmune rates are going up, mental health crisis is increasing. You know, we're just in a spiral, like a death spiral. So if you were king really and had that magic wand because you've been in doing this for so long, I would love to hear your insights about how to navigate this, because there's a lot of people in Washington trying to do good. But Bernard Lowen once said, the well meaning are often ill doing, the well meaning are often ill doing. So we don't want ill doing, we want the well meaning to do good. Right.

[A]

My father and Bernie Lam were friends.

[B]

So it's always nice to hear him, knew him. I was actually part of the International Physicians for the French Nuclear War group back in the 80s when he was Evgeny Chazoff, won the Nobel Prize with the organization. So I don't know if I can say I won the Nobel Prize because I was a member, but the organization won the prize. I don't put it on my resume.

[A]

I think you have to start with what are the things that we can do with public policy? What are the things that we can do on the clinical front and what are the things that individuals have to do. So if you really had the levers of power, you would take strong action on tobacco, alcohol because these are proven killers and we have proven means to prevent them. That we're not implementing taxation restrictions on sales and marketing some of the liability laws on alcohol. So these are really big and they're underappreciated as continuing sources of illness and death. On the nutrition front, the two most well studied, best proven high impact policies would be tax soda and potentially other sugary foods and implement a kind of front of pack warning system. That's clear. And you know, it's interesting we've studied this. There are various systems like NutraScore, ABC traffic lights. They don't work. Work. They don't work. The only thing that actually substantially reduces consumption is this black stop sign. Because people spend at most six seconds making a decision of what to buy in the supermarket and it's just gotta say yes or no. I don't know what a traffic light means. Maybe red is good. I should stop there and like it.

[B]

Right. You have something called the keep it simple. It's my mother said keep it simple. Stupid. The kiss method. Absolutely, yeah. Black warning stop sign. Don't eat this.

[A]

Chapter six. Simplicity. Simplicity is the ultimate sophistication. Leonardo da Vinci. You have to keep it simple. So on nutrition policy you would absolutely tax sugar. You'd absolutely put in a front of pack warning. But I do want to talk about healthcare because sometimes I think before we jump on that.

[B]

So front of PAC labeling is now under review at the FDA and the Biden administration put forth a rule which I thought was kind of lame that basically put a front of package label for sodium, saturated fat and sugar and basically rated them high, medium, low. I don't think that was very helpful and very confusing. And you know, nutrition fact labels are just, you need a PhD to understand them anyway. I know, I mean they would advance from nothing. But it was. They're not really what we should have. Is there a pathway to do that legally that we have with our current laws around freedom of speech and you know, the Supreme Court and all the ways, all the ways that the industry is going to fight pac.

[A]

It's going to be tough.

[B]

It's David and Goliath here. Where's the stone in the fire?

[A]

It's going to be tough. It's touch and go of whether you could get through the Supreme Court a mandate to put even factual stuff on the front of pack. So you'd rather say Too much salt or excess sodium, excess sugar. But because high, medium, low will confuse people. Like maybe high is good, right? Oh, good. We studied this when it came to calorie labeling on menu boards. A lot of college here is like, oh, more calories. I want that.

[B]

Yeah, exactly right.

[A]

What's politically and legally possible in this country is a challenge because this idea that corporations are people and they have free speech rights and you can't make them say things that they don't want to say, even if it's the truth, truth that's challenged.

[B]

So repeal Citizens United is what we gotta do.

[A]

Well, I don't get into politics, I'm a doctor. But I do wanna talk about healthcare because I think sometimes what I hear coming out of some of the folks is it's either or. And we can walk and chew gum at the same time, right? We can prevent a lot of disease and treat as well. And we can walk and chew gum. We can prevent illness and disease and also treat. And I think it's a false dichotomy to say, oh, we're over medicalizing. I do agree that there are some things like ADD meds where there's too much use, but there's underuse of medicines for conditions that are asymptomatic, like high blood pressure, high blood pressure, high lipids, hepatitis C infection, you know, things that you don't feel, things that are invisible that might kill you. And when it comes to blood pressure, the data is really strong. Lower is better. Down to 120 over 80. Reduce your risk of dementia, not only heart attack, stroke, early death, kidney failure, but also your cognitive functioning even lower.

[B]

Like, I mean, he was. Where's the lower limit?

[A]

Like 115, 115, 115. The elegant studies that, that the group in Oxford has done all around the world, starting at 115 over 75, your risk of a heart attack, stroke, stroke or death doubles with every 20 point increase.

[B]

It's a continuum. And I think people don't realize that it's not like 140 over 90 and it was like, oh, 120 over 80. But no, it's like 110 over probably 115 over 70 something.

[A]

So if you were going to remake our health context and health system, you'd not only do the prevention stuff, you'd give people a primary care doctor, you'd change the way we fund healthcare. So it's more like Kaiser Permanente where the payer and the provider have the same interest of keeping you healthy. Right now they have different interests you know, most doctors in America, they want, want their patients to have their blood pressure controlled. But we don't even get that right half the time because it doesn't pay. And if you don't control the blood pressure, heart attack and stroke, that pays. Now, no doctor wants their patient to have a heart attack or stroke, not one. But that's the way our system is structured. So that's what happened.

[B]

Were you New York commissioner when they did the whole diabetes initiative? And they basically identified there were 800,000 diabetics in New York and they put in a whole nutrition curriculum and they got people free nutrition consults and lifestyle change programs. And it was dramatically effective. But the program had to be shut down because the hospitals were freaking out because they were getting $200 for a nutrition consult and not $6,000 for a toe amputation. And this was a whole series in the New York Times that sort of outlined this. Maybe it wasn't during your tenure, but.

[A]

I was like, oh, I had a much less successful diabetes effort. I oversaw the public hospitals and focused on diabetes as the chair of quality assurance there. We made HBA1C mandatorily reportable. We tracked all A1Cs over nine. We reached out to all doctors and all patients with a 1Cs over nine. And we made zero progress. And what I learned about diabetes after years of failure was diabetes is not a sugar disease, as you know perfectly well. It's a metabolic disease. And if you got diabetes, the thing that's going to kill you first is your blood pressure. The thing that is easiest to correct is your lipids. And the thing that's gonna do you the least good and be hardest to control is your sugar. Doesn't mean we shouldn't try. But if you think of comprehensive care of someone with diabetes, get their blood pressure down below 130, maybe even lower, get them on statins, maybe other lipid lowering drugs, increase physical activity because physical activity is the closest thing to a wonder drug. And then do your best to control their sugar, cause that will make a difference. But the health gain of sugar control in a person with diabetes is way less than the health gain of blood pressure control or lipid control. Don't get me wrong, I want to do everything to have the sugar control.

[B]

It's interesting you're saying that because I try to remember the name of this study, but there was a series of studies that were published maybe a decade or so ago where they looked at really aggressive interventions. Lowering blood sugar, sugar, lowering blood pressure, lowering lipids, and the more Aggressive they were, the worse the outcomes were.

[A]

But that was the sugar driving that.

[B]

It wasn't just the ACCORD study.

[A]

The sugar was driving that. And this is the challenge now we.

[B]

Have some better meds because my theory was that they weren't actually dealing with the fundamental metabolic disease and that they were just masking the symptoms and that underneath it, inflammation was still raging. And yes, you can get lipids to come down and you can get blood pressure come down, but if you've got this visceral fat that's spewing out cytokines and inflammation, you're still going to catch.

[A]

There's probably, there's probably some truth to that, but it's also the case that just leave the sugar aside. The benefit from blood pressure control and lipid control and now the SGLT2 inhibitors, the floans are, is really big. There's a big mortality benefit and morbidity benefit from that. Sugar is much more complicated. Once you get past metformin, what else you do to reduce sugar? You know, the SGLT2s do a little bit of sugar reduction, not a whole lot. But I, I really think we, we get diabetes wrong. It is not a sugar disease and we need to treat the whole patient. And that means, you know, another part of the book is burden times amenability, right? How big is the problem and how amenable it is. The highest burden is your blood pressure and the most amenable is your lipids. So get those two things in really good control. And then absolutely, I talk in the book about the six keys to healthier living and it's blood pressure, lipids, physical activity, getting enough sleep, avoiding toxins, and of course, healthy nutrition.

[B]

Those are fundamental and the things that some we have control over. But you talk about air pollution and lead in the book and you know, we're increasingly seeing, you know, the harms of particulate air pollution from industry that is affecting us across the spectrum of disease, from heart disease to cancer to metabolic health. And we're also seeing, despite the fact that we remove lead from paint and from gasoline, which was great, that there's still a huge lead burden. And I see this clinically in my practice. Like I have a patient I'm treating now who, I mean, I have often an affluence clientele and they are drinking out of crystal glasses and crystal wine glasses. And I once went into this shop in town to buy some wine glasses and they were like, well, there's a $5 ones and there's a $50 one. So I'm like, why is this $50? They said, oh, it's Rydell crystal. I'm like, well, what does that mean? He says, well, it has lead in it, makes the wine taste better. I'm like, what? And so all these people eating off these fancy glazed plates and crystal this. And it's stunning how, how, what a burn there is.

[A]

There are a lot of toxins in the world. My group, Resolved to Save Lives, is beginning work to address the global problem of lead poisoning. And it's massive. It's not subtle, it is massive. And it's still. We burn coal, cosmetics, it's in pollution, it's in all sorts of stuff. And we think that Resolved to Save Lives can support governments to implement programs that will prevent literally millions of deaths and lots of people from being terribly lead poisoned. You know, just to talk about lead for a minute, because it's in the book. Alice Hamilton was the first female professor at Harvard University. She created the field of occupational health in the us Worker health. And she was really, really effective at working with factories and getting the lead out so workers wouldn't get poisoned. And in 1924, there was an industrial accident in New Jersey, and more than 40 workers were made severely ill or killed by a lead poisoning incident, an acute poisoning incident. And then there were hearings about is it a good idea or not to put lead in gasoline? And Alice Hamilton said, I am not one of those who believe that this leaded gasoline can ever be made safe. Sure, you can control the factory, but how are you going to control the whole community and country? And just imagine, this was a Cassandra Warning. Cassandra, 1925, exactly 100 years ago. And Cassandra could see the future, but she was cursed. Nobody listened to her. So just imagine, just put yourself for a minute, close your eyes, put yourself in a world where in 1925, we had listened, we had said to industry, no, you can't do that. Generations of Americans would have grown up with less heart attacks, less high blood pressure, less violence, smarter, making more, more creative, more harmonious, lower healthcare costs, less adhd. In the lead Free America that listened to Alice Hamilton, it's a more harmonious, productive, creative society. In our world, we have massive amounts of avoidable suffering, illness, disability and death. When we were growing up, the average level of lead was 15.

[B]

I know. In people's blood.

[A]

In people's blood, yeah. So now one in 3,000.

[B]

Just because now I know what that means. 40 used to be the cutoff, then it was 20, now it's 10. And there's papers that show that even.

[A]

Down to three and a half. Down to three and a half.

[B]

Even down to one, you're seeing clinical effects on cognitive function in kids. Even down to one.

[A]

This is exactly.

[B]

And 39% of Americans have a level of over two.

[A]

This is exactly what the prevention paradox shows, that these few people who had really high levels, like we had a terrible incident in Nigeria with seizures. 400 kids died from acute lead poisoning. That's dramatic. But the bigger harm is lots of people having a low level of toxicity and it's gonna take public action to get rid of that and at resolve to save lives. We're really engaged in trying to do this globally. Cause you can talk about it it, but we like to support societies to do something about it.

[B]

Yeah. I mean, this issue of toxins is again, one of those invisible threats. Right. And it's also, again, a big industrial issue because we live in an industrialized world and we can't switch that off because we're all benefiting from it. And yet it's impacting our health. So from a public health perspective, you know, you've now, you know, you've got on the one hand, Bobby Kennedy talking about, I mean, he was an environmental lawyer. He's the one who got the Hudson river cleaned up from the PCBs that Gee dumped in there and got them to pay over a billion dollars in reparations to fix it. He's been fighting these fights for a long time on the environmental front, but now he's on the focus on the food and health issues. But the EPA doesn't want to hear about the environmental issues. They don't want to hear about glyphosate. They don't want to hear about atrazine. I mean, Senator Grassley and a whole cohort of senators and congressmen wrote a letter to the MAHA commission saying, hey, guys, pesticides are safe. Like, don't make a big deal about this. It's all hippie propaganda. Like, forget about it. Focus on other stuff. And, and I know in the back rooms it was a big battle. It was a huge battle. You know, Lee Zeldin and you know, the USA Secretary Brooke Rollins and Bobby Kennedy. It was, it was a, it was a fist fight. And so this is all industry. And, you know, we've got, but we've got to face that. And as a society, how do we get Americans to wake up and say, no more? Like, just enough is enough.

[A]

See, believe, create, See, believe, create. See the harms that these toxins are causing. See the reason we're not taking Action. See the pathway to progress, to getting rid of them. Believe we can make a difference. We got lead out of paint. We got lead out of gasoline. We got a lot of toxins out of our environment. It's not that we haven't made any progress.

[B]

Oh, now we're increasing culprits.

[A]

We have new ones. You know, we have nanoparticles, which are really scary. Microplastics, endocrine disruptors. The microbiome, probably the greatest unknown in our society, is like, what is actually inside of us. Right. And how do we change that and improve it other than some simple things like more fiber and then create a healthier future by analyzing who wins, who loses, figuring out those windows of opportunity where you can make progress on a specific issue. I'm really discouraged that the current administration rolled back the PFAS law. Right. Water has pfas.

[B]

Those are forever.

[A]

Chemicals forever and everywhere, right? They're forever and everywhere. You know, we really can make a lot of progress. There are things that seem like they're inevitable, but they're not. We've made progress before. Smallpox is gone. Right. Typhoid is gone. And I think if we take the right actions, heart attacks and strokes can be gone as well.

[B]

But nobody's making millions of dollars from typhoid or smallpox. Right? People are making trillions of dollars from the food industry. It's the sing. Biggest industry on the planet, employs more people than anybody else on the planet. Everybody eats. It's like 15, $16 trillion. It's a massive.

[A]

I made that point. I got into trouble making that point.

[B]

I'm like, you know, when I became.

[A]

Health commissioner in New York City, I'd been working on tuberculosis for a decade. And I said, for the last decade, my enemy has been a microbe. Mycobacterium tuberculosis. Now, it's a really low life form. The tobacco executive. And I got a letter from Philip Morris, I still have it, that says, this is a form of hate speech. Yeah. Because no human being should be described as less than human. And, you know, I had to admit they were right. So ever since then, I don't use that phrase. I just say that they're mass murderers Society.

[B]

They're mass murderers. That's good.

[A]

They haven't written again.

[B]

That's good. That's good. I got a letter from the Corn Refiners of America berating me for actually talking about high fructose corn syrup. It was really interesting and it was really hysterical because then the Sugar association called me up and said, hey, would you testify on our behalf. Because, you know, I'm like, no, we'll pay a half a million dollars. No, go away.

[C]

Literally.

[A]

Literally. I'm like, when I was CDC director, we got a directive from Congress to study the marketing of unhealthy food to children, along with three other agencies, CDC and three other agencies. And then the food industry spent, according to reports, at least $175 million lobbying Congress. And we got another letter from Congress saying, you will not write that report.

[B]

Yeah, it's crazy. So Congress told the CDC not to write a scientific report because of 100 plus million dollars that the industry spent to try.

[A]

They couched it in other language, but that's essentially what it was. We had one year where the budget bill had in it a rider that said the CDC can't recommend that people consume less soda sodium. And you have to study it. But the group that studies it can't be anyone who knows anything about sodium. You can't make this stuff up.

[B]

Well, what you just said is really important because, you know, the continuous trope of industry is, you know, we don't know. There's not enough science. We need more science. We need to study this. We can't make any decisions.

[A]

Just like the tobacco industry. That's exactly.

[B]

That's right. That's why I'm bringing it up. So what do you say to that?

[A]

There are certain things that we're certain and for those, we need to take action. And I agree. There are others that we're not so sure. But PFAS isn't good for you, right? Sugar isn't good for you.

[B]

Now, I wanted to say, I want to say to Senator Grassley, here's a glass of atrazine. Just enjoy. You know, here's a glass. You can, you can have a combo package with the glyphosate and the atrazine. You enjoy those. Senator Grassley, I'm like, I mean, I get. He's from Iowa and he's got to protect the farmers, but the farmers are also not happy. The farmers are, you know, struggling. They're more suicides in farmers than any other sub population in America. They're. They're making incredibly small amounts of money or losing money. They, they're not actually healthy because they're affected by all the chemicals they're using and their diseases. And Parkinson's is the number one, you know, group that has Parkinson's disease. And, and they want to change. They want to do different practices, but they're stuck.

[A]

If you think this is bad, sorry.

[B]

I get all I Get all hyped up.

[A]

Well, I'll tell you, if you think this is bad in the US we work globally.

[B]

Oh, it's terrible. Yeah.

[A]

What the industry does globally is. Is even worse, man.

[B]

In America, we're going to ship it overseas.

[A]

Well, they pay off the government very openly. They buy out the news media and put stuff in as if it's news articles. They pay farmers to grow stuff so that there will be a lobby against reducing tobacco or alcohol or sugar consumption. Even if they're not going to buy that, they have contract farmers who are not making any money from that and are getting really sick from tobacco and other other products. But, you know, I remain optimistic because ultimately, one of the things we can see, one of the things that we can reveal is what industry is really doing, what the profit motive is doing. And you see some, you know, accusations about different groups. Well, what's really happening is, yeah, there's a lot of money behind pushing stuff that's very unhealthy. Tobacco, alcohol, unsafe food, unsafe chemicals in our environment. And people want to be healthy. And I don't think that's a democracy, Democratic or Republican issue. I don't think it's a right or left issue. It's about health or sickness. It's about fact or fiction.

[B]

It's so important. I mean, we have a lot of work, a lot of work to do. And I think, you know, your message in your book, the formula for better Health, which definitely should be on everybody's reading list, and you can get a copy now, wherever it's out is, you know, we can't ignore this anymore. And it's gotten to a point where. Where we have to take this on as a society, just as we took on slavery. As we took. I mean, when you think about slavery, and maybe it's a bad analogy, but the entire economy was based on slavery. And then it stopped. And then there's different forms of sort of quasi slavery. They persisted afterwards, but it was basically stopped. And America went on and industry recalibrated and we figured it out. Out, you know, and I feel like it's kind of that moment where we're being enslaved by the food system that is producing foods that are killing us en masse. And. And it's almost an invisible problem.

[A]

One of the aspects of the formula is to strengthen our belief in the possibility of change. And I think one way we do that is by recognizing the progress that we've made in the past, whether it's progress in tobacco or progress in other areas, getting some toxins out of our environment. Environment. I think sometimes public health folks and others are really reluctant to recognize past progress because they think it's a way of saying mission accomplished, foot off the accelerator, everything's fine. No, I think it should give you more impetus, more energy to do more. Another way to strengthen belief is to make small steps. What concerns me about some of the stuff going on today is, is that a lot of the diagnosis is pretty good. Yeah, we have a big problem with nutrition, we have a big problem with obesity. But the prescription is tell people to eat healthy or you know, switch to regular sugar instead of high fructose sugar or even the food additives. You know, it's good to get em out. But this is not going to move the needle. The things that will move the needle are the policy levers. Whether it's on soda tax or clear warning labels or low sodium activities or getting unhealthy food off public property, including government and schools and other areas. So I think making steady progress is really important so we don't just throw up our hands and say, oh, there's nothing we can do about it. There is something we can do about it.

[B]

I think one of the greatest things that could happen, and I love your opinion on this, is we spend. The government itself is the single biggest funder of, of healthcare and through all the different programs, the Department of Defense, the va, Medicare, Medicare, I mean any health service across everything, they're funding 40% of the population's healthcare in some way or another and they're paying almost $2 trillion of the almost $5 trillion healthcare bill every year. If we took 1 billion of that trillion dollars and we did rigorous research showing the harms of ultra processed food, the harms of sugar and starch in a way that, that, that could change minds and change, you know, make the evidence so clear. Kind of like with tobacco, I feel like that could start to kind of be a force that could start to shift the policies. Because right now it's like, oh, there's lack of evidence. I mean even the Dietary Guidelines Committee, when they looked at ultra processed food data they were like, well you can't really say it affects weight. There's one study here, one study there, not enough evidence, blah blah, blah. And the app, what I always say, and I stole this from somebody, I forget who is the absence of evidence is not the evidence of absence. And I think this is where we can lean in as a government to start to fund at a scale that we're funding a lot of other things that are Way downstream from these problems.

[A]

So I would say two things about that. First is there are certain things that we do know already, right? We know that we should be consuming less sodium, less sugar, and we know some of the ways we could implement programs that would make that happen. More fiber, more fruit and vegetables. We don't need a new stuff to show us that. The second thing is, if you're thinking about the US healthcare system, I really think we should focus on primary healthcare. 100 million Americans don't have primary health care. And it's really important, whether it's to interpret the evidence for you or to give you good care or to make sure you get the care you need. There's a lot of good care that Americans don't get. And it's not driven by pharma. You know, just to be clear, neither I nor my group have ever taken money from pharma, nor will we ever. Medicines we recommend are all generic, low cost. But there's just no excuse for this country having a less than 50% blood pressure control rate. And that's to 140, let alone 130 or even lower. And that's a lot of suffering. More than a half a million deaths a year in this country, about 40% of them people under the age of 70, because their blood pressures aren't controlled. We need to do much better at what we know how to do. And, yeah, let's learn more about other things as well.

[B]

It's personal for me, too. Ma had high blood pressure and she had a stroke. You know, I feel like with this, a huge inflection point now in health in America, globally, kind of the cat's out of the bag. The invisible has become visible. And I think there's political will to change things here and around the world. I see it increasingly happen. You know, you and I are about the same age and it's been slow, but it's sort of like have it slow, slow, slow. Then all at once it feels like that moment. I don't know if it'll be a passing moment, but it feels like it's really important. And I think your work and the formula for better health and the framework of how to save millions of lives in your own, including your own, is really important. And there's some simple things that you talk about in your book that are foundational, that we say over and over, but that are real. One of the things I thought was interesting that you brought up in your book that we didn't talk about was B12 as a intervention, not lowering Salt not lowering sugar. It's something you add. And also I was surprised to see that you wrote about in a way that said even if your levels are, quote, normal, there may be a benefit to increasing the amount. So can you just talk a little bit about that? Because I think that was a. I was a little bit of an aha for me.

[A]

Yeah. There are some lab tests that are not perfect. We still have a lot to learn about lipids, vitamin D and B12. Even the very sophisticated lab tests for it can miss a subtle deficiency.

[B]

It means methylmalonic acid.

[A]

Yes, yes, yes.

[B]

Which is a big word. But it's sort of been a way of looking at metabolite of B12. And if B12 is adequate, it's lower, and if it's not adequate, it's higher.

[A]

I think of two ways, two vectors, if you will. How certain are we about something, how big is the benefit and how hard is it to do so when it comes to vitamin B12, to take that as an example, I'm not sure that taking vitamin B12 will help, but it's not going to hurt. It costs, you know, pennies, a pill, and it might help, and it might even help a lot. And you really have no way to know if you're deficient.

[B]

Help what?

[A]

It might help reduce dementia because B12 issues may. May as well. Just like, you know, potassium. Also low potassium is associated with fatigue. So you get enough potassium, you may feel more energetic, you'll certainly live longer, but you may feel more energetic for those years as well. There' misconception that healthy stuff makes you feel bad, that you have to deny yourself pleasure. This is just the opposite.

[B]

I'm a hedonist, Trust me, I like all the pleasures.

[A]

So B12 is an example of something. I take it every day because it might help, can't hurt. Relatively reasonable, straightforward. I have to say, one of the brands I was using, I got back from a long trip, I traveled around the world a lot, and it smelled off. It's like, what? Whoa. That's a bad form of quality control. So I don't use that brand anymore. But remember, Congress has prevented the FDA from regulating additives and vitamins, and that's a real problem. So we have no way of knowing which company is more reliable.

[B]

Yeah, yeah, that's true. And by the way, a lot of people will take B12, then the doctor will check their level and they'll see they're really high and they'll go, oh, you're toxic from B12. Like, it's a Water soluble vitamin. If you take it without folate or folic acid or folate, you can't get problems.

[A]

You can, yeah. You can mask and anemia.

[B]

Yeah, yeah. But.

[A]

But it's basically, you know, it's not just about diet. When the CDC discovered that folate deficiency causes birth defects, really severe neural tube birth defects, and got a mandate for some of our flour to be fortified that prevents about a thousand severe birth defects a year, saves hundreds of millions of dollars. And you don't have to change. No, that's the, that's the sweet spot of public health.

[B]

Oh, my. Tom, I 100% agree with you. And I had a conversation with someone in government recently which was like, we want to really reduce the amount of refined flour in the dietary guidelines. It has to be something that we can't just say, eat half of your grains as whole grains. Like having half of your grain intake as ultra processed, highly pulverized, high glycemic, metabolically chaotic white flour is not a good idea. And they're like, well, there's like all these unintended consequences because people get, get their folic acid and flour. And I'm like that. Yeah. Yes, we impoverished our food, so we had to enrich it. But let's figure out a different solution. Because saying we can't say, to reduce our flour intake because there's vitamins in it that were put in after the fact doesn't make sense to me.

[A]

And here's a really important point, and it's something that happened on my watch that wasn't right. So don't try voluntary measures with the food intake industry. They don't work.

[B]

No, of course not. Oh, we're going to lower our calories.

[A]

We worked with the corn masa flour producers and for whatever reason, it was a voluntary action. No difference. There's a large part of the population consumes corn masa flour. Hispanics, they continue to have folate deficiency. They continue to have birth defects from it. That needs to be mandatory. So if you want to make a change, force it to happen.

[B]

Yeah, 100%. You're talking about primary care. And I'm a family doctor. I'm a primary care doctor. I trained in Santa Rosa Hospital. There were only family doctors, did community medicine, worked in a small town in Idaho with 3,500 people. Family doctor. There was one drunk surgeon. A few family doctors did everything. I get primary care. I work inner city hospitals. I understand it. And what's true is that yes, people need access to good quality primary care care. But we're going to be 100, I think 32,000 physicians short by 2030 in America. And that's concerning. And globally it's even more a shortage of physicians, nurses, healthcare providers. And we're at this interesting moment in the sort of intersection between technology, AI and medicine and healthcare where it seems as though the early indicators are that actually AI can do as good or better a job in assessing and treating people than actual primary care doctors or even specialists for that matter. So it can never be done independent of healthcare. I don't think. It's not just like you throw AI in medicine and then forget about it. But I do think that there's this moment where we can start to reimagine how we deliver care at scale. I mean telemedicine should be approved. I don't know why we, we rolled it back after Covid. It's only because the boards of registration medicine want to make money in each state. There's no reason that your body changes from moving from like Arizona to Colorado or New York to New Jersey. It's like unlike the law which changes, your body doesn't change. And, and, and second, like we, we could deploy at scale a tech solution that is, has embedded within protections but still guides people for a lot of the issues that they have and, and provides kids almost better quality answers. And I know I'm, you know, I'm a 40 year, how many years ago? Like a 40 something three year. I don't know, I'm not good at math but a lot of years of not being a doctor and, and you know, I feel like I'm well trained and well experienced and there's still so much I don't know. And when I see a patient now I'm like, I just can remember da da da. And I kind of look it up and I'm like, wow, I just got so much smarter about how to take care of this patient patient. And it's really, it's not making decision for me, but it's actually like a rocket booster on my medical practice.

[A]

I think there are three things we have to do to really transform healthcare to make it work for people. One is change the financial model so that primary care pays. Right now, a primary care doctor who does wonderful work for 20 years will make less than half what a surgeon who graduated yesterday makes.

[B]

100%.

[A]

That's ridiculous.

[B]

No, it's crazy. That's ridiculous.

[A]

And so we need to change that. Primary care pays and it pays to keep you healthy. That's what works at Kaiser Permanente. If they keep you healthy, they make more money. In the rest of the healthcare system, if you have a heart attack or stroke, they make more money. We have to change that. The second thing is teams nurses.

[B]

So you're kind of talking about either accountable care organizations, single payer system.

[A]

Single payer is a non starter in this country, but some way of making everyone value based health. You know a lot of stuff that says it's value based isn't value based. It's changing the incentives. Another approach is what's called total cost of care which says if you drive down the costs you're going to share in some of those shared savings model. So that that's a. But you have to guard against cheating. It's complicated stuff. So fix the financial model is one second is teams nurses, nurse practitioners, social workers, outreach workers really important and that includes telemedicine.

[B]

Former a million community health workers do a lot to help our country.

[A]

It includes telemedicine. I think very little good came out of COVID but telemedicine really did make a leap forward and we need to use it because it gives people access. And you know one other team member is AI. AI is, I gotta say it blows me away. It is awesome. There are topics that I know cold and it knows them better 100%.

[B]

I'm like wow, I thought I was pretty good at that. Yeah. And I'm like.

[A]

And I didn't know that. And it's, you know the, the open evidence is really impressive. I use it every single day. And you know, the only problem is if it's a, you know, I'm checking on somebody who's being treated by another doctor and it knows better. It's very awkward to say, you know, actually your dose is wrong of that. So I, I do think that this will make it possible to give better care to more people for less money. But we still need to fix the finances and to have a whole team to do it because. Because the nurse is going to be better at talking to the patients. The nurse practitioner is going to go to places the doctor's not going to go to. You do need some hands on care. But I do think AI is not just awesomely good, it gets better every day in a way that's just astonishing.

[B]

I love this conversation. I could go on for hours. I just want to sort of sum up what you're saying which is the core of your message which is changing health in America and globally really is comprised of three things. One, one is addressing the public health crises, addressing the care model and empowering the individual. And I would also say the individual can also work to change the policy because they're the ones who members were listening to. The reason RFK got confirmed was because Senator Cassidy had 200,000 phone calls to his office. Because people spoke up. So people have more power than they think with their voice and their vote. And they can vote with their fork and their voice and their every way that you can vote is important. And I think that's kind of in a message that's empowering. I think we can kind of agree on that.

[A]

You know, it's actually how I what I discuss toward the end of the book about personal politics. If you just take the four or five healthiest habits, less than 5% of Americans have them, less than 5% of our kids are going to have them. And it's not just about willpower. We can encourage you to be healthier and eat healthier, but it's in your self interest to get policies changed. Whether it's at a community, walkable streets and bicycle paths, they work. Whether it's at the state level trying to get tobacco and alcohol and soda taxes through, whether it's at the national level to regulate some of the things that really would make a difference and get menthol out of cigarettes. The personal has a lot to do with not just what you can do in your own life, but what you can do in your community so that you, your family and all of us can live a longer, healthier life.

[B]

I think it might be one more piece to your puzzle. It's like a three legged stool. We can make it. Four legged is litigation because that's worked. It worked for GEA in the Hudson River. It worked for. It's worked for glyphosate, it's worked for tobacco. I think, you know, it's one of the tools, it's one of the four.

[A]

Legacy that we can use to push for progress. There are other tools as well. Building coalitions, building movements, communicating effectively, showing where there's progress and using that progress to encourage other groups to make similar progress. Documenting harms that are happening. We have to keep in mind that there really is a common good, that it's not all win, lose. There are some win win things. If we improve health for everyone, we'll have a more productive society. If other countries are less likely to have disease outbreaks, we'll have more customers, we'll have cheaper goods, we'll have better ability to thrive.

[B]

Yeah, health is a good metric for the world at so many levels. So Tom thank you for your life's work, for being an inspiration to me early on as I look to how do we get out of this mess that I'm seeing in my clinic because I realized I couldn't cure diabetes in my clinic and for staying at it. And with your resolve to save lives effort continuing, people can support it. It's a nonprofit. I think your work is really important and everybody should get your book. The Formula for Better Health. How to save millions of lives. Lives including your own. Thank you so much for coming to Austin and being on the podcast and giving me the chance to meet one of my heroes.

[A]

So thank you so nice of you, Mark. It's great conversation. I've learned from it. And just to be clear, I don't make a penny from the book. Any proceeds will go to groups we work with around the world to advance health products.

[B]

Okay, so everybody buy 10 bucks then.

[A]

Thank you so much.

[C]

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[B]

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[C]

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[B]

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[C]

So check out Dr. Hyman.com because when it comes to your health, nothing less than the very best will do. That's Dr. Hyman.com-r h y m a n.com this podcast, please share it with someone else you think would also enjoy it. You can find me on all social media channels at Dr. Mark Hyman. Please reach out. I'd love to hear your comments and questions. Don't forget to rate, review and subscribe to the Dr. Hyman show wherever you get your podcasts. And don't forget to check out my YouTube channel at Dr. Mark Hyman for video version, versions of this podcast and more. Thank you so much again for tuning in. We'll see you next time on the Dr. Hyman Show. This podcast is separate from my clinical practice at the Ultra Wellness center, my work at Cleveland Clinic and Function Health, where I am Chief Medical Officer. This podcast represents my opinions and my guests opinions. Neither myself nor the podcast endorses the views or statements of my guests. This podcast is for educational purposes only and is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided with the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, please seek out a qualified medical practitioner. And if you're looking for a functional medicine practitioner, visit my clinic, the Ultra Wellness center at ultrawellnesscenter.com and request to become a patient. It's important to have someone in your corner who is a trained, licensed healthcare practitioner and can help you make changes, especially when it comes to your health. This podcast is free as part of my mission to bring practical ways of improving health to the public, so I'd like to express gratitude to sponsors that made today's podcast possible. Thanks so much again for listening.